Advances in the surgical treatment of atrial fibrillation

Abstract

Abstract-Atrial fibrillation (AF) is the most common sustained arrhythmia. It is associated with increased risks of death and stroke; most strokes in AF patients are thought to arise from thrombi in the left atrial appendage. Surgical ablation of AF includes excision of the left atrial appendage and is an effective means of treating this arrhythmia, with the classic Maze procedure curing AF in Ͼ90% of patients and virtually eliminating the risk of late stroke. A complex but safe operation, the Maze procedure has been applied by relatively few surgeons. Key Words: ablation Ⅲ atrial fibrillation Ⅲ stroke A trial fibrillation (AF) currently affects Ϸ2.4 million Americans; this number is expected to increase to Ͼ5.6 million by 2050. 1 The prevalence of AF increases with increasing patient age, and recent data from the Framingham Heart Study suggest that the lifetime risks for development of AF are 1 in 4 for men and women aged Ն40 years. 2 This epidemic has a growing impact on the healthcare system and a multibillion dollar cost. The clinical consequences of AF are well documented. AF is associated with reduced life expectancy and increases the risk of stroke 5-fold, accounting for Ϸ15% of all strokes nationally. 3-8 These AF-related strokes are a major challenge and a focus of several clinical trials investigating strategies for primary and secondary prevention. 4 Currently, antithrombotic therapy is the mainstay for stroke prevention in AF patients.Although there is currently some consensus concerning pharmacological strategies for stroke prevention in AF patients, choice of therapy for the heart rhythm is controversial and evolving. 9,10 Available antiarrhythmic therapies inconsistently restore sinus rhythm and are associated with complications. In fact, the risks associated with antiarrhythmic drug therapy may counterbalance the potential benefit of restoration of sinus rhythm. 9,10 These observations, coupled with increased understanding of the pathogenesis of AF, have resulted in the development of interventional strategies to restore sinus rhythm. Both catheter-based and surgical approaches have demonstrated effectiveness in this regard. Developed by Dr James Cox, the classic Maze procedure is the predicate operation for ablation of AF; long-term data suggest that the Maze procedure eliminates AF in Ͼ90% of patients. 11-14 Despite these unmatched results, the complexity and time associated with the Maze procedure have prevented widespread application by surgeons.Recently, however, there has been increased interest in direct surgical ablation of AF, fueled by technological advances and demonstration that the pulmonary veins and left atrium are the drivers of AF in most patients. 15 New ablation technologies enable surgeons to perform pulmonary vein isolation, create strategically placed, linear left atrial lesions, and excise the left atrial appendage rapidly and safely. 16 -23 Alternate energy sources used to create lines of conduction block and replace surgical incisions of the Maze procedure include radio...

ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation—Executive Summary

“…331 Other studies suggest success rates around 70%. 332 Atrial transport function is maintained and, when combined with amputation or obliteration of the LAA, postoperative thromboembolic events are substantially reduced. Risks include death (less than 1% when performed as an isolated procedure), the need for permanent pacing (with right-sided lesions), recurrent bleeding requiring re-operation, impaired atrial transport function, delayed atrial arrhythmias (especially atrial flutter), and atrioesophageal fistula.…”

“…A wide variety of less invasive modifications are under investigation, including thoracoscopic and catheterbased epicardial techniques. 332 If the efficacy of these adaptations approaches that of the endocardial maze procedure and they can be performed safely, they may become acceptable alternatives for a larger proportion of patients with AF.…”

Mécanismes physiopathologiques de la fibrillation auriculaire

“…De manière fortuite, cette opération isole égale-ment toutes les VP et la paroi postérieure de l'OG. Les taux de succès à long terme, défini comme l'absence de récidive de FA, varient entre 70% et 95% selon le type de population étudiée [35,36]. Malgré cela, l'opération de Maze n'est pas réalisée de manière routinière à l'heure actuelle, notamment en raison de sa complexité et des difficultés techniques, rendant de ce fait de nombreux chirurgiens réti-cents à ajouter une telle procédure à une chirurgie coronarienne ou valvulaire [2].…”

“…Malgré cela, l'opération de Maze n'est pas réalisée de manière routinière à l'heure actuelle, notamment en raison de sa complexité et des difficultés techniques, rendant de ce fait de nombreux chirurgiens réti-cents à ajouter une telle procédure à une chirurgie coronarienne ou valvulaire [2]. Des modifications moins invasives sont en cours d'investigation, comprenant des techniques thoracoscopiques ou par cathétérisme épi-cardique [36].…”

Signal processing of intracardiac recordings for the evaluation of propofol effects during atrial fibrillation.

“…Success rates of around 95% over 15 years of follow-up have been reported in patients undergoing mitral valve surgery [183]. Other studies suggest success rates around 70% [184]. Risks include death (less than 1% when performed as an isolated procedure), the need for permanent pacing (with right-sided lesions), recurrent bleeding requiring reoperation, impaired atrial transport function, delayed atrial arrhythmias (especially atrial flutter), and atrioesophageal fistula.…”