Examining Surgical Ablation for Atrial Fibrillation
Publication Date: March 3, 2017
Last Updated: March 14, 2022
Recommendations
Research Question 1: Does concomitant surgical ablation for atrial fibrillation (AF) increase the incidence of perioperative morbidity?
Recommendation #1. Addition of a concomitant surgical ablation procedure for AF does not increase the incidence of perioperative morbidity.
Class IIa: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because the incidence of perioperative morbidity is not increased by surgical ablation.
Level of Evidence:
Research Question 2A: Does concomitant surgical ablation for AF reduce the incidence of perioperative stroke/transient ischemic attack (TIA)?
Recommendation #2. Addition of a concomitant surgical ablation procedure for AF does not change the incidence of perioperative stroke/TIA.
Class IIa: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because there is no increased risk of perioperative stroke/TIA.
Level of Evidence: Level A
Research Question 2B. Does concomitant surgical ablation for AF reduce the incidence of late stroke/TIA?
Recommendation #3. Overall, addition of a concomitant surgical ablation procedure for AF does not change the incidence of late stroke/TIA, but subgroup analysis of nonrandomized controlled trials found a significant reduction in late stroke/TIA incidence.
Class IIa: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because the incidence of late stroke/TIA is unaffected or decreased by surgical ablation.
Level of Evidence:
Recommendation #4. A surgical procedure that includes concomitant surgical ablation for AF does improve HRQL. Addition of concomitant surgical ablation for AF does improve AF-related symptoms, and this improvement is greater than in patients without surgical ablation for AF.
Class IIa: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because there is significant improvement in HRQL and AF-related symptoms associated with surgical ablation for AF.
Level of Evidence:
Recommendation #5. Addition of concomitant surgical ablation for AF does improve 30-day operative mortality.
Class I: It is recommended to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because there is significant improvement in operative survival associated with surgical ablation.
Level of Evidence: Level A
Research Question 4B: Does concomitant surgical ablation for AF improve long-term survival (>30 days)?
Recommendation #6. Overall, addition of a concomitant surgical ablation procedure for AF improves longterm survival.
Class IIa: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because long-term survival is unaffected or improved by surgical ablation.
Level of Evidence:
Recommendation #7. Overall, hybrid procedures have shown promising results compared with percutaneous catheter ablation in a subgroup of symptomatic patients with AF in whom medical treatment or percutaneous catheter ablation have failed.
Class IIb: Hybrid procedures may be considered as a stand-alone procedure in patients with appropriate indications and by an experienced heart team.
Level of Evidence: Level B-NR
Recommendation #8. Overall, minimally invasive approaches to isolate the pulmonary veins bilaterally have shown promising results compared with percutaneous catheter ablation in a subgroup of symptomatic patients with paroxysmal AF and a small left atrium in whom medical treatment or percutaneous catheter ablation has failed.
Class IIa: It is reasonable to perform stand-alone surgical ablation for pulmonary vein isolation in patients with symptomatic paroxysmal AF and small left atria.
Level of Evidence: Level B-R
Research Question 6: Which surgical ablation devices are associated with reliable transmural lesions?
Recommendation #9. The best evidence exists for the use of bipolar radiofrequency (RF) clamps and cryoablation devices, which have become integral parts of many procedures, including pulmonary vein isolation and the Cox-Maze IV procedure. The use of epicardial unipolar RF ablation outside of clinical trials is not recommended, because its efficacy remains questionable.
Recommendation #1. Addition of a concomitant surgical ablation procedure for AF does not increase the incidence of perioperative morbidity.
Class IIa: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because the incidence of perioperative morbidity is not increased by surgical ablation.
Level of Evidence:
- Level A for deep sternal wound infection, pneumonia, reoperation for bleeding, and renal failure requiring dialysis
- Level B-R for intensive care unit length of stay and total hospital length of stay
- Level B-NR for readmission less than 30 days and renal failure.
Research Question 2A: Does concomitant surgical ablation for AF reduce the incidence of perioperative stroke/transient ischemic attack (TIA)?
Recommendation #2. Addition of a concomitant surgical ablation procedure for AF does not change the incidence of perioperative stroke/TIA.
Class IIa: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because there is no increased risk of perioperative stroke/TIA.
Level of Evidence: Level A
Research Question 2B. Does concomitant surgical ablation for AF reduce the incidence of late stroke/TIA?
Recommendation #3. Overall, addition of a concomitant surgical ablation procedure for AF does not change the incidence of late stroke/TIA, but subgroup analysis of nonrandomized controlled trials found a significant reduction in late stroke/TIA incidence.
Class IIa: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because the incidence of late stroke/TIA is unaffected or decreased by surgical ablation.
Level of Evidence:
- Level A for no change in incidence of late stroke/ TIA (up to 1 year of follow-up after surgery)
- Level B-NR for reduction in incidence of late stroke/TIA (>1 year of follow-up after surgery)
Recommendation #4. A surgical procedure that includes concomitant surgical ablation for AF does improve HRQL. Addition of concomitant surgical ablation for AF does improve AF-related symptoms, and this improvement is greater than in patients without surgical ablation for AF.
Class IIa: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because there is significant improvement in HRQL and AF-related symptoms associated with surgical ablation for AF.
Level of Evidence:
- Level B-R for HRQL
- Level C-LD for AF-related symptoms
Recommendation #5. Addition of concomitant surgical ablation for AF does improve 30-day operative mortality.
Class I: It is recommended to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because there is significant improvement in operative survival associated with surgical ablation.
Level of Evidence: Level A
Research Question 4B: Does concomitant surgical ablation for AF improve long-term survival (>30 days)?
Recommendation #6. Overall, addition of a concomitant surgical ablation procedure for AF improves longterm survival.
Class IIa: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because long-term survival is unaffected or improved by surgical ablation.
Level of Evidence:
- Level A for no change in long-term survival (up to 1 year after surgery)
- Level B-NR for improvement in long-term survival (>1 year after surgery)
Recommendation #7. Overall, hybrid procedures have shown promising results compared with percutaneous catheter ablation in a subgroup of symptomatic patients with AF in whom medical treatment or percutaneous catheter ablation have failed.
Class IIb: Hybrid procedures may be considered as a stand-alone procedure in patients with appropriate indications and by an experienced heart team.
Level of Evidence: Level B-NR
Recommendation #8. Overall, minimally invasive approaches to isolate the pulmonary veins bilaterally have shown promising results compared with percutaneous catheter ablation in a subgroup of symptomatic patients with paroxysmal AF and a small left atrium in whom medical treatment or percutaneous catheter ablation has failed.
Class IIa: It is reasonable to perform stand-alone surgical ablation for pulmonary vein isolation in patients with symptomatic paroxysmal AF and small left atria.
Level of Evidence: Level B-R
Research Question 6: Which surgical ablation devices are associated with reliable transmural lesions?
Recommendation #9. The best evidence exists for the use of bipolar radiofrequency (RF) clamps and cryoablation devices, which have become integral parts of many procedures, including pulmonary vein isolation and the Cox-Maze IV procedure. The use of epicardial unipolar RF ablation outside of clinical trials is not recommended, because its efficacy remains questionable.
a. Empty arrested or beating heart: Recommended ablation devices for pulmonary vein isolation are bipolar RF clamps or reusable/disposable cryoprobes.
b. Beating heart: Bipolar RF clamps are effective to isolate pulmonary veins and recommended with mandatory testing for exit or entrance block.
c. Beating heart: Surface bipolar RF devices may be recommended for free wall linear ablation when lesion integrity can be tested and multiple applications are recommended to achieve adequate lesion depth.
d. Beating heart: Epicardial cryoablation is not recommended, but endocardial cryoablation is recommended for free wall linear ablation because of the high degree of transmurality.
e. Clinical trials of hybrid procedures: only settings where epicardial unipolar RF or unidirectional bipolor RF devices may be applied provided it is accompanied by acute lesion integrity testing.
f. When ablating with any device, coronary arteries should be identified and avoided.
Research Question 7: What is the impact of surgeon experience with surgical ablation on return to sinus rhythm in patients with AF?
Recommendation #10. Training and education should be completed before the performance of surgical ablation. We highly recommend surgeons who are new to surgical AF be proctored by an experienced surgeon for 3 to 5 cases before performing surgical ablation alone.
Class I: Training and education should be considered before the performance of surgical ablation, but the effectiveness of a training program is unclear. More specific research needs to be conducted because there have been limited populations evaluated.
Level of Evidence: Level C
(--)b. Beating heart: Bipolar RF clamps are effective to isolate pulmonary veins and recommended with mandatory testing for exit or entrance block.
c. Beating heart: Surface bipolar RF devices may be recommended for free wall linear ablation when lesion integrity can be tested and multiple applications are recommended to achieve adequate lesion depth.
d. Beating heart: Epicardial cryoablation is not recommended, but endocardial cryoablation is recommended for free wall linear ablation because of the high degree of transmurality.
e. Clinical trials of hybrid procedures: only settings where epicardial unipolar RF or unidirectional bipolor RF devices may be applied provided it is accompanied by acute lesion integrity testing.
f. When ablating with any device, coronary arteries should be identified and avoided.
Research Question 7: What is the impact of surgeon experience with surgical ablation on return to sinus rhythm in patients with AF?
Recommendation #10. Training and education should be completed before the performance of surgical ablation. We highly recommend surgeons who are new to surgical AF be proctored by an experienced surgeon for 3 to 5 cases before performing surgical ablation alone.
Class I: Training and education should be considered before the performance of surgical ablation, but the effectiveness of a training program is unclear. More specific research needs to be conducted because there have been limited populations evaluated.
Level of Evidence: Level C
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Overview
Title
Examining Surgical Ablation for Atrial Fibrillation
Authoring Organization
American Association for Thoracic Surgery