Surgical ablation found to be effective in reducing atrial fibrillation and improving quality of life

New clinical practice guidelines recommend more prominent role for surgery in treatment of Afib.

New clinical practice guidelines have been issued by The Society of Thoracic Surgeons (STS) that include major recommendations for the use of surgical ablation when treating atrial fibrillation (Afib), the most common type of irregular heartbeat. The guidelines, posted online in The Annals of Thoracic Surgery, will appear in the January 2017 print issue.

"These guidelines represent nearly 2 years of effort by some of the nation's leading experts in the surgical treatment of atrial fibrillation," said guidelines co-author Vinay Badhwar, MD, Gordon F. Murray Professor and Chair of the West Virginia University Heart & Vascular Institute. "This important document highlights the increasing global evidence on the safety and efficacy of surgical ablation for the treatment of Afib."

STS believes that the practice of summarizing current scientific evidence into clinical practice guidelines and recommendations may contribute importantly to improving surgical outcomes, as well as the quality of patient care.. In this case, the literature revealed that surgical ablation as a treatment option for Afib has experienced continued development over the last 30 years, with its frequency and success steadily increasing. The guideline writing committee merged these findings into a singular consensus paper to shape practice, concluding that surgical ablation is effective in reducing Afib and improving quality of life, and so deserves a more prominent role in adult cardiac surgery.

In patients with Afib, rapid, disorganized electrical signals cause the two upper parts of the heart (the atria) to quiver. The quivering upsets the normal rhythm between the atria and the lower parts of the heart (the ventricles). As a result, the ventricles may beat fast and without a regular rhythm.

Afib can lead to blood clots, strokes, heart failure, and other heart-related complications. According to the American Heart Association (AHA), untreated Afib doubles the risk of heart-related deaths and is associated with a significantly increased risk for stroke. At least 2.7 million Americans are living with Afib.

"It is recognized that surgical ablation impacts long-term outcomes with improvements in normal heart rhythm, quality of life, and stroke reduction," said Dr. Badhwar. "Current evidence reveals that surgical ablation can be performed without significant impact to major complications or death."

One option for Afib treatment-as the new clinical guidelines recommend-is surgical ablation, also known as the maze procedure. When performing surgical ablation, the surgeon makes very specific and defined lesions in the heart. Scar tissue forms, blocking the abnormal electrical signals while also creating a controlled path for electricity in the heart to follow. The heartbeat should eventually normalize.

Surgical ablation can be done as a standalone procedure or in combination with another heart surgery. In developing these new guidelines, the authors assessed the safety of performing surgical ablation for three surgical approaches: primary open atrial operations where the left atrium, or top chamber of the heart, is already being opened, such as mitral valve repair or replacement and/or tricuspid valve repair; primary closed atrial operations when the left atrium would not otherwise be open, such as coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) operations; and standalone operations when the only goal is to perform surgical ablation to treat Afib.

The new clinical practice guidelines offer evidence-based recommendations that include:

• Surgical ablation for Afib at the time of concomitant mitral operations to restore cardiac rhythm;
• Surgical ablation for Afib at the time of concomitant isolated AVR, isolated CABG, and AVR+CABG operations to restore cardiac rhythm; and * Surgical ablation as a primary standalone procedure to restore cardiac rhythm for symptomatic Afib that is resistant to medication or catheter ablation.

The authors also recommend a multidisciplinary heart team assessment, treatment planning, and long-term follow-up in order to optimize patient outcomes in the treatment of Afib.

"These guidelines may help guide surgeons when faced with a challenging decision on the management of Afib," said Dr. Badhwar. "The guidelines represent an assimilation of the world's literature; they do not supersede the final medical decision of the surgeon. It is important to remember that the ultimate choice of any therapy remains between the patient and their doctor."

Article: The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation, Badhwar V, Rankin JS, Damiano RJ, Gillinov AM, Bakaeen FG, Edgerton JR, Philpott JM, McCarthy PM, Bolling SF, Roberts HG, Thourani VH, Suri RM, Shemin RJ, Firestone S, and Ad N, The Annals of Thoracic Surgery, doi: 10.1016/j.athoracsur.2016.10.076, published online December 2016.