Atrial fibrillation surgical ablation
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Atrial fibrillation surgical ablation On the Web | |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2] Vendhan Ramanujam M.B.B.S [3]
Overview
A surgical option for some patients with atrial fibrillation is the maze procedure. In this procedure, a series of incisions in a cross like pattern are made on the atria, which blocks the abnormal atrial circuits, hence eliminating the atrial fibrillation. A number of improvements have been made to this surgical procedure since it was first invented.
Indications for Catheter and Surgical Ablation
Ablation of atrial fibrillation is recommended when the primary indication is the presence of symptomatic AF, which is refractory or intolerant to at least one class I or III antiarrhythmic medication. The indications are stratified as class I, class IIa, class IIb, and class III indications.[1]
Class I Indications
In symptomatic paroxysmal AF patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, catheter ablation is recommended.
Class IIa Indications
- In symptomatic persistent AF patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, catheter ablation is reasonable.
- In symptomatic paroxysmal AF patients, prior to initiation of antiarrhythmic drug therapy with either class I or III antiarrhythmic agent, catheter ablation is reasonable.
- In patients who are undergoing surgery for other indications with symptomatic paroxysmal AF, refractory or intolerant to at least one class I or III antiarrhythmic medication, surgical ablation is reasonable.
- In patients who are undergoing surgery for other indications with symptomatic persistent AF, refractory or intolerant to at least one class I or III antiarrhythmic medication, surgical ablation is reasonable.
- In patients who are undergoing surgery for other indications with symptomatic longstanding persistent AF, refractory or intolerant to at least one class I or III antiarrhythmic medication, surgical ablation is reasonable.
- In patients who are undergoing surgery for other indications with symptomatic paroxysmal AF prior to initiation of antiarrhythmic drug therapy with either class I or III antiarrhythmic agent, surgical ablation is reasonable.
- In patients who are undergoing surgery for other indications with symptomatic persistent AF prior to initiation of antiarrhythmic drug therapy with either class I or III antiarrhythmic agent, surgical ablation is reasonable.
Class IIb Indications
- In symptomatic longstanding persistent AF patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, catheter ablation may be considered.
- In patients with symptomatic persistent AF prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication, catheter ablation may be considered.
- In patients with symptomatic longstanding persistent AF prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic medication, catheter ablation may be considered.
- In patients who are undergoing surgery for other indications with symptomatic longstanding persistent AF prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic agent, surgical ablation may be considered.
- In symptomatic paroxysmal AF patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, stand alone surgical ablation may be considered if they have not failed catheter ablation but prefer a surgical approach.
- In symptomatic paroxysmal AF patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, stand alone surgical ablation may be considered if they have failed one or more attempts at catheter ablation.
- In symptomatic persistent AF patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, stand alone surgical ablation may be considered if they have not failed catheter ablation but prefer a surgical approach.
- In symptomatic persistent AF patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, stand alone surgical ablation may be considered if they have failed one or more attempts at catheter ablation.
- In symptomatic longstanding persistent AF patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, stand alone surgical ablation may be considered if they have not failed catheter ablation but prefer a surgical approach.
- In symptomatic longstanding persistent AF patients who are either refractory or intolerant to at least one class I or III antiarrhythmic medication, stand alone surgical ablation may be considered if they have failed one or more attempts at catheter ablation.
Class III Indications
In symptomatic paroxysmal or persistent or longstanding persistent AF patients, prior to initiation of antiarrhythmic drug therapy with a class I or III antiarrhythmic agent, stand alone surgical ablation is not recommended.
Surgical Ablation
Maze Procedure
James Cox, MD, and associates developed the Cox-Maze procedure, an open-heart surgical procedure intended to eliminate atrial fibrillation, and performed the first one in 1987. Maze refers to the series of incisions made in the atria, which are arranged in a maze-like pattern. The intention was to eliminate AF by using incisional scars to block abnormal electrical circuits (atrial macro reentry) that AF requires. This procedure required an extensive series of endocardial (from the inside of the heart) incisions through both atria, a median sternotomy (vertical incision through the breastbone) and cardiopulmonary bypass (heart-lung machine). A series of improvements were made, culminating in 1992 in the Cox maze III procedure, which is now considered to be the gold standard for effective surgical cure of AF. The Cox maze III is sometimes referred to as the traditional maze, the cut and sew maze, or simply the maze.[2]
New Surgical Ablation Procedures
Despite its efficacy, the Cox-Maze procedure did not gain widespread application due to its complexity, technical difficulty, and risks. In an attempt to simplify the operation and make it more accessible, the incisions of the traditional cut-and-sew Cox-Maze procedure has been replaced with linear lines of ablation. They are called as minimaze surgeries. These procedures are less invasive than the Cox-Maze procedure and do not require a median sternotomy (vertical incision in the breastbone) or cardiopulmonary bypass (heart-lung machine). The ablation lines are created using a variety of energy sources including radiofrequency energy, cryoablation, and highintensity focused ultrasound.[3]
Currently the limitations of the new surgical ablation procedure using energy delivery devices is that they have to be deployed through a minimal access incision or port. This constraints on the location and number of ablation lesions that can be performed.
Sources
- 2011 ACCF/AHA/HRS Focused Updates Incorporated Into the ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation [4]
- ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter [5]
References
- ↑ 1.0 1.1 Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, Halperin JL, Le Heuzey JY, Kay GN, Lowe JE, Olsson SB, Prystowsky EN, Tamargo JL, Wann S, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL (2006). "ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society". Circulation. 114 (7): e257–354. doi:10.1161/CIRCULATIONAHA.106.177292. PMID 16908781. Retrieved 2013-01-07. Unknown parameter
|month=ignored (help) - ↑ Cox JL, Schuessler RB, Lappas DG, Boineau JP (1996). "An 8 1/2-year clinical experience with surgery for atrial fibrillation". Ann. Surg. 224 (3): 267–73, discussion 273-5. PMID 8813255.
- ↑ Khargi, K.; Hutten, BA.; Lemke, B.; Deneke, T. (2005). "Surgical treatment of atrial fibrillation; a systematic review". Eur J Cardiothorac Surg. 27 (2): 258–65. doi:10.1016/j.ejcts.2004.11.003. PMID 15691679. Unknown parameter
|month=ignored (help) - ↑ Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA et al. (2011) 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 123 (10):e269-367. DOI:10.1161/CIR.0b013e318214876d PMID: 21382897
- ↑ Estes NA, Halperin JL, Calkins H, Ezekowitz MD, Gitman P, Go AS et al. (2008) ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and the Physician Consortium for Performance Improvement (Writing Committee to Develop Clinical Performance Measures for Atrial Fibrillation): developed in collaboration with the Heart Rhythm Society. Circulation 117 (8):1101-20. DOI:10.1161/CIRCULATIONAHA.107.187192 PMID: 18283199