PMC:6019327 / 554702-568634 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/6019327","sourcedb":"PMC","sourceid":"6019327","source_url":"https://www.ncbi.nlm.nih.gov/pmc/6019327","text":"Stand-Alone Surgical Ablation of AF Stand-Alone Operations for AF and Their Outcomes\nThe primary indication for stand-alone surgery that was described in the 2012 Consensus Document was the presence of symptomatic AF, refractory or intolerant to at least one Class I or Class III AAD.2 In current practice, most patients also have experienced at least one unsuccessful catheter ablation before referral, unless the patient has a strong preference for a cure with a single procedure.\nThere has been over two decades of experience with operations performed solely for treatment of AF (stand-alone operations). The wide use of these procedures has been limited by a reluctance to refer patients to surgery for AF, procedural complexity, and limited data regarding outcomes. Moreover, the types of procedures and the technologies used to perform them have multiplied and are variable between operators. This has led to relatively modest-sized single-site case series, or at best multicenter series without comparison groups. In addition, the rigor and methodology of follow-up have changed dramatically over time and have further limited comparisons of outcomes. Lastly, the development of hybrid procedures, especially when staged, make comparisons even more difficult. This section will focus only on single-stage surgeries as sole AF therapies. A discussion of hybrid procedures will follow. Perhaps the best way to distinguish the types of surgeries is by those that require cardiopulmonary bypass and cardiac arrest and those that do not. In order to effectively create a lesion down to the mitral annulus, an open heart is required.\nThe earliest—and one of the largest—reported study of stand-alone operations for AF has been the 112 patients who underwent the cut-and-sew Cox-Maze III procedure by James Cox.1351 This procedure is performed through a sternotomy on cardiopulmonary bypass on an arrested heart and physically cuts and re-sews the atria to create a collection of lines of block. Cryothermia is used to destroy the tissue down to the mitral annulus. Among the 112 patients, 96% were in sinus rhythm with or without AAD therapy, and 80% were in sinus rhythm and free of AAD therapy at last follow-up. There was one late stroke in this group, and 88% of the patients were off chronic anticoagulation at last follow-up. The only risk factor for late recurrence was the preoperative duration of AF.1351 There have been several other published series with similar results that combine both stand-alone and concomitant patients with smaller numbers of patients. This procedure requires a sophisticated level of training and skill. As such, it is performed rarely, and only by experienced surgeons. Ideal patients for stand-alone AF ablation have failed other therapies, want definitive cures, or have clots in the LAA, making other approaches not using cardiopulmonary bypass risk prohibitive.\nWith the introduction of new ablation technology, including bipolar RF energy and new cryoablation systems, there has been renewed interest in less invasive procedures for stand-alone AF ablation. These new tools can be used in the open chest or through small incisions between the ribs. When used in the open chest with a full biatrial Cox-Maze lesion set performed, the procedure has been termed the Cox-Maze IV procedure. Techniques for a Cox-Maze IV procedure through a small, right inframammary incision have also been perfected. As noted in the earlier section on new surgical ablation technology, the outcomes achieved with the Cox-Maze IV procedure are similar to those achieved with the earlier Cox-Maze procedure. Importantly, the cross-clamp times are shorter with the Cox-Maze IV procedure.1301 The advantage of these approaches includes the ability to reliably create the endocardial lesions of the Maze, down to the mitral annulus. Late evaluation of this procedure in 146 stand-alone patients has shown a 72% freedom from AF at 5 years of follow-up and a 59% freedom from AF off antiarrhythmic medications.1306 Cryothermia alone has been used and described in a series of 77 patients, with a 6-month result of 88% freedom from AF, antiarrhythmic medications, and anticoagulants, but late follow-up is lacking.1306,1352\nOther approaches have limited the lesions to only those that can be created from the epicardium without the need to open the heart, and use both cardiopulmonary bypass and cardiac arrest. This approach has limited the extent of lesions from the Maze that can be created, because the mitral line is buried by an epicardial fat pad that makes destruction of tissue in this area unreliable. The minimally invasive surgical approach using video-assisted PV ablation and exclusion of the LAA was first described in 2005.1353 A bipolar RF clamp was used for PVI on the beating heart in 27 patients, among whom 18 had PAF. Among the 23 patients followed for more than 3 months, 21 (91%) were free of AF and 65% were off all AADs. There were four major complications, but no deaths, and no pacemakers were implanted. An additional ablation strategy that has been reported is minimally invasive PVI and partial autonomic denervation.1354 In a study of 74 patients undergoing this approach, 84% of the patients with PAF were free of AF and 57% of patients with persistent or long-standing persistent AF were free of AF at 6 months. There was one death, one hemothorax, one case of transient renal insufficiency, and one patient with a transient brachial plexopathy. A second, larger report from this group in 114 patients reported that 72%, 46.9%, and 32% of patients with paroxysmal, persistent, and long-standing persistent AF, respectively, were free of AF and off antiarrhythmic medications at 195 days of follow-up.1355 Another multi-center series of 100 patients with a similar approach and mean follow-up of 13.6 months reported a sinus restoration rate of 87%, with 64% of patients free from AADs.1356 The results of these and other trials cited earlier in this section have made it clear that a more extensive lesion set than PVI alone is required for successful surgical treatment of persistent and long-standing persistent AF. Most surgeons who still perform this type of procedure have moved toward a hybrid approach in either a single or staged operation. However, a PVI alone remains a reasonable approach for patients with PAF.\nThe Dallas Lesion Set was developed to create a complete approach, which can be performed on a beating heart without cardiopulmonary bypass.1339,1340,1341 The set replicates the LA lesions of the Cox-Maze III, but changes the connection of the PVI to the aortic annulus in continuity with the mitral. Early results have been published on 30 patients.1339,1340 The group included 10 patients with persistent AF and 20 patients with long-standing persistent AF. Electrocardiographic long-term monitoring and the use of AAD data were collected 6 months postprocedure, and follow-up was 100%. Procedure-related complications did not occur during follow-up, nor were there any deaths. At 6 months of follow-up, 90% of the patients with persistent AF and 75% of the patients with long-standing persistent AF were in sinus rhythm. AAD therapy was continued in 22% of the patients with persistent AF and 53% of the patients with long-standing persistent AF. In a series of 100 paroxysmal patients randomized to include the Dallas Lesion Set or not, the additional lesion, as expected in a paroxysmal population, did not impact success at 16 months of follow-up.520 Much like the results of catheter ablation, this suggests that the type of AF will influence the success of the procedure. Persistent AF is likely to require a more extensive lesion set. An important area of interest is the decision to offer a patient surgery or catheter ablation.\nThe AF Catheter Ablation Versus Surgical Ablation Treatment (FAST) trial sought to compare catheter ablation with minimally invasive surgery.601 A total of 124 patients who had drug-refractory AF with dilated atria or failed catheter ablation were randomized to either catheter ablation or minimally invasive surgery using bipolar clamps, with or without additional connecting lesions. At 1 year of follow-up, freedom from AF was 37% in the catheter ablation group and 66% in the surgical group. Although this was somewhat offset by the increased adverse events in the surgical group (34% vs 16%), the only death was in the catheter ablation group.601 A different analysis of 7 studies, including two RCTs, suggested superior freedom from AF in the surgical group, with similar complication rates, except for an increase in pacemaker implantation in surgical patients.1357 However, the technologies and groups were fairly heterogeneous.\nOther approaches, such as epicardial box lesions with suction-assisted unidirectional uni- and bipolar RF and a complete box lesion with bipolar clamps, have been described in numbers insufficient to draw any conclusion. As the new techniques have been introduced, there has been appropriate concern regarding the safety of minimally invasive stand-alone surgery. Although safety is dependent on procedure and site, it has been examined in a systematic review that compiled results from 23 observational studies with 752 patients who underwent minimally invasive stand-alone procedures.1349 Operative mortality was 0.4%. Complication rates attributed to surgery were only 3.2%. Reports from the STS National Database showed an operative mortality rate of 0.74%. The complication rate was considerably higher at 16.43%, although major morbidities such as stroke (0.72%), renal failure (2.45%), and bleeding (0.99%) were low. Pacemakers were implanted in 1.03% of patients.\nThe outcomes of stand-alone AF ablation from the STS database were recently reported.1358 Between 2005 and 2010, a total of 91,801 surgical AF ablations were performed, of which 4893 (5.3%) were stand-alone. During this period of time, the number of stand-alone AF surgeries increased from 552 cases in 2005 to 1041 cases in 2010. The mean age of the stand-alone group was 60 years, and 71% were men. Some 80% of the stand-alone procedures were off pump. The overall operative mortality was 0.74% (1.7% on pump vs 0.5% off pump), the rate of pacemaker implantation was 1%, and the overall complication rate was 16% (28% on pump vs 13% off pump).1358\nThe Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery (AFACT) study compared the outcomes of thoracoscopic surgical AF ablation in 240 patients with advanced AF at a single European center.123 A total of 59% of the patients had persistent AF and 68% had an enlarged LA. One-fourth of these patients had previously failed catheter AF ablation. Patients were randomized to undergo surgical AF ablation alone or combined with epicardial ablation of the four major GP. At 12 months follow-up, no recurrences of AF were observed in 71% and 68% in the GP and control groups, respectively; the incidence of major complications was greater in the group that underwent GP ablation (19% vs 8%, respectively). Major bleeding occurred in nine patients in the GP group, one of whom required sternotomy. Sinus node dysfunction occurred in 12 patients in the GP group and in 4 controls. The authors concluded that GP ablation during thoracoscopic surgery for advanced AF is associated with higher risk and no appreciable improvement in AF control. This center also recently examined the 5-year outcomes of thoracoscopic surgery for AF in 66 patients. A total of 50% of patients experienced no AF recurrences and discontinued AAD therapy at the 5-year follow-up, and 88% of the patients were in sinus rhythm. In this cohort, persistent AF and previous failure of catheter ablation were independently associated with AF recurrence.1359\nSuperior efficacy of a single approach has also been difficult to establish. A systematic review of 48 studies including 3832 patients suggested that the efficacy of bipolar RF was equivalent to the cut-and-sew Maze III technique for stand-alone surgical ablation, as long as both were applied meticulously.1360 Another meta-analysis of 16 published randomized trials indicated that the cut-and-sew Maze III produced slightly better recovery of SR and stroke prevention, but with increased perioperative risk.1361 Definitive recommendations for a surgical approach with or without cardiopulmo-nary bypass await more data.\nUsing a surgical approach with or without cardiopulmonary bypass that creates all, some, or a modification of the maze is reasonable, especially in patients in whom catheter ablation has failed or who are at high risk for an unsuccessful catheter-based result. However, a stand-alone operation should have the ability to create the complete full Maze lesion set, whether it is in a single operation or staged. This approach is especially important for those patients who have persistent AF.\nTherefore, based on the literature and the experience of the writing group members, stand-alone surgical ablation of paroxysmal AAD-refractory AF can be considered for patients who have failed one or more attempts at catheter ablation, and after review of the relative safely and efficacy of catheter ablation vs a stand-alone surgical approach for those who are intolerant or refractory to AAD therapy and prefer a surgical approach (Class IIb, LOE B-NR). For patients with persistent and long-standing persistent AF, stand-alone surgical ablation is reasonable for patients who have failed one or more attempts at catheter ablation, and after review of the relative safely and efficacy of catheter ablation vs a stand-alone surgical approach for those who are intolerant or refractory to AAD therapy and prefer a surgical approach (Class IIa, LOE B-NR, Figure 8). Stand-alone surgical AF ablation is not recommended for patients who have not failed a trial of at least one antiarrhythmic 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