Letter by Maesen et al Regarding Article, “Ablation of Atrial Fibrillation: Patient Selection, Periprocedural Anticoagulation, Techniques, and Preventive Measures After Ablation”

To the Editor:

It is with great interest that we read the article by Link et al¹ in which the authors present an overview of ablation of atrial fibrillation (AF). Among other topics, this review addresses the importance of patient selection by choosing the most appropriate treatment for an individual patient. We strongly agree with the statement that patient selection should be based on shared decision making between the patient and the physician.

In this review,¹ the focus is mainly on transcatheter treatment of AF. However, as stated in the 2012 European Society of Cardiology expert consensus statement on catheter and surgical ablation of AF, stand-alone surgical ablation may be considered in patients with symptomatic AF that is refractory to at least 1 antiarrhythmic drug or who prefer a surgical approach.² It is to be expected that these recommendations will be extended because recent reports on thoracoscopic epicardial surgical AF ablation and hybrid AF ablation (a combination of surgical epicardial and transvenous endocardial ablation) are promising.³ This success might be attributed to the use of bipolar radiofrequency clamping devices, resulting in long-lasting pulmonary vein isolation, and the use of epicardial left atrial appendage closure devices, which also provide electric isolation of the left atrial appendage.⁴ In 2016, Phan et al⁵ published a meta-analysis on thoracoscopic surgical ablation versus catheter ablation of AF. This article clearly illustrates the potential advantages of an epicardial AF ablation on the beating heart.⁵

As mentioned by Link et al,¹ surgery comes with a higher complication rate. However, in the meta-analysis of Phan et al,⁵ the major complication rate was not significantly different between thoracoscopic ablation and catheter ablation of AF. The differences are explained by minor transient complications such as pleural effusion and pneumothoraces, which are related to epicardial access and therefore are higher in the thoracoscopic ablation arm.⁵

Careful consideration of success rate and potential complications in an individual patient is mandatory. Therefore, we advocate that at least patients with nonparoxysmal AF are to be discussed by a heart team consisting of, among others, an electrophysiologist and a rhythm-oriented cardiac surgeon. It is important to acknowledge that current ablation strategies, endocardial or epicardial, still have their limitations based on access and technology. Such a multidisciplinary heart team approach results in a more efficient decision-making process for the therapeutic options for a given patient, whether it is solely catheter based, in need for epicardial access, or a combination of both (hybrid approach).