Treatment of lone atrial fibrillation: a look at the past, a view of the present and a glance at the future

Abstract

Despite its proven efficacy, the Cox-Maze III procedure did not gain widespread acceptance for the treatment of lone atrial fibrillation (LAF) because of its complexity and technical difficulty. Surgical ablation for LAF can now be successfully performed utilizing minimally invasive techniques. This article provides an overview of the current state of the art in the surgical treatment of LAF. A brief review of pathophysiology, pharmacological treatment as well as catheter ablation is also provided. The most widely employed minimally invasive approach to LAF has been the video-assisted bilateral mini-thoracotomy or thoracoscopic pulmonary vein island creation and left atrial appendage removal or exclusion, usually with ganglionic plexi evaluation and destruction. Recently, a hybrid approach has been introduced, which combines a mono or bilateral epicardial approach with a percutaneous endocardial ablation in a single-step procedure to limit the shortcomings of both techniques. Suboptimal results of both catheter ablation and surgery suggest that success in the treatment of LAF will probably rely on a close collaboration between the surgeon and the electrophysiologist. Further studies are warranted to determine whether the hybrid approach is effective, especially in patients with long-standing persistent and persistent LAF.

Surgical Treatment of Atrial Fibrillation

“…Even with reference to lone AF, understanding arrhythmia mechanisms is crucial in view of developing less invasive techniques [21]. More in detail, recent studies are now more focused on the role of autonomic ganglia in being the true triggers and perpetuators of AF and perhaps they will rapidly become the main target of future ablation techniques.…”

“…Nevertheless, maze represents a very invasive operation requiring median sternotomy and, also in experienced hands, 45-60 min of cardiopulmonary bypass and cardiac arrest; as a result, efforts have been made to reduce the operative aggression in parallel with the introduction of alternative energy sources for ablation, reducing the need for "cut-and-sew" incisions. Such an approach led to the development of minimally invasive AF surgery [14,21]. Two main operative techniques have been described:…”

“…Published success rates from hybrid ablation, defined as maintained SR off antiarrhythmic medications at 12 months, are 74.3% overall (76.9% for paroxysmal and 73.4% for persistent/ long-standing persistent AF patients) [21,22]. The three described techniques failed to achieve the same results in terms of freedom from AF recurrence, with the LAMP approach showing Surgical Treatment of Atrial Fibrillation http://dx.doi.org/10.5772/intechopen.76700the best performance (88%) and the subxiphoid posterior pericardioscopy the worst (59.3%).…”

Thoracoscopic Radiofrequency Ablation for Lone Atrial Fibrillation: Box-Lesion Technique

“…The increasing availability of minimally invasive techniques makes a surgical approach more appealing, especially because of its superior capacity to create transmural lesions . Patients with “lone” AF, that is AF in the absence of underlying heart disease, represent a special subgroup of AF patients . The minimally invasive (video‐assisted) surgical approach is a very promising method for the treatment of patients with lone AF.…”

“…2 Patients with ''lone'' AF, that is AF in the absence of underlying heart disease, represent a special subgroup of AF patients. 9 The minimally invasive (video-assisted) surgical approach is a very promising method for the treatment of patients with lone AF. The ''box-lesion'' technique is usually used, whereby a box lesion around pulmonary veins isolates not only the veins but also the posterior left atrial wall, which contains AF triggers in many patients.…”