Surgical ablation of atrial fibrillation combined with mitral valve surgery is effective in reducing the incidence of atrial fibrillation, but at the expense of more frequent pacemaker implantation, and has no impact on short-term survival.44 Surgical ablation should be considered in patients with symptomatic atrial fibrillation and may be considered in patients with asymptomatic atrial fibrillation if feasible with minimal risk. The decision should factor in other important variables, such as age, the duration of atrial fibrillation and LA size. Surgical excision or external clipping of the LA appendage may be considered combined with valvular surgery, although there is no evidence that it decreases thromboembolic risk. For patients with atrial fibrillation and risk factors for stroke, long-term oral anticoagulation is currently recommended, although surgical ablation of atrial fibrillation and/or surgical LA appendage excision or exclusion may have been performed.37 Recommendations for the management of atrial fibrillation in VHD are summarized in the following table.
