Dr. Marc Gillinov discusses the results of a randomized controlled trial from the Cardiothoracic Surgical Trials Network and recommends surgical ablation or maze procedure for patients who are having heart surgery and have pre-existing atrial fibrillation.

What is Atrial Fibrillation?

Atrial fibrillation (AF or AFib) is the most common abnormal heart rhythm. Atrial fibrillation is an irregular, frequently rapid heart rhythm originating in the atria (top chambers of the heart). Instead of the normal situation (normal sinus rhythm) in which a single impulse travels in an orderly fashion through the heart, in AF many impulses begin simultaneously and spread through the atria, causing a rapid and disorganized heartbeat. .

At one time, atrial fibrillation was thought to be a harmless annoyance. However, atrial fibrillation is now recognized as a dangerous condition. Atrial fibrillation doubles the risk of death. It also increases the risk of stroke five to seven times compared to a person without atrial fibrillation. In addition, atrial fibrillation may cause congestive heart failure and uncomfortable symptoms related to a rapid heart rate. Learn more about atrial fibrillation (afib). Advances in ablation (both minimal invasive surgical and catheter) offer the possibility of cure to a large number of patients.

Treatment for atrial fibrillation

The goals of treatment for atrial fibrillation include regaining a normal heart rhythm (sinus rhythm), controlling the heart rate, preventing blood clots and reducing the risk of stroke.

Medical Management of Atrial Fibrillation

Initially, medications are used to treat atrial fibrillation. Atrial fibrillation medications may include:

  • Rhythm control medications (antiarrhythmic drugs)
  • Rate control medications (to slow the heart rate)
  • Coumadin (warfarin - an anticoagulant or blood thinner) to prevent blood clots and stroke

Surgical Treatment for Atrial Fibrillation

Surgical treatment for atrial fibrillation is considered when:

  • Medical therapy does not effectively control or correct atrial fibrillation
  • Medications for atrial fibrillation are not tolerated
  • Anticoagulants (coumadin/warfarin) can not be taken
  • Blood clots, including strokes, occur

Minimally invasive surgery is an option for many patients with atrial fibrillation. Surgical treatment for atrial fibrillation also may be considered when surgery is needed to treat a coexisting heart condition, such as valve or coronary artery disease.

Evaluation

To determine if surgical treatment for atrial fibrillation is appropriate, a thorough evaluation will be performed, which includes:

  • A review of your medical history
  • Echocardiogram (echo)
  • Complete physical examination
  • Holter monitor test
  • Electrocardiogram (ECG)
  • Other tests as needed

After the evaluation, the surgeon will discuss your treatment options and together, you will determine if you are a candidate for surgery.

Who is a candidate for atrial fibrillation surgery?

Dr. Marc Gillinov discusses the results of arandomized controlled trial from the Cardiothoracic Surgical Trials Network and recommends surgical ablation or maze procedure for patients who are having heart surgery and have pre-existing atrial fibrillation.Cleveland Clinic surgeons have the nation's largest experience in the ablation (cure) of atrial fibrillation. Using the very latest technology, including advanced surgical robotics, Cleveland Clinic heart surgeons can now extend treatment to virtually all patients with atrial fibrillation. Surgical treatment for atrial fibrillation is termed a "Maze" procedure or ablation; other commonly used terms include "mini-Maze" or pulmonary vein isolation.While variations of these procedures are common, at Cleveland Clinic we believe that best results are obtained by using less invasive approaches to perform a procedure that closely resembles the classic Maze procedure. Patients considered for surgical ablation fall into two groups:

  1. Patients with isolated atrial fibrillation - may be candidates for minimally invasive (robotically assisted or "keyhole") treatment approaches
  2. Patients with atrial fibrillation who require heart surgery for other reasons, most commonly to treat coronary artery disease or valvular heart disease.

Robotically Assisted and Minimally Invasive Surgery for Patients With Isolated Atrial Fibrillation

Currently, most patients with atrial fibrillation are candidates for minimally invasive surgical ablation. Approaches include robotically assisted and keyhole surgery. Currently, advanced surgical robotics can be used to create all of the lesions of the classic maze procedure; the maze procedure is the surgical ablation approach with the greatest long-term success in treating atrial fibrillation. The robotically-assisted maze procedure includes creation of lines of conduction block (scar tissue) that block the abnormal impulses that cause atrial fibrillation, enabling restoration of normal sinus rhythm. The lines of conduction block are created using cryothermy (freezing) or radiofrequency energy. Robotically assisted surgical ablation also includes exclusion of the left atrial appendage, the primary source of strokes in patients with atrial fibrillation.The robotically assisted maze procedure is appropriate for patients with highly symptomatic atrial fibrillation, patients in whom catheter ablation has failed, and patients who have a history of stroke or other blood clots. The success rate is approximately 80% to 90%, varying with patient characteristics.

Patients With Atrial Fibrillation Who Require Other Heart Surgery

Atrial fibrillation is very common in patients who require heart surgery for other reasons (such as mitral valve surgery, aortic valve surgery, coronary artery bypass grafting, and other surgical procedures). Recent data from Cleveland Clinic demonstrate that untreated atrial fibrillation in such patients increases mortality (see graphs below). Therefore, in patients with a history of atrial fibrillation, Cleveland Clinic surgeons treat the atrial fibrillation during other types of cardiac surgery.

Survival After Heart Surgery

Atrial fibrillation surgery combined with mitral valve repair

Patients with untreated preoperative AF (blue lines) have reduced survival. Now, all AF is ablated at the time of heart surgery.

When patients with AF have valve or bypass surgery, surgeons create a classic Maze lesion set on the heart using either radiofrequency energy or cryothermy. This generally adds 15 minutes to the operative procedure and does not increase operative risk. Sinus rhythm is restored in 75% to 85% of patients, depending upon patient characteristics.

Selected patients with valvular heart disease and atrial fibrillation may be candidates for a minimally invasive approach that enables treatment of both conditions.

This information is about procedures and may include instructions specific to Cleveland Clinic. Please consult your physician for information pertaining to your specific procedure.

Reviewed: 05/15