Current Indications for Atrial Fibrillation Surgery

In 2007, international experts in cardiology and thoracic surgery (HRS, EHRA, ECAS, ACC, AHA, and STS) published a consensus statement (Calkins 2007) regarding catheter and surgical ablation of AF. They stated:

In summary, surgery has been performed for 20 years for AF. It plays an important role in selected patients with AF. With present ablation technology, surgery can be performed with low mortality and through limited access incisions. Programs involved in the stand-alone surgical treatment of AF should develop a team approach to these patients, including both electrophysiologists and surgeons, to ensure appropriate selection of patients.
It is the consensus of this Task Force that the following are appropriate indications for surgical ablation of AF:
  • Symptomatic AF patients undergoing other cardiac surgical procedures
  • Selected asymptomatic AF patients undergoing cardiac surgery in whom the ablation can be performed with minimal risk
  • Stand-alone AF surgery should be considered for symptomatic AF patients who prefer a surgical approach, or have failed one or more attempts at catheter ablation, or are not candidates for catheter ablation

Who might benefit from a curative procedure for AF?

Most patients with atrial fibrillation are best managed with a “rate control plus warfarin” strategy, but some are not. For a curative procedure to help, one must:

  • Have ensured that AF is the problem, rather than another arrhythmia such as Atrial Flutter (which is easily treated by catheter ablation)
  • Have already treated underlying causes of AF, such as sleep apnea, thyroid disorders, and excessive alcohol intake
  • Have important symptoms, as the procedures have been shown to reduce symptoms, but not stroke risk or other issues
  • Have already failed antiarrhythmic therapy
  • Have a reasonably high likelihood of long-term maintenance of normal rhythm based on the type of AF you have, the size of the left atrium, and certain other factors

Only a subset of patients have a high likelihood of a good outcome. Good outcome is unlikely if you have:
  • Untreated conditions such as sleep apnea or excessive alcohol
  • Persistent (continuous rather than intermittent) AF
  • Left atrium more than mildly enlarged
  • Decreased heart pumping function (low left ventricular ejection fraction)

Common Misconceptions

Some patients have unrealistic expectations about curative procedures for AF. Some of these expectations are fostered by misinformation on the internet. Common misconceptions include:
  • That warfarin (Coumadin) can be discontinued in all cases after the procedure
  • That the procedures are almost always successful
  • That successful procedures are always permanent
  • That the procedures have very low risk