Surgical perspectives in the management of atrial fibrillation

Table 4 Adapted from the surgical treatment of atrial fibrillation guidelines by the European Association for Cardio-Thoracic Surgery Clinical Guidelines Committee guidelines

Use of ablative modalities
Unipolar radiofrequency ablation
Concomitant unipolar RFA for AF treatment together with cardiac surgery is effective in restoration of sinus rhythm
Success rates vary between 54%-83% at medium term follow up (at least 12 mo)
Safe procedure - no additional risks
Success rates are higher with: paroxysmal or persistent AF, younger age, smaller LAD
Class IIa recommendation based on multiple small retrospective studies (Level C)
Bipolar radiofrequency ablation
Higher success rates in restoring sinus rhythm compared to no ablation in concomitant cardiac surgery
On average the cross clamp time is increased by 15 min
There is limited evidence to suggest superiority of bipolar over unipolar RFA
1 prospective trial has provided evidence demonstrating superiority of bipolar RFA over microwave ablation
Class I recommendation based on 3 RCTs and multiple small prospective studies (Level A)
Cryoablation
Acceptable intervention for AF treatment during concomitant surgery with acceptable sinus rhythm conversion rates between 60%-82% at 12 mo
Cryoablation is most successful in patients suffering from paroxysmal as opposed to permanent AF (suggested by 6 out of 9 studies reviewed)
Class IIa recommendation based on 1 small RCT and multiple prospective and retrospective studies (Level B)
Microwave ablation
Less effective intervention for AF treatment based on the limited evidence
Success rates in the longer term are less clear - the only RCT to date has found outcomes inferior to RFA
Class III recommendation based on 1 small RCT and multiple small prospective and retrospective studies (Level B)
HIFU
Currently not recommended as an intervention for the treatment of AF during concomitant surgery outside clinical trials due to limited evidence
Success rates seem to be inferior to those of other devices
Significant concerns have been reported
Class III recommendation based on cohort studies (Level C)
Exclusion of laa and standing alone surgical ablation
Exclusion of LAA
No proven benefit of surgical LAA exclusion in terms of stroke reduction or mortality
Ineffective LAA occlusion and potentially increased stroke risk due to poor technique was seen in many studies
Devices designed for LAA exclusion should be preferentially used rather than a cut and sew or stapling technique, if LAA is to be performed
Class IIa recommendation based on multiple cohort studies and one pilot RCT (Level B)
Stand alone surgical ablation
Surgery can be considered for symptomatic patients who are refractory or intolerant to at least 1 anti-arrhythmic medication
Considered for patients with paroxysmal, long standing and persistent AF who prefer surgery to catheter ablation or have failed catheter ablation
Results of both catheter-based and surgery-based ablation should be discussed with the patient
Class IIa recommendations based on 1 RCT and multiple cohort studies (Level B)

RFA: Radiofrequency ablation; AF: Atrial fibrillation; LAD: Left anterior descending; RCT: Randomized controlled trial; HIFU: High intensity focused ultrasound; LAA: Left atrial appendage.