Surgical ablation of atrial fibrillation after the PRAGUE-12 study: more questions than answers

Abstract

This editorial refers to ‘Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study’, by P. Budera et al. , doi:10.1093/eurheartj/ehs290 No doubt surgical research has paved the way to curative treatment of cardiac arrhythmias. Long before the idea of catheter ablation was born, accessory atrioventricular pathways were interrupted by surgical knives, ventricular tachycardia was successfully treated by endocardial resection or scar circumcision, and even the first successful approaches to cure atrioventricular nodal re-entrant tachycardia were done in the surgical operating theatre. However, for these types of arrhythmias, surgical procedures are nowadays performed very rarely, mainly because of the tremendous success of catheter ablation. In atrial fibrillation (AF), current interventional treatment concepts and strategies would have been impossible without the milestone work of cardiac surgeons. The most important contribution came from James Cox and colleagues who established the Maze operation, the first curative treatment option for AF patients.1 In an attempt to replicate the Maze procedure with percutaneous catheters, John Schwarz initiated the development of catheter ablation procedures for AF in the early 1990s. Subsequently, and step by step, techniques and technologies were improved, and today catheter ablation is established as a leading treatment strategy for symptomatic patients with AF. In contrast, today stand-alone surgical ablation of AF does not play such a significant role. As indicated in a recent survey, failed catheter ablation currently is the most frequent indication for stand-alone surgical ablation.2 When compared with catheter ablation, surgical procedures are more invasive, more complex and complicated, and also more expensive. However, many patients with an indication for cardiac surgery because of coronary artery disease or valvular heart disease have or even suffer from …