Late Survival Benefits of Concomitant Surgical Ablation for Atrial Fibrillation During Cardiac Surgery; A Systematic Review and Meta-Analysis

Abstract

Long-term survival benefits following surgical ablation for atrial fibrillation (AF) during cardiac surgery were not confirmed in previous randomized controlled trials or meta-analyses. This study aimed to investigate the long-term efficacy of surgical ablation in patients with AF. MEDLINE, EMBASE, and CENTRAL were searched to identify studies comparing concomitant surgical AF ablation with no surgical ablation during cardiac surgery. The primary outcome was long-term all-cause mortality. Secondary outcomes were stroke, heart failure rehospitalization, major bleeding, freedom from atrial fibrillation, and permanent pacemaker implantation during follow-up. To minimize confounding, only adjusted outcomes were used from observational studies. A total of 38 studies met the inclusion criteria. Of those, nine RCTs and 15 observational studies with 41,678 patients (surgical ablation, n = 19,125; no surgical ablation, n = 22,553) were analyzed for all-cause mortality, with a weighted median follow-up of 62.0 months. Surgical ablation was associated with decreased risks of long-term mortality (hazard ratio (HR): 0.78; 95% confidence interval (CI): 0.71 to 0.84), stroke (HR: 0.60; 95% CI: 0.48 to 0.76), heart failure rehospitalization (HR: 0.92; 95% CI: 0.87 to 0.96), and more freedom from AF during follow-up (relative risk: 1.93; 95% CI: 1.50 to 2.49), whereas surgical ablation was associated with a higher risk of permanent pacemaker implantation during follow-up (HR: 1.35; 95% CI: 1.03 to 1.77). There was no significant difference in major bleeding during follow-up between the two groups. In patients with AF undergoing cardiac surgery, surgical ablation was associated with decreased risks of long-term mortality, stroke, and heart failure rehospitalization than patients with untreated AF. Given that the survival benefits were predominantly observed in observational studies, further randomized trials are necessary to confirm these findings.