Current State of the Surgical Treatment of Atrial Fibrillation

Surgery of atrial fibrillation (AF) was first described in 1991 by James Cox in what was named the Cox-Maze procedure, and over the years it has been considered the gold-standard treatment, with best results in maintaining sinus rhythm in the long term. Nevertheless, the complexity and aggressivity of the first techniques of cut-and-sew limited the application of this procedure, and few centers were dedicated to AF surgery. In the past years, however, new devices able to ablate atrial tissue with cryotherapy, radiofrequency, or ultrasounds have facilitated this operation. In the mid-term, other energy devices with laser or microwave have been abandoned due to a lack of consistency in getting transmural lesions in a consistent and reproducible manner. Additionally, better knowledge of the physiopathology of AF, with the importance of triggering zones around the pulmonary veins, has started new minimally invasive techniques to approach paroxysmal and persistent AF patients through thoracoscopy. 1. Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting 1% of the general population and with its prevalence increasing with age [1]. Most important, AF has well-documented consequences as disabling symptoms, elevated stroke risk and major risk of congestive cardiac failure, being an independent predictor of death [2]. In summary, it represents a high cost on the health public systems of most developed countries. Surgeons were the first ones to treat AF effectively and reverse it to sinus rhythm. James Cox described a series of surgical procedures known as Cox-Maze technique, between 1988 and 1991, that crystallized in the Cox-Maze III. This surgical approach was directed to divide both right and left atria by a series of cuts and sutures to redirect the electrical impulse to close-end paths, to finalize atrial depolarization, and be ready for the next sinus node impulse. This operation also included the exclusion of both atrial appendages and the isolation of the four pulmonary veins and the posterior wall of the left atrium. Although very effective, with over 91% patients maintaining sinus rhythm at 10 years, few surgical groups performed the Cox-Maze procedure due to the aggressiveness of it, with long suture lines and prolonged myocardial ischemic times [3, 4]. In the last decade, three factors have changed the approach of surgeons to AF: first, a better understanding of the electrophysiological basis of AF. In 1998, Haissaguerre described that most patients with paroxysmal AF have electric triggering zones localized within the