Concomitant bipolar radiofrequency ablation for atrial fibrillation in patients undergoing surgery for rheumatic Valvular disease in Sub-Saharan Africa

The rhythm after valve surgery has been shown to impact on long-term outcome with increased thromboembolic risk in patients with persistent atrial fibrillation (AF) despite anticoagulation. Concomitant Cox maze IV (CMPIV) or pulmonary vein isolation using bipolar radiofrequency ablation has been demonstrated to reduce stroke risk when successful in restoring stable sinus rhythm. We report the case of a 27-year-old male with rheumatic mitral stenosis, persistent AF, and left atrial thrombus who underwent concomitant CMPIV radiofrequency ablation during mechanical mitral valve replacement and has subsequently remained in sinus rhythm and free from thromboembolism 10 years postoperatively. Strategies aimed at addressing AF and the left atrial appendage at the time of valve surgery may be beneficial in reducing embolic stroke and should be part of the contemporary surgeons armamentarium. Concomitant ablation when the capacity and expertise is locally available should therefore be considered in low-risk patients without severe left ventricular dysfunction or severe pulmonary hypertension during valve surgery in patients with persistent AF. When ablation is not feasible or equipment unavailable, consideration should then be given at a minimum to excision or exclusion of the left atrial appendage which is the most common source of emboli in AF as an alternative stroke reduction strategy.