Regardless of whether we are dealing with coronary artery disease, aortic valve stenosis, or AF, the decision to treat a problem by catheter intervention or surgery must consider the risk-to-benefit ratio of the two approaches. However, the risk-to-benefit ratio of an interventional procedure depends on more than the safety and efficacy of the two approaches, and generally, safety far outweighs efficacy in the decision-making process (see Chapter 10 ). In addition, different patients have different goals and may prefer one approach even if the risk-to-benefit ratio favors the alternative approach. Some patients prioritize the relative levels of invasiveness above all else, but others seek only better outcomes regardless of the level of invasiveness.

In the case of LSpAF, the most reliable and well-documented information available are the outcomes of catheter ablation and surgical ablation. There are two seminal studies on the results of catheter ablation specifically for the treatment of patients with LSpAF, the 2012 Hamburg Study and the 2023 Winkle and coworkers study. The Hamburg Study showed that the 5-year success rate after a single catheter ablation for LSpAF is 20%, and after multiple catheter ablations for LSpAF, it is 45%. Winkle et al.’s recent 16-year study showed precisely the same 5-year success rate of 45% after multiple catheter ablations for LSpAF. This means that nearly half of all patients with LSpAF can be relieved of their arrhythmia for 5 years by catheter ablation, a sound reason for performing catheter ablation first before subjecting the patient to a more invasive surgical procedure. If multiple catheter ablations fail, the patients can then be referred for surgery either using an off-pump hybrid procedure, an on-pump minimally invasive CryoMaze-III procedure, or an open Maze-III/IV procedure.

The long-term results for patients with LSpAF with the minimally invasive CryoMaze-III procedure and Maze-III/IV procedures, all of which require cardiopulmonary bypass, are 85% to 90%, or roughly twice the success rate achieved with multiple catheter ablations. The 3-year success rates for off-pump hybrid procedures for LSpAF vary from roughly 60% to 80%, thus falling between the catheter results and the surgical results ( Fig. 39.1 ). These results of off-pump hybrid procedures and on-pump CryoMaze-III and Maze-III/IV procedures argue in favor of treating LSpAF with surgery as the initial option and after being appropriately informed, patients should be allowed to participate in the decision. The critical phrase here is “appropriately informed.” It is difficult to convey a true comparison of catheter ablation and surgical ablation of AF to a patient because, of course, all patients would naturally prefer to avoid surgery if possible. The inherent difficulty of providing true “informed consent” can perhaps be better appreciated by the following analogy.

Results of Maze procedures, hybrid procedures, and multiple catheter ablations for the treatment of patients with long-standing persistent atrial fibrillation (AF). See text for further discussion.

Many years ago, Dr. Cox and I were discussing how one might negate the stigma of surgery when explaining to patients their two treatment choices, and he suggested that we might consider using his “orange pill analogy” as a means of presenting an objective comparison of catheter ablation to surgical ablation.

Cardiac surgeons depend almost solely on cardiologists for patient referrals. This means that surgeons depend on the cardiology “gatekeepers” to present the truth, the whole truth, and nothing but the truth to patients when they describe the treatment options that are available. Unfortunately, this does not always happen because catheter ablation for AF is usually presented by cardiologists as being simple (false), safe (true), and effective (misleading), while surgery for AF is presented as being far more dangerous than catheter ablation (false), more painful and debilitating than catheter ablation (true), and no more effective than catheter ablation (false). So, in order to eliminate the stigma of surgery from the discussion, one can “catheter ablation” with a white pill and “surgical ablation” with an orange pill. Table 39.1 shows the relevant numbers for LSpAF.

So here is what I would like our cardiology colleagues to tell their patients when they are counseling them on their various therapeutic options for the treatment of LSpAF: “You have two options here. You can take either a white pill or an orange pill.”

Option 1: If you take the white pill, you will feel mild discomfort in your groin for few hours and soreness for a few days, but you can probably go home the day after you take the pill. However, there is only a small chance that the white pill will have any immediate effect on your AF, and there is a slight chance that you will have a stroke as soon as you swallow it. In addition, there is also a chance that this white pill will permanently narrow the blood vessels draining blood from the lungs into your heart, causing you to have breathing difficulties unless you have an open-heart operation to fix the problem. Incidentally, the white pill contains enough radiation to cause 1 in every 1000 patients to develop cancer. Because we administered 2000 white pills last year, we caused 2 people to have cancer. Finally, because this white pill works in only about 20% of patients, you will likely have to take a second white pill within the next year, and all of the potential side effects that I just described will occur at exactly the same rate with the second pill. If two white pills don’t work, we can give you a third one, but again, the pill will cause the same initial discomfort during your 2 days in the hospital as well as the same incidence of stroke, lung vessel problems, and risk of cancer that the first two pills did. After all this, you will have a 45% chance of being free of your AF after 5 years.

Option 2: If you decide to take the orange pill, you will go to sleep immediately upon swallowing it. When you awaken, you will be sore in your chest, and it will hurt to breathe deeply and cough, but the discomfort will be treated with pain medications and will improve rapidly over the following day or two. However, this orange pill has a 90% to 95% chance of stopping your AF immediately so that we only offer the orange pill to patients once. Even 15 years after you take the orange pill, there is an 85% chance that you will still not have AF. In addition, the risk of stroke or death is the same with the orange pill as with the white pill, but the orange pill will not cause any problems with drainage of blood from your lungs, either now or ever. Oh, and the orange pill is not radioactive.

After hearing this description of the consequences of taking the two different pills, many patients would initially choose to take the orange pill. However, when they later learn that the orange pill is actually surgery, most would likely opt for the white pill. The point of this orange pill analogy isn’t just to make things simpler;— it’s to call out the bias that often shapes how treatment options are presented to patients by their physicians. By translating catheter and surgical ablation into terms with similar levels of stigma (white pills and orange pills), we remove the procedural language that often overwhelms patients and present the decision in terms they can truly understand. The white pill, representing catheter ablation, naturally seems more appealing due to its minimally invasive nature and faster recovery, but it provides significantly lower rates of sustained sinus rhythm and long-term freedom from AF. This difference becomes even more important with age, as the progression of atrial remodeling can lead to structural changes that make AF more resistant to catheter-based treatment. In this context, the surgical option offers not only a more durable solution but also a more complete elimination of the arrhythmogenic substrate.

Truly “informed” consents are tricky and cannot always be perfectly accurate. However, as a person who routinely performs both catheter ablation and surgical ablation for AF, here is my recommendation on how new patients with LSpAF should be treated. Although the “cure rate” of LSpAF after multiple catheter ablations is only 45%, another way of looking at that figure is that nearly half of this most complex and dangerous form of AF can be cured without surgery. Therefore, I believe that at least two attempts at catheter ablation should be tried before sending the patient for surgery. If both procedures fail, there are several options available:

• 1.

  Leave the patient in AF and continue to treat medically, focusing on rate control. This leaves the patient without the benefit of the atrial contribution to cardiac output, and it leaves the patient vulnerable to stroke. The latter should be treated by permanent oral anticoagulation or left atrial appendage occlusion (LAAO).

• 2.

  “Pace and ablate,” that is, ablate the His bundle and implant a permanent pacemaker. This also leaves the patient without the benefit of the atrial contribution to cardiac output and it also leaves the patient vulnerable to stroke.

• 3.

  Perform a hybrid procedure in which the EP and the surgeon perform a combined off-pump, thoracoscopic surgical procedure and endocardial catheter ablation procedure in an effort to control the arrhythmia. The results of this approach for LSpAF vary between 60% and 80% at 3 years.

• 4.

  Perform a minimally invasive on-pump CryoMaze-III or open Maze-III/IV procedure. Both of these procedures yield success rates of around 90% at 5 years. Sinus rhythm with return of atrial function occurs in the vast majority of patients, and the incidence of long-term stroke is virtually eliminated because of the combination of a normal rhythm and LAAO.

• 5.

  Perform a median sternotomy for a CryoMaze-III or Maze-III/IV procedure. This is recommended only for patients who are not candidates for the minimally invasive approach (number 4).

In my opinion, the biggest mistake that is made in terms of patient care after two or more failed catheter ablations is to choose options 1 or 2. The fact that patients have subjected themselves to multiple catheter ablations to be relieved of their AF is sufficient evidence that they seriously desire to be free of it. Therefore, there is little justification for simply surrendering to the disease without offering surgery to a patient like this. Unfortunately, some patients who have failed multiple catheter ablations are never even told that surgical therapy for AF is available, much less that it is safe and highly successful. It is also common practice for some physicians to routinely recommend “pace and ablate” to patients who have failed multiple catheter ablations. Unfortunately, this approach leaves the patient with no synchronous atrial function and at risk of stroke unless the pace and ablate approach is accompanied by LAAO. Furthermore, pace and ablate does not always relieve the symptoms of AF and because these patients are so symptomatic, they require surgery for relief of their symptoms. I believe that the best option for patients who have failed multiple catheter ablations for LSpAF is a Maze procedure or a simple LAAO.