Surgical treatment of atrial fibrillation: an updated review

The first Cox-maze procedure was performed in 1987, demonstrating the feasibility of a non-pharmacological treatment for atrial fibrillation (AF). Since then, surgery for AF has changed over time, in parallel with technological advances. Replacement of surgical incisions with linear ablation lines made a previously cumbersome procedure accessible to most surgeons, without compromising success. On the other hand, new ablation technologies paved the way for the development of minimally invasive surgery, which may potentially extend the scope of surgery to patients who would otherwise be deemed unsuitable. Nonetheless, literature on minimally invasive surgery is still scarce and randomized clinical trials currently under way are expected to shed light on some controversial issues. Moreover, successful AF treatment will probably rely on close collaboration between surgery and electrophysiology. Indeed, the hybrid procedure, though still in its very beginning, seems to combine the best of catheter and surgical ablation. However, further studies are warranted to determine the effectiveness of this promising strategy, especially in patients with persistent and longstanding persistent AF. Better understanding of AF pathophysiology as well as more accurate preoperative localization of AF triggers will bring about the possibility of tailoring specific lesion sets and ablation modalities to individual patients. This, in turn, will increase recovery and maintenance of sinus rhythm, with significant benefits in long-term outcomes.