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Original Articles: Adult Cardiac

Invited Commentary

Cardiac Surgery Division, S. Raffaele University Hospital, Via Olgettina 60, 20132 Milan, Italy

(Email: stefano.benussi{at}hsr.it).

Patients with atrial fibrillation are a high-risk subset of surgical candidates. The study by Louagie and colleagues [1] adds evidence that concomitant ablation at the time of an open heart procedure produces excellent long-term survival.

One additional strong message of the article is that in patients with permanent atrial fibrillation who undergo cardiac operations, you must get rid of the left atrial appendage, regardless of what you do about the arrhythmia or the main cardiac problem. Oddly enough, surgeons meticulously remember to obliterate or resect the appendage during ablation operations but tend to forget about it when atrial fibrillation is left unaddressed.

It makes sense to exclude the appendage in all patients with permanent or longstanding persistent atrial fibrillation, irrespective of the ablation strategy, but even more so when no concomitant ablation is done. The only time in which I believe appendage obliteration is debatable is when patients have a high probability of a good rhythm after ablation (paroxysmal, recent onset persistent). The decision is especially difficult when heart function strongly relies on atrial transport (eg, severe left ventricular dysfunction, hypertrophic obstructive cardiomyopathy).

This article also reiterates the excessive rate of postoperative pacemaker implantation after concomitant ablation. This was a major finding of the review by Gammie and colleagues [2] of the Society of Thoracic Surgeons database and deserves further consideration. Are the causes related to preoperative factors such as sinus node dysfunction due to long-standing atrial fibrillation or to the ablation procedure?

The final message is that concomitant treatment of atrial fibrillation improves clinical outcomes in our patients. Thanks to modern ablation devices, ablation is achievable with the addition of a few minutes of cardioplegia time. The fascinating challenge ahead is to ascertain which of our surgical techniques are instrumental for improving survival and functional recovery and which are possibly increasing the rate of adverse outcomes such as postoperative pacemaker implantation.

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1. Louagie Y, Buche M, Eucher P, et al. Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone Ann Thorac Surg 2009;87:440-447.[Abstract/Free Full Text]
2. Gammie JS, Haddad M, Milford-Beland S, et al. trial fibrillation correction surgery: Lessons from the Society of Thoracic Surgeons National Cardiac Database Ann Thorac Surg 2008;85:909-915.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stefano Benussi Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Benussi, S. Search for Related Content PubMed PubMed Citation Articles by Benussi, S. Related Collections Electrophysiology - arrhythmias Related Article