Ann Thorac Surg 2008;86:1882. doi:10.1016/j.athoracsur.2008.08.039
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Saqib Masroor, MD, MHS
Department of Cardiothoracic Surgery, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226
(Email: smasroor{at}mcw.edu).
Results of surgical treatment of atrial fibrillation (AF) are more difficult to interpret than those of catheter ablation or medical therapy. They typically do not have the hundreds of patients found in cardiology trials. Therefore, the benefit has to be substantially larger to generate the same p value. On the other hand, the patients are sicker and more symptomatic, with longer duration of AF and multiple failed therapies. Many patients undergo concomitant cardiac surgery. Hence, improvement in quality of life (QOL) is more likely to be observed, but harder to attribute solely to cure of AF, rather than the concomitant procedure.
Lundberg and colleagues [1] report a study facing similar challenges. Thirty-four patients underwent the Cox maze III procedure with a mean follow-up of 35 months. Eight (24%) patients underwent concomitant cardiac surgery, such as coronary bypass, mitral valve surgery, and so forth. The reported success rate of 90% restoration of sinus rhythm in this population of only 25% paroxysmal AF patients was associated with a sustained improvement in QOL to levels seen in a normal healthy population. Are the results of this study commendable? Without a doubt! Are they relevant? Maybe!
A similar study was published in 2000 with a 1-year follow-up rather than 3 years [2]. Similar results have also been reported with catheter ablation of AF [3–5]. Pappone [3] demonstrated an improved survival and QOL in patients who underwent catheter ablation versus those treated medically for rhythm control. The QOL for these patients returned to levels seen in a normal healthy population at 12-month follow-up and remained as such for the mean follow-up of 900 days. Even though the patients were healthier and 70% were in paroxysmal AF, the study demonstrated the benefits of maintaining SR. In addition, AF recurrences were associated with impaired physical and mental functioning.
In contrast to multiple catheter ablations, surgeons have just "one shot" at curing AF. With the bar already set higher, and the "gold standard" maze not the standard of care in most institutions, the clinical relevance of Lundberg and colleagues' [1] work in today's cardiac surgery practice is called into question. No energy source or lesion set has consistently produced results comparable with the Cox maze III procedure. Surgeons performing ablations for AF using alternative energy sources or lesions, or both, may not observe these benefits reported by the authors. However, it is important to better understand the disease itself, as well as continually strive to improve the technique and technology to make it less invasive and more effective. Until surgeons can consistently achieve success rates of 85% to 95% with minimal morbidity, we can not expect to see the relatively healthier patients that cardiologists typically ablate in their electrophysiology laboratories. The patients may spend up to 12 hours in the laboratory for a catheter ablation, but they still go home the next day. And that is quality of life!
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References
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- Lundberg C, Albåge A, Carnlöf C, Kennebäck G. Long-term health-related quality of life after maze surgery for atrial fibrillation Ann Thorac Surg 2008;86:1878-1882.[Abstract/Free Full Text]
- Lonnerhom S, Blomstrom P, Nilsson L, Oxelbark S, Jideus L, Blomstrom-Lundqvist C. Effects of the Maze operation on health-related quality of life in patients with atrial fibrillation Circulation 2000;101:2607-2611.[Abstract/Free Full Text]
- Pappone C, Rosanio S, Augello G, et al. Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: outcomes from a controlled nonrandomized long-term study J Am Coll Cardiol 2003;42:185-197.[Abstract/Free Full Text]
- Purerfellner H, Martinek M, Aichinger J, Nesser HJ, Kempen K, Janssen JP. Quality of life restored to normal in patients with atrial fibrillation after pulmonary vein ostial isolation Am Heart J 2004;148:318-325.[Medline]
- Goldberg A, Menen M, Mickelsen S, et al. Atrial fibrillation ablation leads to long-term improvement of quality of life and reduced utilization of healthcare resources J Interv Card Electrophysiol 2003;8:59-64.[Medline]
Related Article
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Long-Term Health-Related Quality of Life After Maze Surgery for Atrial Fibrillation
- Catharina Lundberg, Anders Albåge, Carina Carnlöf, and Göran Kennebäck
Ann. Thorac. Surg. 2008 86: 1878-1882.
[Abstract]
[Full Text]
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References