Abstract
Atrial fibrillation (AF) is associated with substantial morbidity, mortality, and economic burden and confers a lifetime risk of up to 25%. Current medical management involves thromboembolism prevention, rate, and rhythm control. An increased understanding of AF pathophysiology has led to enhanced pharmacological and medical therapies; however this is often limited by toxicity, variable symptom control, and inability to modulate the atrial substrate. Surgical AF ablation has been available since the original description of the Cox Maze procedure, either as a standalone or concomitant intervention. Advances in novel energy delivery systems have allowed the development of less technically demanding procedures potentially eliminating the need for median sternotomy and cardiopulmonary bypass. Variations in the definition, duration, and reporting of AF have produced methodological limitations impacting on the validity of interstudy comparisons. Standardization of these parameters may, in future, allow us to further evaluate clinical endpoints and establish the efficacy of these techniques.
Highlights
Atrial fibrillation (AF) is associated with significant morbidity and mortality in both medical and surgical patients
This review describes the evolution of AF surgery, from “cut and sew” to ablative techniques, using novel energy delivery systems
During Maze IV procedure, whilst both left and right arteriotomies are performed surgically, radiofrequency ablation reproduces many of the surgical incisions of Maze III procedure with additional cryoablation added to complete the lesion set to the mitral annulus (Figures 1(a) and 1(b))
Summary
Atrial fibrillation (AF) is associated with significant morbidity and mortality in both medical and surgical patients. His work outlined a series of “cut and sew” lesions which aimed to direct electrical impulses in one direction through the atrium, disrupting the macro reentrant circuits which allow the development and propagation of AF This procedure, whilst effective, was not without its complications, and the resultant inability to mount a tachycardic response to exercise and left atrial dysfunction led to two further adaptations of this procedure culminating in the Cox Maze III lesion set [5]. These modifications resulted in an improvement in the rates of postoperative sinus rhythm and long-term sinus node function, leading to fewer pacemaker implantations after surgery. We discuss its role both as a standalone and concomitant procedure and highlight the current indications and outcomes for the most common techniques described in the literature
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