The modern surgical management of atrial fibrillation

Atrial fibrillation is the most common arrhythmia disorder. Its incidence is especially high among patients with valvular heart disease. Patients with atrial fibrillation are at a six-fold increased risk of stroke and a two-fold increased risk of mortality. Medical management for rhythm control of patients with atrial fibrillation is suboptimal and no better than simple rate management. However, catheter-based therapies are undergoing intense development. The surgical management of atrial fibrillation has undergone considerable innovation in the last two decades; it is the subject of this review. The "cut-and-sew" Cox-maze III is considered the standard for surgical therapy for atrial fibrillation. More recently, several modifications of the Cox maze lesion set and the development of alternative energy sources to achieve transmural atrial lesions have led to a more simplified maze procedure. This simplified left-sided maze procedure has demonstrated excellent efficacy at intermediate and long-term follow-up. Therefore, the modified maze procedure should be offered to all mitral valve surgery patients and potentially to all cardiac surgery patients with a history of paroxysmal, persistent, or permanent atrial fibrillation.