Standardized 4-step surgical approach to address atrial fibrillation during coronary artery bypass grafting in a patient with severely reduced left ventricular function: a case report

Atrial fibrillation (AF) may result in haemodynamic deterioration and is particularly detrimental in patients with severely impaired left ventricular function. In this high-risk population, the maintenance or restoration of sinus rhythm (SR) in cardiac surgery are of paramount importance, warranting the use of all available surgical strategies to comprehensively address atrial fibrillation. We report the case of a 60-year-old man who underwent successful out-of-hospital cardiopulmonary resuscitation following an acute myocardial infarction. Coronary angiography revealed severe three-vessel coronary artery disease, accompanied by highly reduced left ventricular function. The patient had a history of symptomatic paroxysmal AF and had recently undergone electrical cardioversion to restore SR after the index myocardial infarction. In addition to surgical coronary revascularization via median sternotomy, a standardized four-step concomitant AF procedure was performed. This approach included bipolar radiofrequency ablation, exclusion of the left atrial appendage, transection of the ligament of Marshall, and left-sided posterior pericardiotomy. The patient was successfully weaned from cardiopulmonary bypass in SR and maintained stable SR throughout an 8-month follow-up period without AF recurrence. This case highlights the importance of systematically addressing AF during cardiac surgery, especially in high-risk patients with severely reduced ventricular function, where maintenance of sinus rhythm may have haemodynamic benefits.