Thoracoscopic Surgical Treatment of Atrial Fibrillation With Electrophysiologic End Points

Abstract

Since the description of initial surgical treatment of atrial fibrillation (AF) by Cox et al, the original cut-and-sew technique underwent several revisions, culminating in the Cox Maze III procedure, which has been reported to effectively restore sinus rhythm and decrease thromboembolic events in patients with AF.1,2 Article see p 262 After the seminal observation that reported initiation of AF by pulmonary vein arrhythmogenicity3 and subsequent contributions on pulmonary vein (PV) and non–PV-dependent mechanisms in the genesis of AF, percutaneous catheter ablation has rapidly evolved to eliminate both paroxysmal and persistent AF over the last decade. Numerous reports from registries and randomized clinical trials demonstrated the efficacy, safety, and feasibility of catheter ablation to eliminate AF in appropriately selected patients through the use of well-defined clinical and ECG end points with rigorous long-term follow-up. Given the complexity of the classic cut-and-sew Cox Maze procedure and the skill it requires, surgical treatment of AF has also evolved with an emphasis on (1) less invasive approaches that eliminate the need for a sternotomy and cardiopulmonary bypass, (2) tissue ablation using energy sources similar to those commonly used during percutaneous catheter ablation procedures as an alternative to the challenging and more invasive cut-and-sew technique, and (3) ablation strategies that more or less replicate the lesion sets targeted during percutaneous catheter ablation procedures, primarily on the basis of recent advances in the understanding of the mechanisms of AF.4–9 Although commonly referred as “mini-Maze,” most of the currently used surgical approaches utilize energy sources similar to those used in percutaneous catheter ablation procedures and attempt to create lesion sets to isolate the PVs with additional …