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Editors' Note |
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by W. Randolph Chitwood, Jr., M.D.
Is 80% good enough?
In this update from the Minimally Invasive Surgery Innovation Center, Drs. Song and Puskas have given us superb "state of the art" insight into both current and future surgical therapy for atrial fibrillation (AF). Whether combined with valvular heart disease or as what commonly is called "lone atrial fibrillation", this malady continues to impart major morbidity and mortality. Both surgeons and electrophysiologists have pursued a permanent cure for atrial fibrillation hotly since Dr. Jim Cox developed his eponym operation in the late 1970s. Through successful iterations his procedure became the gold standard with well over a 95% success rate in ablating atrial fibrillation. As Song and Puskas reveal most cardiac surgeons never adopted the Cox MAZE operation because of the perceived complexity. Moreover, only a few centers were willing to combine it with mitral valve surgery. What a wonderful combination this seems to be - restoration of valvular function and normal sinus rhythm? An even more compelling reason for surgical ablation is to reduce the stroke risk in over 2.2 million Americans with AF. Thus, an excellent scientific discovery fell short because of limited dispersion in clinical practice. Was it the operative complexity, the sternotomy access, the mystery of atrial fibrillation, the lack of emphasis on AF side effects, or cardiologist's reluctance to refer patients that thwarted the expansion of the surgical treatment of atrial fibrillation?
The combination of minimally invasive methods, new tissue ablative energy sources, disappointing catheter-based results, and falling coronary surgery volume all have become the springboard for a resurgence of and the dispersion of a renewed interest in AF surgical ablation. As suggested in this update, the race between energy sources is heated (or chilly). Which device will give reproducible transmural tissue ablation with no collateral damage? As reversion from atrial fibrillation remains around 80% with all of these new devices, there still are many questions. Perhaps we have forgotten how to do intra-atrial mapping to confirm in surgical patients what Haissaguerre has proposed as the focal origin of AF. For sure atrial fibrillation emanates from a tissue source and propagates through an inhomogeneous muscular matrix, which is perhaps "up or down" regulated by cellular ion exchanges. Do we need to revisit surgical electrophysiologic mapping? Many of us now are routinely applying these new energy sources using endoscopic, robotic, or direct-vision minimally invasive methods. We are finding good results in lone AF patients as well as mitral valve repair patients. Various ablative techniques have expanded through use of new bipolar radiofrequency devices used through a sternotomy. Still we all seem to have only 80% positive results. Thus there seems to be a "generation gap' between the efficient "cut and sew" MAZE operation of Dr. Cox and our less traumatic truly minimally invasive tissue ablations. Is 80% good enough? The challenges rest upon our shoulders to work out the answers. The full benefit of these operations will become manifest only when surgeons can gain near 100% AF ablation using minimally invasive techniques applied rapidly to select tissues.
Review Recent Advances in Surgery for Atrial Fibrillation by Drs. Howard Song and John Puskas
Join the discussion - Atrial fibrillation ablation: is 80% good enough?
Take the survey - Surgical Treatment of Atrial Fibrillation |
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