title: Surgical Treatment of Atrial Fibrillation.
abstract: Atrial fibrillation (AF) is the most common chronic arrhythmia in the adult population. Ablation lines have largely replaced the historical and challenging cut and sew techniques. Surgical ablation of AF is commonly performed in cases with other indications for cardiac surgery and less commonly as a stand-alone therapy. Pulmonary vein isolation is the cornerstone of this procedure. Extended left atrial ablation lines may increase efficacy in cases with longstanding persistent or permanent AF. Additional efficacy by adding right atrial ablation is controversial but is often performed in cases undergoing right atrial or atrial septal surgery. Left atrial volume reduction is recommended in cases with large left atria and AF undergoing another cardiac surgery. Arrhythmia recurrence is not uncommon after surgical ablation of AF and varies among studies due to heterogeneity in patient population, lesion set and endpoints. Freedom from AF recurrence was 65-87% at 12 months and 58-70% at 2 years follow-up. Long-term monitoring is recommended due to an increased prevalence of asymptomatic recurrences. The strongest predictors of AF recurrence are longstanding or persistent AF and a large left atrium. The most common mechanisms of recurrence are pulmonary vein reconnection, nonpulmonary vein triggers, and gaps in the ablation lines. About 20% of atrial tachyarrhythmia recurrences are atrial flutter or atrial tachycardia. There are not enough data in the surgical literature to support withdrawal of anticoagulation after surgical AF ablation. Patients selected for stand-alone surgical ablation usually have low risk profiles and low postoperative mortality rates (0.2%).
authors.affiliation: Division of Cardiovascular Health and Diseases, University of Cincinnati, Cincinnati, Ohio.
authors.forename: Elsayed
authors.initials: E
authors.lastname: Abo-Salem
authors.affiliation: Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA.
authors.forename: Deborah
authors.initials: D
authors.lastname: Lockwood
authors.affiliation: Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
authors.forename: Lucas
authors.initials: L
authors.lastname: Boersma
authors.affiliation: Department of Cardiology, BG-Kliniken Bergmannsheil, University of Bochum, Bochum, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Deneke
authors.affiliation: Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.
authors.forename: Laurent
authors.initials: L
authors.lastname: Pison
authors.affiliation: Department of Surgery, Texas Tech University HSC, Lubbock, Texas, USA.
authors.forename: Ralph F
authors.initials: RF
authors.lastname: Paone
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Texas Tech University HSC, Lubbock, Texas, USA.
authors.forename: Kenneth M
authors.initials: KM
authors.lastname: Nugent
keywords: atrial fibrillation; cryoablation; ligament of Marshall; maze; minimally invasive surgery; pulmonary vein isolation; radiofrequency ablation; surgical ablation