Ann Thorac Surg 2006;81:1337-1338
© 2006 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Adam E. Saltman, MD, PhD
Department of Cardiothoracic Surgery, University of Massachusetts, 55 Lake Ave N, S3-747, Worcester, MA 01655
(Email: adam.saltman{at}umassmed.edu).
The use of ablative technologies during the last few years has allowed the cardiac surgeon to treat many more patients who present to the operating room with atrial fibrillation. Although patients with mitral valve disease have been the most extensively studied, patients with coronary disease clearly comprise the largest absolute number of cases presenting to the surgeon. Akpinar and colleagues [1] have nicely shown in this article that this group of patients can undergo ablation in an off-pump setting both safely and effectively.
However the authors have touched on several very important and still controversial points in the general and specific treatment of patients with atrial fibrillation and concomitant structural heart disease. The selection of a treatment endpoint is one. Should we be assessing acute conduction block into and out of the pulmonary veins as an endpoint for pulmonary vein isolation? It is not clear whether acute block portends long-term success or whether the absence of block abrogates it. Data are presently accumulating that completely transmural lesions may not be necessary to "cure" paroxysmal atrial fibrillation, and in fact more attention should probably be paid to autonomic innervation as a target for ablation in these patients.
The selection of procedure is another. Is pulmonary vein isolation the right operation for patients with permanent fibrillation? Akpinar and colleagues [1] suggest that it is not and that more extensive lesions are likely necessary to affect a cure in these more complicated patients. Data accumulating in the electrophysiology literature reinforce this approach (ie, more tissue ablation seems to give higher cure rates, but there may be significant functional detriment). Patient selection is yet a third point. Who is going to fail ablation? We are now coming to understand that long-standing atrial fibrillation in the presence of left ventricular dysfunction and atrial fibrillation in the presence of large atria all decrease the success rate of ablative therapies. Should these patients be denied an attempt at ablation if their chance of success is only 50% to 60%, even if the procedure is quick and safe or even if he or she is undergoing heart surgery anyway? Answers to these will have to await further improvement in our therapy as well as a careful assessment of risks and benefits to the patient.
The field of ablative therapy for atrial fibrillation is evolving rapidly and we are only beginning to understand the indications, contraindications, and procedures to be used for specific patients. The authors of this article have shown that the largest group of patients presenting for cardiac surgical treatment (ie, those with coronary artery disease) can be safely and effectively treated and should become an often-used part of the surgeon's armamentarium.
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- Akpinar B, Sanisoglu I, Guden M, Sagbas E, Caynak B, Bayramoglu Z. Combined off-pump coronary artery bypass grafting surgery and ablative therapy for atrial fibrillationearly and mid-term results. Ann Thorac Surg 2006;81:1332-1338.[Abstract/Free Full Text]
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