Article

Stand-alone AF Surgery: Do the Risks Justify a Class IIA Indication?

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DOI:https://doi.org/10.15420/aer.2017.6.4.S1

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The copyright in this work belongs to Radcliffe Medical Media. Only articles clearly marked with the CC BY-NC logo are published with the Creative Commons by Attribution Licence. The CC BY-NC option was not available for Radcliffe journals before 1 January 2019. Articles marked ‘Open Access’ but not marked ‘CC BY-NC’ are made freely accessible at the time of publication but are subject to standard copyright law regarding reproduction and distribution. Permission is required for reuse of this content.

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

  1. Catheter or surgical ablation should be considered for patients suffering from symptomatic, persistent, or longstanding persistent AF refractory to drugs to improve symptoms.
  2. Surgery should be considered when catheter ablation has failed.
  3. 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

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