Patient-Specific Characteristics Determine Success of Surgical Atrial Fibrillation Ablation in Patients with Persistent Atrial Fibrillation


  • Kimberly N. Hong
  • Mark J. Russo
  • Mathew R. Williams
  • Adeel Abbasi
  • Robert Sorabella
  • Timothy P. Martens
  • Craig R. Smith Jr
  • Mehmet C. Oz
  • Michael Argenziano



Surgical atrial fibrillation ablation (SAFA) has not achieved the efficacy of Cox's original maze procedure, although technical improvements continue to be made. It is possible that biologic factors determine SAFA success. Therefore we examined how patient-specific characteristics affected SAFA success in 353 atrial fibrillation (AF) patients who underwent SAFA at a single institution. Among these, 257 (72.8%) had continuous AF and 96 (27.2%) had intermittent AF. For 297 patients (84.1%) postoperative follow-up was >3 months. We compared SAFA success in patients whose procedure involved only pulmonary vein isolation with those whose procedure involved extensive lesion sets. Multivariate analysis included AF duration, left atrial size, preoperative atrial flutter, concomitant procedures, lesion sets, and energy source. Early SAFA success was classified as freedom from AF between postoperative months 3 and 6, and intermediate success between postoperative months 6 and 12. Receiver-operating characteristic (ROC) curves and stratum-specific likelihood ratios (SSLR) were generated to compare intermediate failure by left atrial size (LAS) thresholds. SAFA was more successful in the intermittent than the continuous AF group (n = 66, 86% vs n = 165, 71%; P = .014). When pulmonary vein isolation was compared only to more extensive lesion sets, there was no difference in success in the intermittent (34, 91% vs 32, 81%; P = .24) or continuous groups (67, 73% vs. 98, 69%; P = .603). Success for intermittent AF patients was not correlated with variables considered; in continuous AF patients, predictors included presence of concomitant mitral valve repair/replacement (P = .075), decreasing LAS (P = .025) and absence of preoperative atrial flutter (P = .001). In the continuous AF group, ROC curves and corresponding areas under the curve (AUC) were 0.60 (0.50-0.71) for failure at 6 months to 1 year. SSLR analysis generated 2 strata for LAS: <8 cm with SSLR = 0.87 (0.74-1.0) and ? 8 cm SSLR = 2.98 (1.07-8.3). In patients with intermittent AF, SAFA achieved acceptable results regardless of tested preoperative and intraoperative variables. In continuous AF, patient-specific characteristics affected success more than intraoperative variables. Failure was more than 3-fold greater in continuous AF patients with an LAS ? 8 cm. In both patient types, more extensive lesion sets were not shown to improve outcomes. Future improvements in SAFA may depend on pharmacologic and/or surgical substrate modification.


Barbuti A, Ishii S, Shimizu T, Robinson RB, Feinmark SJ. 2002. Block of the background K+ channel TASK-1 contributes to the arrhythmogenic effects of platelet-activating factor. Am J Physiol Heart Circ Physiol 282:H2024-30.nChen JM, Levin HR, Michler RE, Prusmack CJ, Rose EA, Aaronson KD. 1997. Reevaluating the significance of pulmonary hypertension before cardiac transplantation: determination of optimal thresholds and quantification of the effect of reversibility on perioperative mortality. J Thorac Cardiovasc Surg114:627-34.nCox JL. 2004. Cardiac surgery for arrhythmias [Review]. J Cardiovasc Electrophysiol 15(2):250-62.nCox JL. 2004. Surgical treatment of atrial fibrillation: a review. Europace. 5 Suppl 1:S20-9.nCox JL, Ad N, Palazzo T, et al. 2000. Current status of the Maze procedure for the treatment of atrial fibrillation. Semin Thorac Cardiovasc Surg12:15-9.nFuster V, Ryden LE, Cannom DS, et al. 2006. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 114(7):e257-354.nGillinov AM, Blackstone EH, McCarthy PM. 2002. Atrial fibrillation: current surgical options and their assessment [Review]. Ann Thorac Surg. 74(6):2210-7.nGillinov AM, Bhavani S, Blackstone EH, et al. 2006. Surgery for permanent atrial fibrillation: impact of patient factors and lesion set. Ann Thorac Surg 82(2):502-13; discussion 513-4.nHaissaguerre M, Jais P, Shah DC, et al. 1998. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. New Engl J Med 3(339):659-66nHanda N, Schaff HV, Morris JJ, Anderson BJ, Kopecky SL, Enriquez-Sarano M. 1999. Outcome of valve repair and the Cox maze procedure for mitral regurgitation and associated atrial fibrillation. J Thorac Cardiovasc Surg 118(4):628-35.nHanley JA, McNeil BJ. 1982. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology143:29-36.nHanley JA, McNeil BJ. 1983. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology148:839-43.nKuo JY. Chen SA. 2007. Is vagal denervation a good alternative or just adjunctive to pulmonary vein isolation in catheter ablation of atrial fibrillation. J Am Coll Cardiol 49(12):1349-51.nMohr FW, Fabricius AM, Falk V, et al. 2002. Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: short-term and midterm results. J Thorac Cardiovasc Surg123:919-27.nPappone C, Santinelli V, Manguso F, et al. 2004. Pulmonary vein denervation enhances long-term benefit after circumferential ablation for paroxysmal atrial fibrillation, Circulation109:327-34.nPierce JC, Cornell RG. 1993. Integrating stratum-specific likelihood ratios with the analysis of ROC curves. Med Decis Making13:141-51.nSenatore G, Stabile G, Bertaglia E, et al. 2005. Role of transtelephonic electrocardiographic monitoring in detecting short-term arrhythmia recurrences after radiofrequency ablation in patients with atrial fibrillation. J Am Coll Cardiol45:873-6.nSie HT, Beukema WP, Ramdat Misier AR, Elvan A, Ennema JJ, Wellens HJ. 2001. The radiofrequency modified maze procedure: a less invasive surgical approach to atrial fibrillation during open-heart surgery. Eur J Cardiothorac Surg 19(4):443-7.nSpitzer G, Richter P, Knaut M, Schuler S. 1999. Treatment of atrial fibrillation in open heart surgery: the potential role of microwave energy. Thorac Cardiovasc Surg47:374-8.nVan Gelder IC, Hemels ME. 2004. The progressive nature of atrial fibrillation: a rationale for early restoration and maintenance of sinus rhythm. Pacing Clin Electrophysiol 27(2):266-82.nWilliams MR, Russo MJ, Oz MC, Argenziano M. Epicardial cardiac ablation using laser energy. Heart Surg Forum. 2006;9(2):E598-600.nWijffels MC, Kirchhof CJ, Dorland R, Power J, Allessie MA. 1997. Electrical remodeling due to atrial fibrillation in chronically instrumented conscious goats: roles of neurohumoral changes, ischemia, atrial stretch, and high rate of electrical activation. Circulation. 96(10):3710-20.nWirth KJ, Paehler T, Rosenstein B, et al. 2003. Atrial effects of the novel K(+)-channel-blocker AVE0118 in anesthetized pigs. Cardiovasc Res 60(2):298-306.n



How to Cite

Hong, K. N., Russo, M. J., Williams, M. R., Abbasi, A., Sorabella, R., Martens, T. P., Smith Jr, C. R., Oz, M. C., & Argenziano, M. (2007). Patient-Specific Characteristics Determine Success of Surgical Atrial Fibrillation Ablation in Patients with Persistent Atrial Fibrillation. The Heart Surgery Forum, 10(6), E468-E472.




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