Member of the 2016 ESC guideline committee, Dr Bart P van Putte of Nieuwegein and Amsterdam, the Netherlands, spoke about how the risks and benefits of the different ablation recommendations should be balanced if there is a Class IIa or a Class I indication.
Dr van Putte started by highlighting the three surgical recommendations with a Class IIa indication in the guidelines:8
- Catheter or surgical ablation should be considered for patients suffering from symptomatic, persistent, or longstanding persistent AF refractory to drugs to improve symptoms.
- Surgery should be considered when catheter ablation has failed.
- Minimally invasive surgery should be considered for patients suffering from persistent or post-ablation AF.
Dr van Putte defined the meaning of stand-alone AF surgery. This term comprises three different types of surgery – thoracoscopic Maze surgery (a thoracoscopic procedure without extracorporal circulation); a Maze-IV procedure done by sternotomy, necessitating extracorporal circulation (a somewhat invasive procedure); and the Maze-IV procedure performed through port access, i.e. a minithoractomy necessitating extracorporal circulation (becoming more of a priority treatment in hospitals). He compared these three procedures with AF ablation, including short- and long-term results, and complication rates.
The overall 1-to-5-year success rates are at least comparable with catheter ablation, which means that the freedom-from-AF rates after 1 to 5 years vary from 65 to 80 %.8 In addition, overall complication rates in most papers are approximately 9 %,13 which is comparable with 11 % for patients who undergo a single-catheter ablation.8
Dr van Putte believes that the risks do justify a Class IIa indication. There seems to be a balanced relationship between risks and benefits. What is the consequence of this Class IIa indication for stand-alone AF surgery for the near future? He thinks more patients will be referred for this treatment, and secondly, more trials will be done. More evidence will result in a change of indication.8