Valve replacement surgery for older individuals with preoperative atrial fibrillation: The effect of prosthetic valve choice and surgical ablation

Abstract

Prosthetic valve type selection combined with surgical ablation during left-sided heart valve replacement in older individuals with atrial fibrillation remains controversial. A total of 573 patients aged 60 years or older (median, 65; range, 60-84) who underwent left-sided valve replacement surgery in the presence of atrial fibrillation from 1990 to 2010 were evaluated for all-cause mortality during a median follow-up period of 58.0 months (interquartile range, 33.1-84.1). Mechanical and bioprosthetic valves were implanted in 356 (62.1%) and 217 (37.9%) patients, respectively, and 203 patients (35.4%) underwent surgical ablation concomitantly. During the follow-up period, 166 patients died. The 5- and 10- year survival rate was 76.3% ± 2.1% and 58.4% ± 3.2%, respectively. On Cox regression analysis, age (P < .001), diabetes (P = .014), left ventricular ejection fraction (P = .010), left atrial size (P = .038), the requirement for coronary bypass (P = .015), and cardiopulmonary bypass time (P < .001) emerged as significant and independent predictors of death. In addition, surgical ablation was protective against all-cause mortality (hazard ratio, 0.63; P = .033). The improved survival observed with surgical ablation was verified by propensity score adjustment models (hazard ratio, 0.64; 95% confidence interval, 0.30-0.99; P = .046). The choice of prosthetic type, however, affected neither survival (P = .79) nor event-free survival (P = .48). Long-term survival after valve replacement in older individuals with atrial fibrillation was affected by several preoperative characteristics and the performance of surgical ablation but not by the choice of prosthesis. These findings suggest that surgical atrial fibrillation ablation should always be considered for these patients, regardless of the prosthesis type used.