Why do most patients with atrial fibrillation referred for other cardiac surgery not receive concomitant ablation? A plea for a more aggressive surgical approach

colleagues 2 reported the results from St Louis with the Cox-Maze III procedure. The average crossclamp time was 90 minutes for a lone Maze III procedure, with the majority of these patients undergoing operation by the originator of this operation, Dr James Cox. In the hands of less expert surgeons, this procedure often required even more time. The mortality rate was 2% with a major complication rate of 12%. With the introduction of the ablation-assisted Maze IV procedure in 2004, there has been a dramatic decrease in both the difficulty of the operation and the time required to complete the full lesion set. 3 In comparing our experience with the stand-alone Cox-Maze IV with the Cox-Maze III procedure, we found that the crossclamp time was nearly cut in half, with a significant decrease in the major complication rate from 10% to 1%. 4 By using ablation devices to simplify the procedure, this operation can now be widely applied to a broader spectrum of patients with excellent results. However, few reports have looked at the safety and efficacy of the Cox-Maze procedure in high-risk patients. In this excellent report examining their single-center results in 370 patients, Dr Ad and colleagues found no significant differences in morbidity or mortality among the low-risk, intermediate-risk, and high-risk patients. 1 Moreover, the procedure had similar efficacy in terms of restoration of sinus rhythm in all of the groups. These important data hopefully will lead to surgeons having a more aggressive attitude to performing Maze procedures in patients referred for other cardiac surgery. There is overwhelming evidence that surgeons are still reluctant to perform concomitant surgical ablation. In studies examining the Society of Thoracic Surgeons database, only approximately 20% to 39% of patients with atrial fibrillation have surgical ablation at the time of surgery. 5 Although this may have been appropriate with the historical Cox-Maze III procedure, it ignores the advances that have occurred with the introduction of both ablation devices and less-invasive approaches. It is time for surgeons to reassess their preconceptions and be more open to performing ablation for atrial fibrillation at the time of concomitant cardiac surgery. As surgeons, we have the unique opportunity to restore sinus rhythm and improve the quality of life in these patients. The Cox-Maze procedure remains the single most efficacious intervention for atrial fibrillation. This report and others have provided evidence that both low-risk and high-risk patients benefit in a similar fashion. 1 Hopefully, surgical practice will begin to reflect these advances, and more patients will be thought to be candidates for this important therapeutic intervention. There are 2 caveats that need to be emphasized regarding this recommendation. First, these results are from a single center, in which a very experienced surgeon performed the majority of the procedures. Whether similar results can be obtained at less-experienced centers remains to be established. The superb outcomes in this report emphasize the importance of both surgeon experience and defining late outcomes. 1 This is an operation in which success or