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Cardiac Surgery Division, San Raffaele University Hospital, Via Olgettina 60, 20132 Milan, Italy
(Email: stefano.benussi{at}hsr.it).
This article by Gammie and colleagues [1] reports the trend of surgical ablation for atrial fibrillation (AF) in modern times.
The worldwide increase in popularity of surgical ablation started at the turn of the millennium, before any evidence from randomized trials or any official guideline encouraged concomitant ablation. Today, solid scientific evidence on the clinical benefits of AF surgery is available, and there is a growing consensus for concomitant ablation in patients affected by AF who are undergoing heart operations. Modern devices have made ablation a small addition to open heart operations. In patients undergoing mitral surgery, Gammie and colleagues found ablation added 9 minutes to cross-clamp time and—within the limitations of a retrospective database analysis—could not demonstrate any increased morbidity. Nevertheless, most patients who would potentially benefit from it are not given concomitant ablation. In fact, Gammie and colleagues’ estimates from The Society of Thoracic Surgeons database may have underestimated the proportion of untreated patients because they excluded from the study centers with no ablation record.
This reluctance depends on different factors, among which are cultural reluctance, lack of scientific evidence, and poor initial results. As this report points out, surgeons are progressively opening their minds to AF ablation. Scientific evidence is accumulating, although the paucity of randomized trials and of late controls is still a problem. But unsatisfactory clinical results remain the major cause of skepticism toward concomitant ablation.
Collateral damage, especially of the esophagus and coronaries, has been a major concern, but modern approaches allow reliable prevention.
The major barrier for greater utilization is probably postoperative rhythm outcome. There is now plenty of evidence pointing to a direct cause–effect relationship between the completeness of ablation and clinical efficacy. Gaps in the ablation lines may allow relapsing arrhythmias. Also, the choice of lesion set is crucial: pulmonary vein encircling, alone, can be an option only for true paroxysmal and recent onset AF. Most AF cases should be given a complete left lesion set, entailing a mitral connecting line and probably some right lines. As it is the case for beating-heart coronary surgery and mitral repair, high success rates in AF surgery can only result from meticulous adherence to the rules. Paradoxically, the same simplicity that favored the recent surge of AF surgery can threaten its widespread recognition if brought to the extremes.
Once it is accepted that clinical outcome reflects the quality and the extent of surgical ablations, the popularity of AF surgery will build based on reliable results.
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