Commentary: Beyond rhythm control: The increasing appeal of surgical treatment of atrial fibrillation

Abstract

Four decades ago, early work started on surgical treatment of atrial fibrillation (AF) with procedures such as left atrial isolation. This paved the way to one of the most comprehensive and arguably the best treatment for AF, the Cox maze procedure. Since 1990s, catheter ablations, mostly related to the appeal of the less-invasive approach, have slowly taken over the treatment of majority of these patients but with subpar outcomes. Nevertheless, in more recent years, minimally invasive surgical AF ablation has gained momentum with increased use of thoracoscopic and hybrid techniques, supported by clinical trials showing greater rate of success than with catheter ablation. In this issue of the Journal, Kim and colleagues reported their results of bilateral total thoracoscopic ablation (TTA) in 31 patients with drug-refractory or failed previous catheter ablation AF with low left ventricular ejection fraction (LVEF,<50%) performed between 2012 and 2018. The authors showed that the rate of arrythmia-free off antiarrhythmia drugs with a single procedure of TTA was 61.3% at a median follow-up of 32 months. The authors defined freedom from AF by 12lead electrocardiogram or 24-hour Holter monitoring at each follow-up visits. Their results are comparable with the rate of long-term success of TTA in the published literature ranging from 38% to 83% for up to 5 years. More importantly, the authors reported a sustained and significant improvement in LVEF between baseline and longterm follow-up (from 39.7 6.1% to 58.1 7.5%;