The most beneficial options for patients with arrhythmia and concomitant structural heart disease: a review

Atrial fibrillation (AF) substantially increases the risks of heart failure, stroke, and death, reduces patient quality of life and productivity, and increases healthcare resource utilization and costs. Many of the comorbidities present in cardiac surgery patients overlap with the risk factors for AF. AF can precede and contribute to the development of structural heart disease or can progress as atrial pathology worsens, creating substrate for AF across both atria. Published evidence makes clear that not treating pre-existing AF has negative consequences for patients undergoing cardiac surgery. Therefore, concomitant treatment of AF during cardiac surgery is paramount. The objective of this review is to provide expert perspective on current treatment options for patients with AF and concomitant structural heart disease, including a discussion of relevant literature. Ideally, bi-atrial Cox-Maze surgical ablation will be performed, which is supported by long-term data on its benefits including sinus rhythm restoration, reduced anti-arrhythmic drug (AAD) dependency, and mortality. When Cox-Maze is not appropriate either due to patient or operator factors, there is a role for limited lesion sets that prioritize the left atrial pathology and give primacy to isolation of the left atrial posterior wall and pulmonary veins (PVs). Always, effective closure of the left atrial appendage must be included. Consensus guidelines recommend surgical ablation to treat AF in patients with structural heart disease, which should be part of the comprehensive management of patients with heart disease requiring intervention accompanied by AF.