Surgical Ablation for Atrial Fibrillation is Efficacious in Patients with Giant Left Atria

Published:November 24, 2022DOI:
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      The Cox-Maze IV procedure (CMP-IV) is the most effective treatment for atrial fibrillation (AF). Increased left atrial (LA) size has been identified as a risk factor for failure to restore sinus rhythm. This has biased many surgeons against ablation in patients with giant left atria (GLA), defined as LA diameter greater than 6.5cm. This study aimed to define the efficacy of the CMP-IV in patients with GLA.


      From April 2004 through March 2020, 786 patients with a documented LA diameter underwent elective CMP-IV, 72 of whom had GLA. Median follow-up duration was 4 years (interquartile range [IQR] 1-7 years). Recurrence was defined as any documented atrial tachyarrhythmia (ATA) lasting 30 seconds. ATA recurrence and survival were analyzed across GLA versus non-GLA groups.


      Median age at surgery was 65 years (IQR 56-73). Median LA diameter within the GLA group was 7.0cm (range 6.6-10.0). There were no significant differences in rates of postoperative complications between the two groups, including rate of postoperative stroke and pacemaker placement (GLA 14%, non-GLA 12%, p = 0.682). A trend toward increased 30-day mortality in the GLA group did not reach statistical significance (GLA 6%, non-GLA 2%, p=0.051). Freedom from ATAs at 5 years postoperatively was comparable between the two groups (GLA 82%, non-GLA 84%).


      The CMP-IV had good efficacy in patients with GLA. Our results suggest that LA diameter >6.5 cm should not preclude a patient from undergoing surgical ablation for AF.

      Graphical abstract



      AAD (antiarrhythmic drug), AF (atrial fibrillation), ATA (atrial tachyarrhythmia), BMI (body mass index), CABG (coronary artery bypass graft), CHA2DS2-VASc (congestive heart failure hypertension age ≥75 (doubled) diabetes mellitus prior stroke, transient ischemic attack or thromboembolism (doubled) vascular disease age 65 to 74 sex category (female)), CHB (complete heart block), CHF (congestive heart failure), CI (confidence interval), CL (confidence limits), CMP (Cox-Maze procedure), CMP-IV (Cox-Maze IV procedure), CPB (cardiopulmonary bypass), GEE (generalized estimating equation), GLA (giant left atrium), HF (heart failure), ICU (intensive care unit), ILR (implantable loop recording), IQR (interquartile range), LVEF (left ventricular ejection fraction), MV (mitral valve), MVR (mitral valve repair or replacement), NYHA (New York Heart Association), OAC (oral anticoagulant), POC (People of Color), RR (risk ratio), SA (surgical ablation), SD (standard deviation), SR (sinus rhythm), SSS (sick sinus syndrome), STS (Society of Thoracic Surgeons), TEE (transesophageal echocardiography)
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