EComment. New initiatives to get less invasive approaches for atrial fibrillation back on track

Abstract

I have read with great interest the article by Starck et al. [1]. It seems to me that this report is an important and constructive tool for futures considerations. According to the Expert Consensus Document on Catheter and Surgical Ablation of Atrial Fibrillation [2], the pool of patients in this article was stratified as Class IIa indication with evidence supporting graded as Level C. In other words, surgical ablation for atrial fibrillation (AF) is reasonable for patients undergoing surgery for other indications. The surgical technique described by Cox et al. [3], termed as Cox-maze III procedure, when properly performed in a standard “cut-and-sew” fashion, cures AF in nearly 100% of the patients with or without concomitant disease [4]. However, this is an open procedure performed on a non-beating heart during cardiopulmonary bypass. In addition, despite the high success rate for curing AF, long aortic clamp times have always been the hallmark in this procedure. Simplification of the maze procedure has evolved with the use of different ablation tools such as microwave, cryotherapy, ultrasound, and radiofrequency energy sources to create the atrial lesions instead of employing the incisional technique used in the classic maze procedure. So the original Cox's concept is moving forward, but the procedure as a whole is respected only in appearance. These newer streamlined surgical approaches forget or do not consider the exclusion of the left atrial appendage (LAA) as an integral part of implementation in a global procedure. Indeed, all these less invasive approaches are almost exclusively focused in the pulmonary veins isolation when paroxysmal AF is treated. The high success rate of the Cox-maze III procedure lies not only in curing the AF, but also removing the LAA. As the authors in this article here have emphazised, the primary reason for occluding the LAA is to reduce the stroke risk arising from this anatomical structure. We need new initiatives to get the development of new technological approaches for AF back on track, and I feel that, beyond the elimination of a source of AF triggers, this report opens the way for new and more comprehensive proposals for AF treatment. If the LAA occlusion can be achieved by means of a thoracoscopic approach, as demonstrated by Benussi et al. [5], the central idea discussed here is that LAA occlusion must be understood as complementary to existing minimally invasive current approaches in the treatment of AF. Conflict of interest: none declared.