J Korean Med Assoc.  2013 Sep;56(9):805-816. 10.5124/jkma.2013.56.9.805.

Surgical treatment of atrial fibrillation

• Yoo JS
• Kim JB
• Lee JW

• KMID: 2015676
• DOI: http://doi.org/10.5124/jkma.2013.56.9.805

Abstract

Despite its proven efficacy in the treatment of atrial fibrillation (AF), the Cox-Maze III procedure has not been widely accepted owing to its complexity and technical difficulty. New ablation technologies have led to the development of various simplified lesion sets, including minimally invasive techniques. Given recent improvements in the percutaneous catheter ablation technique, it seems to have replaced surgical treatment of AF, especially for lone AF. However, suboptimal results of catheter ablation have been reported, and it has been well established that the Cox-Maze III procedure is still the gold standard for surgical AF ablation. Nevertheless, many physicians and patients are reluctant to undergo surgery for lone AF because of its invasiveness. In this regard, improvements in minimally invasive technology should be directed toward replicating the original Cox-Maze III technique and ultimately on performing it on the beating heart without cardiopulmonary bypass. This review provides an overview of the current state of the art and future directions in the surgical treatment of AF. Based on a better understanding of the mechanisms of AF and various treatment techniques, and improvements in diagnostic techniques, the appropriate option among various surgical techniques should be selected tailored to individual patients, making the surgical treatment of AF available to a larger population of patients.

Keyword

Atrial fibrillation; Ablation; Maze procedure

MeSH Terms

Atrial Fibrillation
Cardiopulmonary Bypass
Catheter Ablation
Heart
Humans

Figure

• 

  Figure 1 The traditional cut-and-sew Cox-Maze III procedure (From Cox JL, et al. J Thorac Cardiovasc Surg 1991;101:569-583, with permission from Elsevier) [13].

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  Figure 2 Structure and mechanisms of atrial fibrillation. (A) Schematic drawing of the left and right atria as viewed from the posterior. The extension of muscular fibers onto the pulmonary veins can be appreciated. Shown in yellow are the five major left atrial autonomic ganglionic plexi and axons. Shown in blue is the coronary sinus, which is enveloped by muscular fibers that have connections to the atria. Also shown in blue is the vein and ligament of Marshall, which travels from the coronary sinus to the region between the left superior pulmonary vein (LSPV) and the left atrial appendage. (B) The large and small reentrant wavelets that play a role in initiating and sustaining atrial fibrillation. (C) The common locations of pulmonary veins (red) and also the common sites of origin of non-pulmonary vein triggers (green). (D) Composite of the anatomic and arrhythmic mechanisms of atrial fibrillation. SVC, superior vena cava; RSPV, right superior pulmonary vein; LIPV, left inferior pulmonary vein; RIPV, right inferior pulmonary vein; IVC, inferior vena cava (From Calkins H, et al. Heart Rhythm 2012;9: 632.e21-696.e21, with permission from Elsevier) [10].

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  Figure 3 Similar line patterns, different type of lesions. (A), (B), and (C) show the lines described by Cox in the cut-and-sew Cox-Maze III. (D), (E), and (F) show pattern for a Cox-Maze IV, combining incisions and bipolar radifrequency ablation (dotted lines). LAA, left atrial appendage; MV, mitral valve; CS, coronary sinus (From Castella M, et al. J Thorac Cardiovasc Surg 2008;136:419-423, with permission from Elsevier) [14].

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  Figure 4 Diagram of the left atrial (A) and right atrial (B) ablation procedures using cryoablation (dotted lines). SVC, superior vena cava; LAA, left atrial appendage; PV, pulmonary vein; MV, mitral valve; IVC, inferior vena cava; RAA, right atrial appendage; TV, tricuspid valve; CS, coronary sinus (From Kim JB, et al. Ann Thorac Surg 2011;92:1397-1404, with permission from Elsevier) [22].

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  Figure 5 The Dallas epicardial lesion set for minimal access left atrial maze. 1, 2 and 3 indicates position of the temporary pacing and recording electrodes for intraoperative physiological evaluation to insure complete isolation across each lesion line. LAA, left atrial appendage; PV, pulmonary vein; LA, left atrial (From Edgerton JR, et al. Ann Thorac Surg 2009;88:1655-1657, with permission from Elsevier) [27].

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  Figure 6 A significant difference in cardiac event-free rate was observed between patients with preoperative sinus rhythm and atrial fibrillation (AF) undergoing degenerative mitral valve repair. SR, sinus rhythm; HR, hazard ratio (From Eguchi K, et al. Eur Heart J 2005;26:1866-1872, with permission from Elsevier) [32].

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