Ablation of Atrial Fibrillation

with Concomitant Cardiac Surgery

A. Marc Gillinov, MD,* and Adam E. Saltman, MD, PhD†

Atrial fibrillation is present in approximately 35% of patients presenting for mitral valve
surgery and in 1 to 6% of adult patients undergoing other forms of cardiac surgery. If left
untreated, atrial fibrillation is associated with increased morbidity, and, in some subgroups,
increased mortality. Therefore, concomitant management of the arrhythmia is indicated in
most cardiac surgery patients with preexisting atrial fibrillation. Although the cut-and-sew
Cox-maze III procedure is extremely effective, it has been supplanted by newer operations
that rely on alternate energy sources to create lines of conduction block. Early and
mid-term results are good with a variety of technologies. Choice of lesion set remains a
matter of debate, but results of ablation appear to be enhanced by a biatrial lesion set.
Targeted areas for improvement in concomitant ablation include acceptance of uniform
standards for reporting results, development of improved technology for ablation and
intraoperative assessment, and creation of instrumentation that facilitates minimally inva-
sive approaches.
Semin Thorac Cardiovasc Surg 19:25-32 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS atrial fibrillation, mitral valve, ablation

A lthough it has long been recognized that atrial fibrillation

(AF) is common in patients presenting for mitral valve
surgery and for other types of cardiac surgery, routine abla-
tion of AF in such patients is a recent phenomenon. This
change in surgical practice is attributable to new data clarify-
ing the pathogenesis and dangers of untreated AF and devel-
opment of new ablation technologies that facilitate ablation.
For cardiac surgical patients presenting with AF, surgeons
now offer a more complete operation that corrects both the
structural heart disease and the AF. Currently, most concom-
itant surgical ablation procedures rely on alternate energy
sources to create lines of conduction block. Available modal-
ities include radiofrequency, microwave, laser, ultrasound,
*The Cleveland Clinic, Cleveland, Ohio.
†Maimonides Medical Center, Brooklyn, NY.
Dr. Gillinov is a consultant to Edwards Lifesciences, LLC and to AtriCure,
Inc. He has received honoraria for speaking from Medtronic, Inc., St.
Jude Medical, Inc., and Guidant Corporation. He receives research sup-
port from the Atrial Fibrillation Innovation Center, a Third Frontier
project funded by the State of Ohio.
Dr. Saltman is a consultant to and has received honoraria for speaking from
Boston Scientific/Guidant Cardiac Surgery. He has received research
support from Guidant, Medical CV, and Estech LICS.
Address reprint requests to A. Marc Gillinov, MD, Surgical Director, The
Center for Atrial Fibrillation, Department of Thoracic and Cardiovascu-
lar Surgery, The Cleveland Clinic Foundation/F24, 9500 Euclid Avenue,
Cleveland, OH 44195. E-mail: gillinom@ccf.org
and cryothermy. The purposes of this review were to (1)
review the rationale for surgical ablation of AF in cardiac
surgical patients; (2) describe the classic maze procedure and
its results; and (3) detail new approaches to surgical ablation
of AF that employ alternate energy sources.
Rationale for Surgical Ablation
AF Prevalence
AF is present in up to 50% of patients undergoing mitral
valve surgery and in 1 to 6% of patients presenting for
coronary artery bypass grafting (CABG) or aortic valve
surgery.1-4 Because AF is particularly common in patients
with mitral valve dysfunction, most studies examining
concomitant ablation focus on this group. As in the gen-
eral population, the prevalence of AF in patients with mi-
tral valve disease increases with increasing patient age
(Fig. 1). In patients with mitral valve dysfunction, AF is a
marker of advanced cardiovascular disease. Compared
with mitral valve patients without AF, those with AF
have higher New York Heart Association functional class,
more severe left ventricular dysfunction, and greater left
atrial enlargement.4-7 Recently published data focusing on
CABG patients confirm similar associations with AF in this
population.4

1043-0679/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. 25

doi:10.1053/j.semtcvs.2007.01.002
26
Figure 1 Prevalence of atrial fibrillation versus age in patients with degenerative mitral valve disease.
AF Dangers
AF is associated with increased mortality and morbidity in
mitral valve and CABG patients.3,4,8 In nonsurgical patients
with degenerative mitral valve disease, AF is an independent
risk factor for cardiac mortality and morbidity.3 In patients
undergoing mitral valve surgery, persistence of postoperative
AF is both a marker and a risk factor for increased mortality;
in addition, AF is associated with morbidity that includes
stroke, other thromboembolism, and anticoagulant-related
hemorrhage.8-11 In some patients, AF causes symptomatic
tachycardia, reduced cardiac output, and, ultimately, tachy-
cardia-induced cardiomyopathy. For these reasons, the pres-
ence of AF should be factored into the operative strategy in
cardiac surgical patients.
The onset of AF is a relative indication for mitral valve
surgery in those with mitral valve dysfunction.2 In most in-
stances, however, mitral valve surgery alone does not ablate
AF.5-7,12 When duration of preoperative AF exceeds 6
months, 70 to 80% of patients will remain in AF if they are
treated by mitral valve surgery alone.5,6,12 In contrast, when
AF has been present for 3 months or less, particularly if it is
paroxysmal, mitral valve surgery results in 80% conversion
to sinus rhythm.5,6 Therefore, ablation should be added to
the mitral valve procedure in any patient with AF greater than
6 months’ duration or in any patient with AF that is not
paroxysmal.
A.M. Gillinov and A.E. Saltman
AF Mechanisms and
Implications for Surgical Ablation
Because the pathogenesis of AF in cardiac surgical patients is
incompletely understood, there is no consensus concerning
ablation strategy in these patients. Clinical presentation of AF
differs between individuals, and current guidelines account
for this by classifying AF as paroxysmal, persistent, or per-
manent.13 Alternatively, AF may be classified as intermittent
or continuous.14 It is certain that, similar to clinical presen-
tation, the pathogenesis of AF varies between patients; how-
ever, the extent to which mechanisms of focal activity and
reentry contribute to the initiation and maintenance of AF is
disputed.15 Although the electrophysiologic causes of AF re-
quire further investigation, the anatomical basis of AF is in-
creasingly clear.
Endocardial electrophysiologic mapping data demonstrate
that the pulmonary veins and posterior left atrium are the
critical anatomic sites in humans with isolated AF.16,17 There
is only limited direct evidence pointing to similar mecha-
nisms of AF in patients with mitral valve disease or other
serious structural heart disease. Nevertheless, available map-
ping studies support the importance of the left atrium as the
driving chamber in mitral valve patients.18-23 In many mitral
patients with permanent AF, regular and repetitive activation
can be identified in the posterior left atrium in the regions of
Ablation of atrial fibrillation
the pulmonary vein orifices and left atrial appendage.18-22
However, the pathophysiology of AF is more complex than
this, as such foci are not identified in all mapped patients, and
some patients also manifest right atrial focal or reentrant
activation.18
Although routine real-time intraoperative mapping is cur-
rently not available to guide AF ablation in cardiac surgery
patients,23 an anatomic approach to ablation based on our
understanding of pathophysiology and empiric results is rea-
sonable. In fact, such an anatomic (rather than map-guided)
approach is rapidly becoming the foundation for catheter-
based ablation of AF.24-26 A left atrial procedure that includes
a box-like lesion around all four pulmonary veins and a le-
sion to the mitral annulus appears to eliminate AF in 70 to
90% of mitral valve patients, suggesting the importance of
the left atrium and pulmonary veins in cardiac surgical pa-
tients.22,27-30
The Maze Procedure
The Cox maze III operation, or maze procedure, is the gold
standard for surgical treatment of AF, and other approaches
to AF ablation should be measured against it.31-33 Based on
the limited understanding of the pathophysiology of AF
available in the 1980s, the biatrial lesion set of the maze
procedure is unmatched in effectiveness. In the maze proce-
dure, multiple left and right atrial incisions and cryolesions
are placed to interrupt the multiple reentrant circuits of AF
(Fig. 2). The maze procedure includes isolation of the pul-
monary veins and posterior left atrium with connecting le-
sions to the mitral annulus and left atrial appendage, inci-
sions and cryolesions in the right atrium, and excision of the
left atrial appendage.
The addition of a classic maze procedure does not increase
operative mortality or morbidity.32-36 However, it is associ-
ated with a 5 to 10% need for implantation of a permanent
pacemaker, most commonly in those with preexisting sinus
Figure 2 Left atrial lesion set of the maze procedure. Small circles
represent pulmonary vein orifices and white oval represents the
mitral valve. Dashed lines represent surgical incisions.
27
node dysfunction or in patients having multi-valve surgery.
Results of a concomitant maze procedure vary somewhat
between different groups, with restoration of sinus reported
in 70 to 96% of patients.34-36
Over time, some patients develop recurrent AF.34-36
Greater left atrial diameter, longer duration of preoperative
AF, and advanced patient age all increase the late prevalence
of AF. Five years after a concomitant maze procedure, the
predicted prevalence of AF is only 5% in mitral valve patients
with a 4-cm left atrium; in contrast, the predicted prevalence
is 15% in similar patients with a 6-cm left atrium. These data
suggest the possibility that earlier operation and left atrial size
reduction in those with left atrial enlargement (⬎6 cm) might
improve results.37-40
The maze procedure is associated with important clinical
benefits in patients with mitral valve disease. Recent data
suggest that restoration of sinus rhythm improves survival in
patients with AF and mitral valve disease.9 This survival ben-
efit requires confirmation by further study. Other advantages
of the maze procedure in mitral valve patients with AF are well
documented, including reduced risks of stroke, other thrombo-
embolism, and anticoagulant-related hemorrhage.9-11,41
The reduced risk of late stroke after a maze procedure
deserves particular emphasis. In the largest series focusing on
late cerebrovascular events, Cox and colleagues noted only a
single late stroke at a mean follow-up of 5 years in 300 pa-
tients having a classic maze procedure.41 This remarkable
freedom from late stroke is likely attributable to both resto-
ration of sinus rhythm in the majority of patients and to
excision of the left atrial appendage, an integral component of
the maze procedure.
These results confirm the safety of the maze procedure, its
efficacy at restoring sinus rhythm, and its associated clinical
benefits, most notably the virtual elimination of late strokes.
Despite these excellent results, the maze procedure has been
relatively underutilized, and today, it is almost obsolete. Most
surgeons have been reluctant to add a maze procedure to the
operative course of patients having mitral valve or other car-
diac surgery. However, with recent advances in our under-
standing of the pathogenesis of AF and development of new
ablation technologies, surgeons are increasingly likely to ab-
late AF using simpler techniques that require only a few
minutes of operative time.
New Approaches to
Surgical Ablation of Atrial Fibrillation
Lesion Sets
Similar to recent approaches to catheter-based ablation, new
surgical techniques for AF ablation are anatomically focused,
concentrating on the creation of lines of conduction block in
the left atrium.42-44 Because the left atrium is opened for
mitral valve procedures, precise creation of lesions is possi-
ble. A variety of lesion sets have been employed to ablate AF
in patients with mitral valve disease. Most include pulmonary
vein isolation, excision or exclusion of the left atrial append-
age, and linear left atrial connecting lesions.42-46 The pulmo-
28
nary veins may be isolated with a box-like lesion as in the
maze procedure, or, alternatively, with separate right- and
left-sided ovals around the pulmonary veins. With the advan-
tage of direct vision, the surgeon can easily create a lesion
from the left pulmonary veins to the mitral annulus; this
lesion improves results, particularly in patients with perma-
nent AF and mitral valve disease.47,48 In patients with left
atrial enlargement (⬎6 cm), we recommend left atrial reduc-
tion, as this may increase restoration of sinus rhythm.37
The issue concerning the creation of biatrial lesion sets
(more closely mimicking the Cox maze III set) versus creating
left atrial lesions alone remains contentious. It is clearly easier
and faster to create a more limited lesion set, yet recent data
indicate that patients undergoing both right and left atrial
treatment have a better long-term result at maintaining sinus
rhythm.49 Through the judicious selection of a single tech-
nology or multiple technologies, as discussed below, it is now
becoming possible to create right-sided lesions without
opening the right atrium or prolonging cardiopulmonary by-
pass or aortic cross-clamp times. In this manner the largest
number of patients can be treated in the most efficacious and
safest fashion.
Review of the Available Energy Sources
The classic method for creating lesions to block conduction is
cutting and sewing tissue. Once the healing process is com-
plete, there is a linear scar composed mostly of collagen with
little or no cellular material. It is not electrically conductive
and the lesion is, by definition, “transmural.” The goal of any
energy source, therefore, is to create a similar scar by expos-
ing tissue to extremes of temperature, inducing thermal in-
jury, coagulation necrosis, and healing.
To produce such an injury, the tissue must be either heated
to 50°C or frozen to ⫺60°C.50,51 The quantity of tissue in-
jured is usually directly proportional to the duration of time
the tissue is held at either extreme of temperature. The vari-
ous energy sources differ mainly in the method by which they
transfer energy to the tissue and how deeply that energy is
conducted into the tissue. A review of characteristics, advan-
tages, and disadvantages of each energy source is presented
in Table 1. (It should be noted that as of 2006 the devices
discussed below are FDA-labeled for the ablation of soft tis-
sues but not for the treatment of AF. The specific treatment of
AF is therefore considered “off-label” usage.) Despite differ-
ent energy sources and methods of application, when applied
to the left atrial endocardium of the arrested heart, the vari-
ous ablation devices are associated with similar safety and
effectiveness.52
Radiofrequency
Radiofrequency current is alternating electrical current that
results in heat propagation by both resistive and passive
mechanisms. Devices used to deliver radiofrequency energy
may be unipolar or bipolar and may be irrigated or dry.
Advantages of bipolar radiofrequency include directional en-
ergy delivery, which minimizes the risk of collateral tissue
damage, and the use of two electrodes, which is purported to
A.M. Gillinov and A.E. Saltman
facilitate determination of transmurality; however, bipolar
systems cannot be used to create all connecting lesions. A
potential benefit of irrigated systems is the possibility of cre-
ating deeper lesions.
The most extensive experience has been with dry unipolar
radiofrequency devices. Employing dry unipolar radiofre-
quency and a variety of different lesion sets, investigators
have reported long-term freedom from AF in 70 to 100% of
patients.52 Analyzing 16 studies that employed dry unipolar
radiofrequency for ablation in 1187 patients, Khargi and col-
leagues found that AF was eliminated in 78% of patients
(reported success ranged from 42 to 92%).52 There have been
several complications attributed to the use of dry unipolar
radiofrequency, the most worrisome being esophageal in-
jury, which is usually fatal.53,54 Employing irrigated unipolar
radiofrequency to create a lesion set similar to that of the Cox
maze III in 200 patients, Sie and colleagues reported approx-
imately 80% freedom from AF at 40 months.55,56 Similar
results have been achieved in large series of patients having
ablation with bipolar radiofrequency.57,58 In most series em-
ploying bipolar radiofrequency, the connecting lesion to the
mitral annulus has been created with cryothermy or other
unipolar energy sources.
Microwave
Microwave generates heat by causing vibration/rotation of
water molecules. The ablation tool consists of an antenna
mounted on a shielded shaft to direct the microwaves to the
site of ablation. There has been extensive experience with the
use of microwave energy to facilitate ablation in concomitant
heart surgery. The Flex 4 and Flex 10 devices can be used to
create long, linear lesions from the endocardial or epicardial
surface. Experimental evidence suggests that greatest tissue
penetration is obtained when the heart is either arrested or
beating and decompressed on cardiopulmonary bypass.59
Microwave can be used to create transmural lesions on the
arrested heart, but transmurality is inconsistently achieved
when applied to the beating, full heart.59 In a prospective
randomized trial, Schuetz and colleagues used a combination
of microwave ablation and atrial size reduction to restore
sinus rhythm in 80% of patients presenting with permanent
atrial fibrillation.60 In another report, microwave and unipo-
lar, irrigated radiofrequency produced equivalent results
(80% freedom from AF at 1 year) when used to reproduce the
lesion set of the Cox maze III procedure.61 As with other
ablation techniques, success of microwave ablation is related
to preoperative duration of AF and left atrial size.62
Laser
Laser relies on high-energy optical waves to heat tissue. Laser
light penetrates the tissue directly with minimal lateral ex-
pansion, creating a discrete, narrow line of ablation. Preclin-
ical results confirm that laser may be used to create lesions
from both the epicardium and the endocardium.63-65 Early
clinical experience with laser-based ablation confirms that
this technology may be used to reproduce virtually all of the
Ablation of atrial fibrillation 29

Table 1 Characteristics, advantages, and disadvantages of methods of tissue ablation

Energy Source Method Advantages
Dry Unipolar RF Contact resistive 1. Well understood
heating technology
2. High tissue
temperatures
3. Flexible delivery system
Irrigated unipolar RF Contact resistive 1. Higher energy delivery
heating at lower operating
temperature
2. Small tip can make
many lesions
3. Complete operator
control over lesion set
Dry bipolar RF Contact resistive 1. Shielded energy source
heating 2. Very localized lesion
3. Possible transmurality
feedback, used to
control energy delivery
4. Rapid ablation
Irrigated bipolar RF Contact resistive 1. Device more malleable
heating than dry bipolar RF
2. Irrigation avoids char
Otherwise as with dry
bipolar RF
Microwave Radiation into 1. Shielded energy source
tissue 2. Flexible probe
3. Penetrates fat well
4. Does not require direct
tissue contact
High-intensity focused Radiation into Same as microwave
ultrasound tissue
Laser Radiation into Same as microwave
tissue
Cryothermy Direct tissue 1. Wide safety margin
freezing (otherwise as with
microwave)
Disadvantages Brand Name
1. Poor temperature ESTECH Cobra®
control
2. Fat does not heat
well or conduct well
3. No transmurality
feedback
4. Dosimetric energy
delivery
5. Collateral damage
from conduction
into surrounding
structures
1. Highly operator- Medtronic Cardioblate®
dependent
(otherwise same as
dry unipolar RF)
1. Fixed device shape, AtriCure®
limiting lesion types
2. Large device,
making minimal
access difficult
Same as dry bipolar RF Medtronic Cardioblate®
(except more flexible BP
delivery system)
1. Dosimetric energy Boston Scientific Flex 4®
delivery and Flex 10®
2. No transmurality
feedback
Same as microwave St. Jude Medical
Epicor™
Same as microwave MedicalCV AtriLaze
1. Question about Cooper Medical
energy “sink” Frigitronics®;
problems Otherwise CryoCath SurgiFrost™
similar to microwave

lesions of the Cox maze III procedure with excellent early and 6-month clinical results document sinus rhythm in 80%
results and no device-related complications.63 of patients who initially had permanent AF.

Ultrasound
High-intensity focused ultrasound uses acoustic energy to
create a transmural lesion when applied to the epicardial
surface. The ablation tool consists of a series of transducers
that are placed on the epicardium but are separated from
direct contact with cardiac tissue by a thin perforated mem-
brane. Ablation proceeds in three stages, beginning with the
endocardial layer and progressing to the epicardium. Preclin-
ical studies have confirmed transmurality with this system66
Cryothermy
Cryothermal atrial lesions may be created with nitrous oxide,
which achieves temperatures of ⫺60°C, and with argon,
which achieves temperatures of approximately ⫺150°C. In
either case, application of the cryoprobe to the tissue results
in formation of a well-demarcated region of frozen tissue,
visible as an ice ball. The cryothermal lesion has extensive
local cell disruption but preservation of tissue architecture
because collagen is spared during the freeze–thaw cycle.67
30
With cryothermy, there is low risk of atrial perforation and
minimal thrombus formation on the ablated tissue.67 Cryo-
thermy probes are best applied to the arrested heart, as cir-
culating blood rapidly rewarms tissue. Like other unipolar
systems, cryothermy devices do not include a mechanism for
transmurality assessment. Rather, a transmural lesion is as-
sumed to be present after a preset time and when an ice ball
is visible on both the endocardium and the epicardium.
Clinical experience with cryothermy has been extensive, as
creation of cryolesions at the mitral and tricuspid annuli is a
component of the standard maze procedure. In addition,
nitrous oxide based cryolesions have been used to replace
incisions of the maze procedure with excellent long-term
results.68 More recently, argon-based cryothermy has been
used to facilitate surgical ablation, with 74 to 95% of patients
free of AF at 6 months to 1 year after ablation.69,70
Challenges and
Future Directions
Advances necessary to improve AF ablation in cardiac surgi-
cal patients include uniform definitions and methods for re-
porting results, improved technology to facilitate ablation
and its intraoperative assessment, and refinement of mini-
mally invasive procedures.
Reporting Results
Standard terminology and methods for reporting results are
absent from the cardiac surgery and electrophysiology liter-
ature, and current reporting is haphazard and subject to crit-
icism.71 Although there are now guidelines for categorizing
the clinical pattern of AF (paroxysmal, persistent, or perma-
nent), these are inconsistently applied. Techniques for posta-
blation rhythm assessment vary, with no generally accepted
standard. Ideally, simple and convenient technology for
long-term and continuous rhythm monitoring will be devel-
oped. Data obtained with such systems could be analyzed in
uniform fashions to determine (1) absolute freedom from AF,
(2) AF burden in individual patients, and (3) prevalence of
AF in treated populations.71
Ablation Technology and
Intraoperative Assessment
Current surgical ablation technology has several limitations.
No single ablation device enables creation of all lesions from
the epicardial aspect with ease of use, absence of collateral
damage, and guaranteed lesion transmurality. In addition,
because we do not yet have the capability to perform real-
time, epicardial mapping in the operating room, we cannot
tailor ablation to patients’ particular electrophysiologic char-
acteristics. Although anatomically based approaches are usu-
ally successful, it is likely that a strategy based on both ana-
tomic and electrophysiologic findings will improve results.
Minimally Invasive Approaches
Although most operations that include both mitral valve sur-
gery and ablation are performed through a sternotomy, it is
A.M. Gillinov and A.E. Saltman
now possible to perform minimally invasive procedures. This
may be achieved via a small right thoracotomy69 or through a
partial upper sternotomy. These procedures have been per-
formed with bipolar radiofrequency, unipolar heat-based
systems, and cryothermy.69,72 However, they are technically
challenging, as minimally invasive or keyhole approaches
using current technology are hampered by difficult access to
the posterior left atrium and left atrial appendage. Refine-
ment in ablation technology is necessary to facilitate wide-
spread application of minimally invasive cardiac surgery with
ablation.
Conclusions
AF is common in patients presenting for cardiac surgery. Left
untreated, AF increases morbidity and jeopardizes survival.
Recent data demonstrate that AF ablation improves outcomes
in these patients. Therefore, virtually all cardiac surgery pa-
tients with AF should have AF ablation. The cut-and-sew
maze procedure is obsolete, replaced by operations that use
alternate energy sources to create lines of conduction block
rapidly with little risk of bleeding. Minimally invasive cardiac
surgery with AF ablation is now possible. Continued
progress will facilitate tailored ablation approaches for indi-
vidual patients and further improve results.
Acknowledgments
Data presented from The Cleveland Clinic Foundation were
drawn from the experience of all staff surgeons and collected
by Kathleen M. Hill, RN and Jeanne Shewchik, RN and ana-
lyzed by Eugene H. Blackstone, MD and Jeevanantham
Rajeswaran, MSc. New statistical methodology to assess suc-
cess of ablation was developed by E.H. Blackstone and J.
Rajeswaran. We thank Tess Knerik for expert editorial assis-
tance.
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