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Ann Thorac Surg 2007;83:1324-1325
© 2007 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Isala Klinieken, Groot Wezenland 20, JW Zwolle, 8011 JW, the Netherlands
b Department of Cardiology and Electrophysiology, Isala Klinieken, Groot Wezenland 20, JW Zwolle, 8011 JW, the Netherlands
(Email: hauw.sie{at}hetnet.nl).
I would like to congratulate Stulak and associates [1] on their article that is of importance to those of us involved in the treatment of atrial fibrillation (AF).
The surgical treatment of AF was initiated more than two decades ago with atrioventricular node ablation and evoluated in the 1980s to the left atrial isolation procedure and the corridor operation.
These operations had in common that they were merely designed to achieve a nonphysiological regular rhythm, irrespective of functionality of both atria.
It was not until 1987, when the maze procedure was introduced by Dr Cox. This operation was designed to restore sinus rhythm as well as atrial contractility. Because of the excellent reported results, even now, 20 years later, we still consider the Cox maze procedure the gold standard in the surgical treatment of AF.
However, AF is a complex disease with a variety of forms currently classified as paroxysmal, persistent, and permanent. Each form with its own specific appearance presented as idiopathic or with structural heart disease. Unbiassed assessment of the incidence of arrhythmias both preoperatively and postoperatively is extremely difficult. Therefore proper determination of efficacy and comparison of results of various treatment modalities is almost impossible.
The authors elegantly illustrated the differences in outcome of AF therapy dependent on the method used in analyzing different patient subsets.
Unfortunately there is no uniform method in assessing and reporting patient outcome after any type of invasive treatment of AF. The ideal would be a continuous monitoring of cardiac rhythm to measure AF burden, but this would require implantation of a permanent monitoring device, which is not yet available for clinical practice.
In this study, 160 patients (48%) had paroxysmal AF of whom the arrhythmia was diagnosed as lone AF in 51 patients (32%). To date, in these patients with lone paroxysmal drug resistant symptomatic AF, catheter ablation will be the first choice of therapy. However, with regard to permanent or persistent AF there is limited data on the efficacy of percutaneous approaches to eliminate this arrhythmia.
Furthermore, in this article the maze procedure is reported to be less successful in the group of patients with structural heart disease compared with lone AF patients. In general lone AF patients are considered to have smaller atria.
Stulak and colleagues’ results are consistent with others who have concluded that an increased left atrial size is one of the predictors of late recurrence of AF after the Cox maze procedure. However, should we therefore deny patients with structural heart disease, chronic AF, and left atrial dimension of greater than 50 mm to undergo a Cox maze procedure in addition to their primary cardiac surgical operation or just accept a lower success rate? Thanks to the current available technology that enables us to substantially simplify the maze procedure, the additional operative risk is now negligible.
During follow-up, the risk of stroke was 11% in all survivors and 1.3% in patients with lone AF. Thus patients with structural heart disease seem to remain at high risk for thromboembolic complications. Due to limitations in the monitoring of cardiac rhythm after surgery or any other AF treatment, one can only speculate the prevalence of silent episodes of AF and the risk of stroke.
Finally, indeed there is no agreement whether or not to continue anticoagulation therapy in these patients.
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