New STS Guidelines Call for More Surgical AF Ablation

Marlene Busko

December 23, 2016

MORGANTOWN, WV — The Society of Thoracic Surgeons has released clinical practice guidelines for surgical ablation of atrial fibrillation (AF) and urges     greater use of the technique to better patient care. They were published online by lead author Dr Vinay Badhwar (West Virginia University, Morgantown) and colleagues December 19, 2016 in the    Annals of Thoracic   Surgery[1].

The guidelines review current knowledge and provide recommendations for three clinical scenarios: when surgical ablation for AF is done at the same time as     mitral-valve surgery, at the same time as aortic-valve surgery or CABG, or as a stand-alone procedure.

However, they also call for more surgical ablation of AF because "given that [surgical ablation] can currently be applied without increase in operative     risk of mortality or major morbidity and that benefits to long-term rhythm control and quality of life appear consistent, the more frequent performance of     guideline-directed [surgical ablation] may improve patient outcomes."

Asked to comment to heartwire from Medscape, electrophysiologist Dr     Sanjay Dixit (University of Pennsylvania and Philadelphia VA Medical Center) sees the value of performing ablation for AF at the same time as other open-heart surgery but questions the recommendation for standalone surgery.

"AF at the end of the day is a quality-of-life arrhythmia; it's not a life-threatening illness," Dixit said. "Do you address it by a procedure that is     minimally invasive, or with a procedure that can sometimes be a lot more invasive than the disease itself?

"One of the reasons why stenting and angioplasty has become so popular" compared with CABG, Dixit continued, "is because you can achieve the same end point     with much less morbidity. It’s a very similar analogy for AF, too."

Evolving Surgical Procedure

Dr James Cox completed the first ablation procedure, Maze 1, in 1987, and now there is the Cox-Maze IV, which uses cryoablation, Dr J Scott Rankin (West     Virginia University, Morgantown) pointed out to heartwire.

There has been a growing consensus about how to perform the operation and what to expect. Moreover, operating times have been reduced, and "it is clear     that [surgical ablation] is effective in reducing AF and improving quality of life," the group writes.

Five-year data     from surgical ablation for AF performed concomitantly with mitral-valve surgery showed that "it works, and it's going to be stable and effective long term,"     Rankin said. "It is possible that data from continued longitudinal follow-up of larger patient cohorts will further illuminate the survival benefit of     [surgical ablation]," the group adds.

"Reasonable" for Select Patients

Dixit observed that the 2014 American Heart Association (AHA)/American College of Cardiology(ACC)/Heart Rhythm Society (HRS) guideline[2] for   the     management of patients with AF were developed for catheter ablation. But they briefly mention surgical AF, stating: "An AF surgical ablation procedure is     reasonable for selected patients with AF undergoing cardiac surgery for other indications (class IIa, level C)" and "a stand-alone AF surgical ablation     procedure may be reasonable for selected patients with highly symptomatic AF not well managed with other approaches (class IIb, level B)."

However, "surgical ablation for AF—[even] off pump, minimally invasive surgery—is still a very invasive procedure relative to catheter ablation, and     there is a certain amount of recovery time that's needed after a procedure like that," Dixit said.

Moreover, patients may need a pacemaker if some surgical lesions damage the normal pacing of the heart. The guidelines note that in a registry study,     "patients who underwent surgical ablation . . . had a 26% greater likelihood of requiring a permanent pacemaker," although some meta-analyses found no     risk.

There is also much more data from patients who have undergone catheter vs surgical ablation for AF, and trials of surgical ablation have not     consistently validated the electrical block. Not many trials have compared the two techniques in a rigorous way, Dixit noted.

"Until there are compelling data from rigorous prospective, randomized studies that compare the two and show clear benefit from surgical over     catheter ablation, it is probably not good clinical practice to expose your patient to such an invasive procedure; on the other hand, if the patient is     getting open-heart surgery for some other reason and if they have atrial fibrillation, then it is quite reasonable to have them undergo surgical ablation     during that open-heart surgery," Dixit summarized.

Executive Summary of Recommendations With Strongest Evidence

  • Surgical ablation for AF can be performed without additional risk of operative mortality or major morbidity and is recommended at the time of     concomitant mitral operations to restore sinus rhythm (class I, level A).

  • Surgical ablation for AF can be performed without additional operative risk of mortality or major morbidity and is recommended at the time of     concomitant isolated aortic-valve replacement, isolated coronary artery bypass graft surgery, and aortic-valve replacement plus coronary artery bypass     graft operations to restore sinus rhythm (class I, level B nonrandomized).

  • Surgical ablation for symptomatic AF in the absence of structural heart disease that is refractory to class I/III antiarrhythmic drugs or catheter-based     therapy or both is reasonable as a primary stand-alone procedure, to restore sinus rhythm (class IIA, level B randomized).


Rankin disclosed a financial relationship with AtriCure. Disclosures for the coauthors are listed in the guideline.

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