Surgical treatment for isolated atrial fibrillation: Minimally invasive vs classic cut and sew maze

Objective: We sought to compare outcomes after two surgical approaches for the treatment of atrial fibrillation (AF): a minimally invasive, staged hybrid approach combining surgery with catheter ablation, [Hybrid Maze (HM)] and the classic cut and sew Maze (CM). Methods: From April 2004 to March 2010, 63 stand-alone AF procedures were performed by two surgeons at a single center and followed up for ≥6 months. CM was offered to all patients. After July 2007, patients were also prospectively offered a two-stage HM: stage 1 = a beating heart bipolar radiofrequency pulmonary vein isolation and left atrial appendage ligation; stage 2 = transvenous catheter ablation connecting the pulmonary veins to each other and the mitral annulus when AF was present after stage 1. Outcomes were compared between 25 HM and 38 CM using χ² or Fisher exact test analysis. Results: Postoperatively, there was no difference in 30-day mortality (0%), complications (4% HM vs 18% CM), or median length of stay (5 days). At last follow-up, 88% of HM and 95% of CM were free from AF; 80% of HM and 90% of CM were free from AF and antiarrhythmic medication (P ≥ 0.3). Twenty-nine percent of HM required a subsequent catheter ablation (stage 2) when compared with 8% of the CM patients (P = 0.04). Freedom from AF and antiarrhythmic medication at 1 year was 52% for the HM and 87.5% for the CM (P = 0.004). Conclusions: In AF patients reluctant to undergo a CM but willing to undergo subsequent catheter ablation, a minimally invasive approach is a reasonable strategy. Because pulmonary vein isolation alone may be sufficient in two-thirds of patients and delayed reconnection is common, an interval two-stage hybrid approach may prove preferable over a one-stage combined hybrid approach; however, successful sinus restoration may take longer with this approach.