A wider scope on the treatment of atrial fibrillation

Atrial fibrillation (AF) is the most common chronic arrhythmia, and its incidence and prevalence are expected to double within the forthcoming decades [1–3]. Currently, approximately 250,000 patients have AF in the Netherlands, corresponding to a prevalence of 5.5% in patients older than 55 years [4]. The vast majority of those patients can effectively be treated with pharmacological rate or rhythm control. However, there is a small subset of patients that remains severely symptomatic despite treatment with class 1 or 3 antiarrhythmic drugs. For those patients, an invasive approach can be indicated [5, 6]. Historically, this means either a classic Cox-Maze 3 operation or a catheter isolation of the pulmonary veins. The Maze operation, although associated with impressive success rates in some centres, has been abandoned as standalone procedure because of its surgical complexity and the requirement of cardiopulmonary bypass. Catheter ablation for atrial fibrillation is less invasive and is being performed by an increasing number of operators and centres. The procedure has a lower efficacy, particularly in patients with persistent AF or an enlarged left atrium. Moreover, patients are frequently not free of AF after a single procedure, and more than one procedure might therefore be required. In a recent meta analysis, the single procedure success of catheter ablation for AF was 57%, which rose to 71% after multiple procedures in selected patients [7]. The 5-year freedom of AF rates from Bordeaux, one of the most esteemed AF ablation centres in the world, were 29% after a single procedure (40% after one year), which increased to 63% after up to 7 procedures [8]. The volume of the number of catheter ablations for AF in comparison with the number of patients with AF is limited: approximately 2200 catheter ablations for AF were performed in the Netherlands in 2010 (exact data from two centres missing, S.A.I.P. Trines, personal communication), accounting for less than 1% of the number of patients with AF [4]. Bearing this in mind, a thoracoscopic surgical approach toward pulmonary vein isolation was developed in an effort to combine the efficacy reported with surgical ablation with a less invasive approach. There are several small studies showing the feasibility and safety of thoracoscopic pulmonary vein isolation, and a recent systematic review demonstrates that absence of AF recurrence (without the use of antiarrhythmic drugs) is 79% in paroxysmal AF and 69% in persistent AF after a single procedure in the studies published so far [9]. The number of patients and the number of studies are low, but there also seems to be a tendency toward better outcomes when the procedures are performed in a hybrid fashion, that is, by a surgeon and electrophysiologist together. Data from Maastricht and from our own hospital show that in a mixed population of patients with paroxysmal and persistent AF 83 and 86%, respectively, are free of AF without the use of antiarrhythmic drugs one year after the procedure [9–11]. This suggests that a hybrid procedure, where the ablation lines are controlled for conduction block during the procedure, is associated with less AF recurrence. Thoracoscopic or minimal invasive surgery for AF has not been established in the Guidelines as a ‘reasonable alternative’ for either antiarrhythmic drugs or catheter ablation, which might be due to the limited availability of published evidence. The most recent European Society of Cardiology (ESC) Guidelines for AF award a 2B recommendation for standalone minimally invasive surgery for AF only for patients with a previously failed catheter ablation [5]. The 2007 Heart J. R. de Groot (*) Heart Center, Department of Cardiology, Academic Medical Center/University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands e-mail: [email protected] Neth Heart J (2012) 20:143–145 DOI 10.1007/s12471-012-0266-x