Surgical options for treatment of atrial fibrillation.

If we want to improve the outcomes, increase the success and reduce the complication rate of existing treatment strategies in concomitant and stand-alone atrial fibrillation (AF) procedures, we will have to increase our understanding of the pathophysiology, and of the disease, the limitations of current energy sources and ablation catheters, the different possible lesion sets, as well as improve communication between the electrophysiologist and cardiac surgeon. The technical limitations of percutaneous endocardial ablation procedures and the empirical techniques in surgical AF procedures necessitate new and innovative approaches. Surgeons should aim to improve the quality of the lesion set and minimize the invasiveness of existing techniques. The Maze procedure remains the basis upon which most of the more limited concomitant ablation procedures are and will be designed, but in stand-alone patients, recent progress has directed us towards either a single-step or sequential combined percutaneous endocardial procedure with a thoracoscopic epicardial procedure on the beating heart. A dedicated team of electrophysiologists and cardiothoracic surgeons can now work together to perform AF procedures. This can guide us to determine if there is an additional value of limiting the lesion set of the Maze procedure in concomitant surgery, and of an epicardial access in the treatment of stand-alone AF on the beating heart. If so, we will better understand which energy sources, lesion sets and surgical techniques are able to give us a three-dimensional knowledge and a three-dimensional treatment of AF. As a result, we can expect to obtain a higher single procedure long-term success rate with an acceptable low complication rate.