Surgical ablation of atrial fibrillation with concomitant cardiac surgery: a state-of-the-art review

Patients with preoperative atrial fibrillation (AF) undergoing cardiac surgery face a heightened risk of complications and reduced survival. Concomitant surgical ablation (SA) has shown promise in mitigating the arrhythmic burden, prompting guideline upgrades by major scientific societies. However, SA remains underutilized, with performance rates varying between 22% and 48%, depending on the type of procedure. The goal of this narrative review is to summarize current evidence to aid physicians in decision making regarding AF management during cardiac surgery. This review examines existing literature on the prevalence, management and outcomes of AF in cardiac surgery. We assess epidemiological data, summarize trends in clinical practice and review the rationale and techniques for treating AF surgically. Emerging challenges, including barriers to implementation and novel therapeutic advancements, are also discussed. Evidence underscores the detrimental impact of preoperative AF on perioperative and long-term outcomes, including higher mortality, morbidity and thromboembolic risk. Concomitant SA, particularly the Cox-maze IV procedure, significantly improves sinus rhythm restoration, reduces mortality and mitigates complications like stroke. However, the procedure remains underperformed due to concerns about complexity, prolonged operative time and training gaps. Emerging hybrid techniques, novel mapping systems and technologies like pulsed field ablation may enhance outcomes and broaden SA adoption. Concomitant SA is an effective yet underutilized therapy that can improve survival and reduce AF-related complications in cardiac surgery patients. Addressing implementation barriers and integrating advancements in technology and surgical approaches are key to optimizing patient outcomes.