have failed one or more attempts at catheter ablation who prefer a surgical approach after review of safety and efficacy of options. For paroxysmal AF, it may also be considered after one or more catheter attempts. SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Atrial fibrillation" and "Society guideline links: Arrhythmias in adults".) INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. th th The Basics patient education pieces are written in plain language, at the 5 to 6 grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more th th sophisticated, and more detailed. These articles are written at the 10 to 12 grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Beyond the Basics topic (see "Patient education: Atrial fibrillation (Beyond the Basics)") https://www.uptodate.com/contents/atrial-fibrillation-surgical-ablation/print 12/23 7/5/23, 9:12 AM Atrial fibrillation: Surgical ablation - UpToDate SUMMARY AND RECOMMENDATIONS Several surgical techniques have been developed for the control of refractory atrial fibrillation (AF) and maintenance of sinus rhythm. In most patients, these techniques are employed as adjunctive therapy in patients undergoing other cardiac surgery for some other reason, such as mitral valve or coronary artery bypass surgery. (See 'Indications' above.) These surgical procedures appear effective at eliminating or reducing the frequency of AF in a high percentage of patients. (See 'Maze procedure' above and 'Endocardial surgical ablation' above.) After surgical ablation, we continue anticoagulation in patients at high risk for stroke. For all others, we often discontinue anticoagulation two to three months after successful restoration of sinus rhythm and particularly in patients at high risk for bleeding. Patients in persistent AF should receive continued anticoagulation. This practice applies only to patients who have had the left atrial appendage removed or ligated. Patients with recurrent AF after one of these procedures may be candidates for electrophysiology study and catheter ablation. (See 'Treatment failures' above and "Atrial fibrillation: Catheter ablation".) ACKNOWLEDGMENT The UpToDate editorial staff thank Alan Cheng, MD, who contributed to earlier versions of this topic review. Use of UpToDate is subject to the Terms of Use. REFERENCES 1. Ferguson TB Jr, Cox JL. Surgery for atrial fibrillation. In: Cardiac Electrophysiology: From Cell to Bedside, 2nd ed, Zipes DP, Jalife J (Eds), Saunders, Philadelphia 1995. p.1567. 2. Henn MC, Lancaster TS, Miller JR, et al. Late outcomes after the Cox maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg 2015; 150:1168. 3. Cox JL, Canavan TE, Schuessler RB, et al. The surgical treatment of atrial fibrillation. II. Intraoperative electrophysiologic mapping and description of the electrophysiologic basis https://www.uptodate.com/contents/atrial-fibrillation-surgical-ablation/print 13/23 7/5/23, 9:12 AM Atrial fibrillation: Surgical ablation - UpToDate of atrial flutter and atrial fibrillation. 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Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial. Circulation 2012; 125:23. 37. Muneretto C, Bisleri G, Bontempi L, et al. Successful treatment of lone persistent atrial fibrillation by means of a hybrid thoracoscopic-transcatheter approach. Innovations (Phila) 2012; 7:254. 38. Kiser AC, Landers MD, Boyce K, et al. Simultaneous catheter and epicardial ablations enable a comprehensive atrial fibrillation procedure. Innovations (Phila) 2011; 6:243. 39. Lee R, McCarthy PM, Passman RS, et al. Surgical treatment for isolated atrial fibrillation: minimally invasive vs. classic cut and sew maze. Innovations (Phila) 2011; 6:373. 40. Chiappini B, Mart n-Su rez S, LoForte A, et al. Cox/Maze III operation versus radiofrequency ablation for the surgical treatment of atrial fibrillation: a comparative study. Ann Thorac Surg 2004; 77:87. 41. Stulak JM, Dearani JA, Sundt TM 3rd, et al. Superiority of cut-and-sew technique for the Cox maze procedure: comparison with radiofrequency ablation. J Thorac Cardiovasc Surg 2007; 133:1022. https://www.uptodate.com/contents/atrial-fibrillation-surgical-ablation/print 16/23 7/5/23, 9:12 AM Atrial fibrillation: Surgical ablation - UpToDate 42. Doty JR, Doty DB, Jones KW, et al. Comparison of standard Maze III and radiofrequency Maze operations for treatment of atrial fibrillation. J Thorac Cardiovasc Surg 2007; 133:1037. 43. Gillinov AM, Saltman AE. Ablation of atrial fibrillation with concomitant cardiac surgery. Semin Thorac Cardiovasc Surg 2007; 19:25. 44. Budera P, Straka Z, Osman k P, et al. Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study. Eur Heart J 2012; 33:2644. 45. 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Calkins H, Hindricks G, Cappato R, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017; 14:e275. https://www.uptodate.com/contents/atrial-fibrillation-surgical-ablation/print 18/23 7/5/23, 9:12 AM Atrial fibrillation: Surgical ablation - UpToDate Topic 1046 Version 36.0 https://www.uptodate.com/contents/atrial-fibrillation-surgical-ablation/print 19/23 7/5/23, 9:12 AM Atrial fibrillation: Surgical ablation - UpToDate GRAPHICS MAZE III procedure Modification of the posterior incisions to the vena cava and placement of the septal incision posterior to the orifice of the superior vena cava (SVC) are noted. CS: coronary sinus; FO: foramen ovale; IVC: inferior vena cava; LAA: left atrial appendage; MV: mitral valve; RAA: right atrial appendage; SAN: sinoatrial node; TV: tricuspid valve. Reproduced from: Cheng A, Shah A, Hogue CW. Cardiac electrophysiology: Diagnosis and treatment. In: Kaplan's Cardiac Anesthesia, 6th ed, Kaplan JA, Reich DL, Lake CL, Konstadt SN (Eds), Saunders, Philadelphia 2011. Illustration used with the permission of Elsevier Inc. All rights reserved. Graphic 58985 Version 2.0 https://www.uptodate.com/contents/atrial-fibrillation-surgical-ablation/print 20/23 7/5/23, 9:12 AM Atrial fibrillation: Surgical ablation - UpToDate Schema of the maze procedure and the radial approach for atrial fibrillation The large outer circle denotes the atria and its outer limit is bounded by the atrioventricular annular margins. The small circle indicates the sinoatrial node (SAN), the shaded area indicates the isolated portion of the atrium, and the atrial coronary arteries, arising at the atrioventricular groove, are also schematically drawn. Arrows indicate the activation wavefront from the sinoatrial node, radiating toward the annular margins. The radial approach (right panel) preserves a more physiologic activation sequence and the blood supply to most atrial segments, whereas the atrial incisions of the maze procedure (left panel) desynchronize the activation sequence, and some of the incisions cross the atrial coronary arteries. Reprinted with permission from the Society of Thoracic Surgeons. Netta T, Cox R, Schuessler RB, et al. Ann Thorac Surg 1999; 67:27. http://www.elsevier.com/locate/jacc http://www.sciencedirect.com Graphic 69962 Version 2.0 https://www.uptodate.com/contents/atrial-fibrillation-surgical-ablation/print 21/23 7/5/23, 9:12 AM Atrial fibrillation: Surgical ablation - UpToDate Schematic representation of atrial activation in sinus rhythm and after the maze procedure or the radial approach The normal activation sequence of the left atrium is maintained with the radial approach while it is altered with the Maze procedure. Thick lines represent the surgical incisions and the solid areas represent parts of the atria surgically isolated or excised; dashed lines represent normal conduction pathways between the atrial appendages, the interatrial septum, and the crista terminalis. Arrows indicate the activation sequence. AVN: atrioventricular node; SAN: sinoatrial node; RAA: right atrial appendage; LAA: left atrial appendage; SVC: superior vena cava; IVC: inferior vena cava; PVs: pulmonary veins. Reprinted with permission from the Society of Thoracic Surgeons. Netta T, Cox R, Schuessler RB, et al. Ann Thorac Surg 1999; 67:27. Graphic 50845 Version 3.0 https://www.uptodate.com/contents/atrial-fibrillation-surgical-ablation/print 22/23 7/5/23, 9:12 AM Atrial fibrillation: Surgical ablation - UpToDate Contributor Disclosures Richard Lee, MD, MBA No relevant financial relationship(s) with ineligible companies to disclose. Gabriel S Aldea, MD No relevant financial relationship(s) with ineligible companies to disclose. Edward Verrier, MD No relevant financial relationship(s) with ineligible companies to disclose. Bradley P Knight, MD, FACC Grant/Research/Clinical Trial Support: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; MDT [Electrophysiology]; Philips [Electrophysiology]. Consultant/Advisory Boards: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; CVRx [Heart failure]; MDT [Electrophysiology]; Philips [Electrophysiology]; Sanofi [Arrhythmias]. Speaker's Bureau: Abbott [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Transeptal catheterization]; BSCI [Electrophysiology]; MDT [Electrophysiology]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/atrial-fibrillation-surgical-ablation/print 23/23