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Review
. 2025 Jul 1;67(7):ezaf187.
doi: 10.1093/ejcts/ezaf187.

Surgical ablation of atrial fibrillation with concomitant cardiac surgery: a state-of-the-art review

Mariusz Kowalewski  1   2   3   4 , Emil Julian Dąbrowski  5 , Anna Kurasz  5 , Michał Święczkowski  5 , Giuseppe Maria Raffa  6 , Michał Kawczyński  2 , Luca Aerts  2 , Łukasz Kuźma  1   4   5 , Wojciech Wańha  1   4   7 , Jakub Batko  1   4   8 , Radosław Litwinowicz  4   8   9 , Tomasz Urbanowicz  4   10 , Sebastian Stec  1   11 , Roberto Lorusso  2 , Thorsten Hanke  12 , Bart Maesen  2 , Paolo Meani  4   13 , Daniele Ronco  4   13   14 , Michele Pilato  3 , Francesco Musumeci  3 , Patrick McCarthy  15 , James L Cox  15 , Luigi Pannone  16 , Jose L Merino  17 , Helmut Pürerfellner  18 , Vinay Badhwar  19 , Mark La Meir  20 , Carlo de Asmundis  16 , Gregory Y H Lip  21   22 , Piotr Suwalski  1   4 ; Thoracic Research Centre, endorsed by the European Society of Cardiology Cardiovascular Surgery Working Group
Collaborators, Affiliations
Review

Surgical ablation of atrial fibrillation with concomitant cardiac surgery: a state-of-the-art review

Mariusz Kowalewski et al. Eur J Cardiothorac Surg. .

Abstract

Patients with preoperative atrial fibrillation (AF) undergoing cardiac surgery face a heightened risk of complications and reduced survival. Concomitant surgical ablation (SA) has shown promise in mitigating the arrhythmic burden, prompting guideline upgrades by major scientific societies. However, SA remains underutilized, with performance rates varying between 22% and 48%, depending on the type of procedure. The goal of this narrative review is to summarize current evidence to aid physicians in decision making regarding AF management during cardiac surgery. This review examines existing literature on the prevalence, management and outcomes of AF in cardiac surgery. We assess epidemiological data, summarize trends in clinical practice and review the rationale and techniques for treating AF surgically. Emerging challenges, including barriers to implementation and novel therapeutic advancements, are also discussed. Evidence underscores the detrimental impact of preoperative AF on perioperative and long-term outcomes, including higher mortality, morbidity and thromboembolic risk. Concomitant SA, particularly the Cox-maze IV procedure, significantly improves sinus rhythm restoration, reduces mortality and mitigates complications like stroke. However, the procedure remains underperformed due to concerns about complexity, prolonged operative time and training gaps. Emerging hybrid techniques, novel mapping systems and technologies like pulsed field ablation may enhance outcomes and broaden SA adoption. Concomitant SA is an effective yet underutilized therapy that can improve survival and reduce AF-related complications in cardiac surgery patients. Addressing implementation barriers and integrating advancements in technology and surgical approaches are key to optimizing patient outcomes.

Keywords: Ablation; Atrial fibrillation; Cardiac surgery.

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Figures

None
Graphical abstract
Figure 1:
Figure 1:
Summary or recommendations for ablation during cardiac surgery [, , S28, S29]. AF: atrial fibrillation; APHRS: Asia Pacific Heart Rhythm Society; AVR: aortic valve replacement; CABG: coronary artery bypass grafting; EACTS: European Association of Cardio-Thoracic Surgery; ECAS: European Cardiac Arrhythmia Society; PAF: paroxysmal atrial fibrillation; nPAF: non-paroxysmal atrial fibrillation; SOLAECE: Latin American Society of Electrophysiology and Cardiac Stimulation.
Figure 2:
Figure 2:
Decision-making flowchart for choice of atrial fibrillation ablation technique. Reproduced from McCarthy and Cox [33]. AF: atrial fibrillation; AVR: aortic valve replacement; BA: bi-atrial; CAB: coronary artery bypass; LA: left atrium; LAA: left atrial appendage; LAAO: left atrial appendage occlusion; LSP: long-standing persistent; NOAC: new or novel oral anticoagulant; PAF: paroxysmal atrial fibrillation; preop: preoperative; PVI: pulmonary vein isolation; RH: right heart.
Figure 3:
Figure 3:
Evolution of the Cox-maze procedure.
Figure 4:
Figure 4:
Factors related to sinus rhythm conversion after surgical ablation [S30–S35]. AF: atrial fibrillation; ATA: atrial tachyarrhythmia; CABG: coronary artery bypass grafting; HLoS: hospital length of stay; ICU: intensive care unit; ILR: implantable loop recorder; LA: left atrium; MVS: mitral valve surgery; SR: sinus rhythm; y: year.
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Comment in

References

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