The efficacy of intraoperative atrial radiofrequency ablation for atrial fibrillation during concomitant cardiac surgery—the Surgical Atrial Fibrillation Suppression (SAFS) Study

  • Rick A. Veasey
  • Oliver R. Segal
  • Janet K. Large
  • Michael E. Lewis
  • Uday H. Trivedi
  • Andrew S. Cohen
  • Jonathan A. J. Hyde
  • A. Neil Sulke



Studies assessing radiofrequency ablation (RFA) for atrial fibrillation (AF) performed at the time of concomitant cardiac surgery have reported high success rates. The efficacy of this treatment has primarily been determined by a single electrocardiogram (ECG) or 24-h Holter monitor at follow-up. We sought to assess the true efficacy of this procedure using prolonged cardiac rhythm monitoring.


One hundred patients with paroxysmal (n = 47) and persistent AF (n = 53) requiring cardiac surgery were enrolled. Patients were clinically reviewed 6 weeks post-operatively and were monitored with 7-day Holter with full disclosure, 6 months post-surgery. A cohort of 50 patients also underwent 7 day Holter monitoring preoperatively. AF recurrence was defined as >30 s of AF.


At 6 months, 75% of patients were in sinus rhythm according to a single ECG. However, only 62% of patients were free from AF on 7-day Holter; all AF episodes in these patients were asymptomatic. The procedure resulted in a significant decrease in AF burden from 56.2% at baseline to 27.5% at 6 months follow-up, (p < 0.001). Predictors of AF recurrence were (1) pre-operative AF duration; (2) persistent compared with paroxysmal AF; (3) increasing left atrial diameter and (4) requirement for mitral valve surgery.


Surgical RFA for the treatment of AF, during concomitant cardiac surgery, is a successful procedure and significantly reduces AF burden. However, 13% of patients have asymptomatic AF episodes only identified with continuous monitoring. This has important implications for post-operative anti-arrhythmic and anticoagulant management and for the definition of surgical AF ablation success.


Atrial fibrillation Surgical RF ablation Prolonged Holter monitoring Cardiac surgery 


Conflicts of Interest

None declared




  1. 1.
    Dewilde, S., Carey, I. M., Emmas, C., Richards, N., & Cook, D. G. (2006). Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care. Heart, 92(8), 1064–1070.PubMedCrossRefGoogle Scholar
  2. 2.
    Savelieva, I., & Camm, A. J. (2001). Clinical trends in atrial fibrillation at the turn of the millenium. Journal of Internal Medicine, 250(5), 369–372.PubMedCrossRefGoogle Scholar
  3. 3.
    (1994) Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 154(13):1449–57.Google Scholar
  4. 4.
    Benjamin, E. J., Wolf, P. A., D’Agostino, R. B., Silbershatz, H., Kannel, W. B., & Levy, D. (1998). Impact of atrial fibrillation on the risk of death: The Framingham Heart Study. Circulation, 98(10), 946–952.PubMedGoogle Scholar
  5. 5.
    Elahi, M., Hadjinikolaou, L., & Galinanes, M. (2003). Incidence and clinical consequences of atrial fibrillation within 1 year of first-time isolated coronary bypass surgery. Circulation, 108(Suppl 1), II207–II212.PubMedGoogle Scholar
  6. 6.
    Feinberg, W. M., Blackshear, J. L., Laupacis, A., Kronmal, R., & Hart, R. G. (1995). Prevalence, age distribution, and gender of patients with atrial fibrillation. Analysis and implications. Archives of Internal Medicine, 155(5), 469–473.PubMedCrossRefGoogle Scholar
  7. 7.
    Cox, J. L., Jaquiss, R. D., Schuessler, R. B., & Boineau, J. P. (1995). Modification of the maze procedure for atrial flutter and atrial fibrillation. II. Surgical technique of the maze III procedure. The Journal of Thoracic and Cardiovascular Surgery, 110(2), 485–495.PubMedCrossRefGoogle Scholar
  8. 8.
    Cox, J. L., Schuessler, R. B., & Boineau, J. P. (2000). The development of the Maze procedure for the treatment of atrial fibrillation. Seminars in Thoracic and Cardiovascular Surgery, 12(1), 2–14.PubMedGoogle Scholar
  9. 9.
    Sundt, T. M., III, Camillo, C. J., & Cox, J. L. (1997). The maze procedure for cure of atrial fibrillation. Cardiology Clinics, 15(4), 739–748.PubMedGoogle Scholar
  10. 10.
    Chen, M. C., Chang, J. P., & Chang, H. W. (2004). Preoperative atrial size predicts the success of radiofrequency maze procedure for permanent atrial fibrillation in patients undergoing concomitant valvular surgery. Chest, 125(6), 2129–2134.PubMedCrossRefGoogle Scholar
  11. 11.
    Halkos, M. E., Craver, J. M., Thourani, V. H., Kerendi, F., Puskas, J. D., Cooper, W. A., et al. (2005). Intraoperative radiofrequency ablation for the treatment of atrial fibrillation during concomitant cardiac surgery. The Annals of Thoracic Surgery, 80(1), 210–215.PubMedCrossRefGoogle Scholar
  12. 12.
    Raman, J., Ishikawa, S., Storer, M. M., & Power, J. M. (2003). Surgical radiofrequency ablation of both atria for atrial fibrillation: Results of a multicenter trial. The Journal of Thoracic and Cardiovascular Surgery, 126(5), 1357–1366.PubMedCrossRefGoogle Scholar
  13. 13.
    Chiappini, B., Martin-Suarez, S., Loforte, A., Arpesella, G., Di, B. R., & Marinelli, G. (2004). Cox/Maze III operation versus radiofrequency ablation for the surgical treatment of atrial fibrillation: A comparative study. The Annals of Thoracic Surgery, 77(1), 87–92.PubMedCrossRefGoogle Scholar
  14. 14.
    Calkins, H., Brugada, J., Packer, D. L., Cappato, R., Chen, S. A., Crijns, H. J., et al. (2007). HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: Recommendations for personnel, policy, procedures and follow-up. A report of the heart rhythm society (HRS) task force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm, 4(6), 816–861.PubMedCrossRefGoogle Scholar
  15. 15.
    Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., et al. (2006). ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation–executive summary: A report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation). Journal of the American College of Cardiology, 48(4), 854–906.PubMedCrossRefGoogle Scholar
  16. 16.
    Sueda, T., Imai, K., Ishii, O., Orihashi, K., Watari, M., & Okada, K. (2001). Efficacy of pulmonary vein isolation for the elimination of chronic atrial fibrillation in cardiac valvular surgery. The Annals of Thoracic Surgery, 71(4), 1189–1193.PubMedCrossRefGoogle Scholar
  17. 17.
    Abreu Filho, C. A., Lisboa, L. A., Dallan, L. A., Spina, G. S., Grinberg, M., Scanavacca, M., et al. (2005). Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease. Circulation, 112(9 Suppl), I20–I25.PubMedGoogle Scholar
  18. 18.
    Akpinar, B., Sanisoglu, I., Guden, M., Sagbas, E., Caynak, B., & Bayramoglu, Z. (2006). Combined off-pump coronary artery bypass grafting surgery and ablative therapy for atrial fibrillation: Early and mid-term results. The Annals of Thoracic Surgery, 81(4), 1332–1337.PubMedCrossRefGoogle Scholar
  19. 19.
    Deneke, T., Khargi, K., Grewe, P. H., Laczkovics, A., von, D. S., Lawo, T., et al. (2002). Efficacy of an additional MAZE procedure using cooled-tip radiofrequency ablation in patients with chronic atrial fibrillation and mitral valve disease. A randomized, prospective trial. European Heart Journal, 23(7), 558–566.PubMedCrossRefGoogle Scholar
  20. 20.
    Doukas, G., Samani, N. J., Alexiou, C., Oc, M., Chin, D. T., Stafford, P. G., et al. (2005). Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: A randomized controlled trial. JAMA, 294(18), 2323–2329.PubMedCrossRefGoogle Scholar
  21. 21.
    Geidel, S., Ostermeyer, J., Lass, M., Geisler, M., Kotetishvili, N., Aslan, H., et al. (2006). Permanent atrial fibrillation ablation surgery in CABG and aortic valve patients is at least as effective as in mitral valve disease. Thoracic and Cardiovascular Surgeon, 54(2), 91–95.PubMedCrossRefGoogle Scholar
  22. 22.
    Gillinov, A. M., McCarthy, P. M., Blackstone, E. H., Rajeswaran, J., Pettersson, G., Sabik, J. F., et al. (2005). Surgical ablation of atrial fibrillation with bipolar radiofrequency as the primary modality. The Journal of Thoracic and Cardiovascular Surgery, 129(6), 1322–1329.PubMedCrossRefGoogle Scholar
  23. 23.
    McCarthy, P. M., Gillinov, A. M., Castle, L., Chung, M., & Cosgrove, D., III. (2000). The Cox-Maze procedure: The Cleveland Clinic experience. Seminars in Thoracic and Cardiovascular Surgery, 12(1), 25–29.PubMedGoogle Scholar
  24. 24.
    Prasad, S. M., Maniar, H. S., Camillo, C. J., Schuessler, R. B., Boineau, J. P., Sundt, T. M., III, et al. (2003). The Cox maze III procedure for atrial fibrillation: Long-term efficacy in patients undergoing lone versus concomitant procedures. The Journal of Thoracic and Cardiovascular Surgery, 126(6), 1822–1828.PubMedCrossRefGoogle Scholar
  25. 25.
    Schaff, H. V., Dearani, J. A., Daly, R. C., Orszulak, T. A., & Danielson, G. K. (2000). Cox-Maze procedure for atrial fibrillation: Mayo Clinic experience. Seminars in Thoracic and Cardiovascular Surgery, 12(1), 30–37.PubMedGoogle Scholar
  26. 26.
    Hindricks, G., Piorkowski, C., Tanner, H., Kobza, R., Gerds-Li, J. H., Carbucicchio, C., et al. (2005). Perception of atrial fibrillation before and after radiofrequency catheter ablation: Relevance of asymptomatic arrhythmia recurrence. Circulation, 112(3), 307–313.PubMedCrossRefGoogle Scholar
  27. 27.
    Klemm, H. U., Ventura, R., Rostock, T., Brandstrup, B., Risius, T., Meinertz, T., et al. (2006). Correlation of symptoms to ECG diagnosis following atrial fibrillation ablation. Journal of Cardiovascular Electrophysiology, 17(2), 146–150.PubMedCrossRefGoogle Scholar
  28. 28.
    Neumann, T., Erdogan, A., Dill, T., Greiss, H., Berkowitsch, A., Sperzel, J., et al. (2006). Asymptomatic recurrences of atrial fibrillation after pulmonary vein isolation. Europace, 8(7), 495–498.PubMedCrossRefGoogle Scholar
  29. 29.
    Oral, H., Veerareddy, S., Good, E., Hall, B., Cheung, P., Tamirisa, K., et al. (2004). Prevalence of asymptomatic recurrences of atrial fibrillation after successful radiofrequency catheter ablation. Journal of Cardiovascular Electrophysiology, 15(8), 920–924.PubMedCrossRefGoogle Scholar
  30. 30.
    Senatore, G., Stabile, G., Bertaglia, E., Donnici, G., De, S. A., Zoppo, F., et al. (2005). Role of transtelephonic electrocardiographic monitoring in detecting short-term arrhythmia recurrences after radiofrequency ablation in patients with atrial fibrillation. Journal of the American College of Cardiology, 45(6), 873–876.PubMedCrossRefGoogle Scholar
  31. 31.
    Vasamreddy, C. R., Dalal, D., Dong, J., Cheng, A., Spragg, D., Lamiy, S. Z., et al. (2006). Symptomatic and asymptomatic atrial fibrillation in patients undergoing radiofrequency catheter ablation. Journal of Cardiovascular Electrophysiology, 17(2), 134–139.PubMedCrossRefGoogle Scholar
  32. 32.
    Ziegler, P. D., Koehler, J. L., & Mehra, R. (2006). Comparison of continuous versus intermittent monitoring of atrial arrhythmias. Heart Rhythm, 3(12), 1445–1452.PubMedCrossRefGoogle Scholar
  33. 33.
    Purerfellner, H., Aichinger, J., Martinek, M., Nesser, H. J., Ziegler, P., Koehler, J., et al. (2004). Quantification of atrial tachyarrhythmia burden with an implantable pacemaker before and after pulmonary vein isolation. Pacing and Clinical Electrophysiology, 27(9), 1277–1283.PubMedCrossRefGoogle Scholar
  34. 34.
    Veasey, R. A., Silberbauer, J., Schilling, R. J., Morgan, J. M., Paul, V., Furniss, S. S., et al. (2010). The evaluation of pulmonary vein isolation and wide-area left atrial ablation to treat atrial fibrillation in patients with implanted permanent pacemakers: The previously paced pulmonary vein isolation study. Heart, 96(13), 1037–1042.PubMedCrossRefGoogle Scholar
  35. 35.
    Montenero, A. S., Quayyum, A., Franciosa, P., Mangiameli, D., Antonelli, A., Barbieri, L., et al. (2004). Implantable loop recorders: A novel method to judge patient perception of atrial fibrillation. Preliminary results from a pilot study. Journal of Interventional Cardiac Electrophysiology, 10(3), 211–220.PubMedCrossRefGoogle Scholar
  36. 36.
    Hong, P. S. G., Freemantle, N., Shubber, S., Fonseka, M., Nahhas, A., Athulathmudali, C., et al. (2008). Comparing remote monitoring of syncope patients with protocol driven management: The Eastbourne Syncope Assessment study II (EaSyAS II). Journal of Interventional Cardiac Electrophysiology, 21, 137.CrossRefGoogle Scholar
  37. 37.
    Defaye, P., Dournaux, F., & Mouton, E. (1998). Prevalence of supraventricular arrhythmias from the automated analysis of data stored in the DDD pacemakers of 617 patients: The AIDA study. The AIDA multicenter study group. Automatic interpretation for diagnosis assistance. Pacing and Clinical Electrophysiology, 21(1 Pt 2), 250–255.PubMedCrossRefGoogle Scholar
  38. 38.
    Israel, C. W., Gronefeld, G., Ehrlich, J. R., Li, Y. G., & Hohnloser, S. H. (2004). Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: Implications for optimal patient care. Journal of the American College of Cardiology, 43(1), 47–52.PubMedCrossRefGoogle Scholar
  39. 39.
    Silberbauer, J., Veasey, R. A., Cheek, E., Maddekar, N., & Sulke, N. (2009). Electrophysiological characteristics associated with symptoms in pacemaker patients with paroxysmal atrial fibrillation. Journal of Interventional Cardiac Electrophysiology, 26(1), 31–40.PubMedCrossRefGoogle Scholar
  40. 40.
    Savelieva, I., & Camm, A. J. (2000). Clinical relevance of silent atrial fibrillation: Prevalence, prognosis, quality of life, and management. Journal of Interventional Cardiac Electrophysiology, 4(2), 369–382.PubMedCrossRefGoogle Scholar
  41. 41.
    Page, R. L., Wilkinson, W. E., Clair, W. K., McCarthy, E. A., & Pritchett, E. L. (1994). Asymptomatic arrhythmias in patients with symptomatic paroxysmal atrial fibrillation and paroxysmal supraventricular tachycardia. Circulation, 89(1), 224–227.PubMedGoogle Scholar
  42. 42.
    Gage, B. F., Waterman, A. D., Shannon, W., Boechler, M., Rich, M. W., & Radford, M. J. (2001). Validation of clinical classification schemes for predicting stroke: Results from the national registry of atrial fibrillation. JAMA, 285(22), 2864–2870.PubMedCrossRefGoogle Scholar
  43. 43.
    Oral, H., Chugh, A., Ozaydin, M., Good, E., Fortino, J., Sankaran, S., et al. (2006). Risk of thromboembolic events after percutaneous left atrial radiofrequency ablation of atrial fibrillation. Circulation, 114(8), 759–765.PubMedCrossRefGoogle Scholar
  44. 44.
    Rossillo, A., Bonso, A., Themistoclakis, S., Riccio, G., Madalosso, M., Corrado, A., et al. (2008). Role of anticoagulation therapy after pulmonary vein antrum isolation for atrial fibrillation treatment. J Cardiovasc Med (Hagerstown), 9(1), 51–55.CrossRefGoogle Scholar
  45. 45.
    Ad, N., Henry, L., Schlauch, K., Holmes, S. D., & Hunt, S. (2010). The CHADS score role in managing anticoagulation after surgical ablation for atrial fibrillation. The Annals of Thoracic Surgery, 90(4), 1257–1262.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Rick A. Veasey
    • 1
  • Oliver R. Segal
    • 1
    • 2
  • Janet K. Large
    • 1
  • Michael E. Lewis
    • 3
  • Uday H. Trivedi
    • 3
  • Andrew S. Cohen
    • 3
  • Jonathan A. J. Hyde
    • 3
  • A. Neil Sulke
    • 1
  1. 1.Department of CardiologyEast Sussex Hospitals NHS TrustEastbourneUK
  2. 2.Department of Electrophysiology, The Heart HospitalUniversity College LondonLondonUK
  3. 3.Department of Cardiothoracic SurgeryRoyal Sussex County HospitalBrightonUK

Personalised recommendations