Concomitant Surgical Ablation Research Articles

Long-term efficacy of concomitant surgical ablation for atrial fibrillation with cardiac surgery

Abstract Background Concomitant surgical ablation (SA) is recommended at the time of cardiac surgery in patients with atrial fibrillation (AF) but it is only performed in the minority due to perceived barriers such as increased risk, longer procedure duration and additional technical skills required [1,2]. Furthermore, long-term outcome reporting is limited to only a few high-volume centres. Purpose We sought to report on our centre’s 11-year experience with cardiac surgery and concomitant SA. Methods This was a retrospective observational study on 625 patients with AF who underwent SA in addition to other cardiac surgery at our centre between April 2011 and March 2022. Patients undergoing standalone SA were excluded. Complications were recorded up to 30 days post-procedure. Freedom from atrial tachyarrhythmias (ATA) was determined by electrocardiography, Holter monitoring and pacemaker interrogation at various time points, if available, with or without additional therapies for AF. Results Mean age was 69 +/- 9.9 years and the median duration of AF was 1.2 years (interquartile range 0.4-3.8), persistent in 79% of patients. The median left atrial volume index (LAVI) was 55 ml/m2 (interquartile range 43-71). Concomitant surgery included coronary artery bypass grafting (26%), mitral (68%), aortic (27%), tricuspid (21%) and/or other (5%). Biatrial Cox-Maze IV was performed in 51% of patients and the left atrial appendage was occluded in 74%. Major complications included 30-day mortality (3%), stroke (3%) and pacemaker implantation (4%). Freedom from ATAs was 80% (312/391), 64% (154/240), 53% (76/144) and 44% (33/75) at 1, 3, 5 and 7 years, respectively (Figure 1). Cox regression demonstrated diabetes mellitus, AF duration, persistent AF and LAVI as predictors of 7-year ATA recurrence. Conclusion Concomitant SA for AF has good early and acceptable longer-term rhythm outcomes with no significantly increased complication rate, which should encourage greater uptake of the procedure.

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

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.

Impact of Preoperative Sinus Rhythm on Concomitant Surgical Ablation's One-Year Success in Patients with Atrial Fibrillation: A Prospective Registry Cohort Study.

Background: The surgical ablation (SA) of atrial fibrillation (AF) during cardiac surgery is performed in only 8-40% of patients. We performed a subgroup analysis of the 1-year follow-up from the German CArdioSurgEry Atrial Fibrillation (CASE-AF) registry to determine how preoperative sinus rhythm (SR) prior to SA affected the outcomes. Methods: The CASE-AF registry enrolled AF patients scheduled for cardiac surgery with concomitant SA. The in-hospital and one-year follow-up data were collected prospectively and analyzed retrospectively. Results: From September 2016 to August 2020, 964 patients were enrolled in the CASE-AF registry. Among them, 333 patients were in SR immediately before surgery (study cohort). A complete follow-up was achieved for 95.6%. Both the severity of the AF (modified European Heart Rhythm Association symptom classification, p < 0.001) and the frequency of AF symptoms (p = 0.006) were significantly reduced at one year compared to the preoperative baseline. Almost 90 percent of the patients underwent left atrial appendage occlusion (LAAO) during the procedure. The one-year mortality (4.1%) and stroke rates (3.2%) were low. SR was evident in 70.3% of the patients at the one-year follow-up. Conclusions: Patients with AF who have SR at the time of surgery should not be excluded from SA, as it appears to be a safe and effective procedure.

Is it feasible to treat atrial fibrillation at the time of minimally invasive coronary artery bypass grafting?

Coronary artery bypass grafting remains the most common operation performed by cardiac surgeons. As a result, a cardiac surgeon with a typical practice will most commonly encounter atrial fibrillation when performing coronary artery bypass grafting. In this review, we first emphasize the importance of treating atrial fibrillation in patients undergoing coronary bypass grafting. We review benefits of concomitant surgical ablation and its importance relative to complete coronary revascularization. We then discuss options to treat atrial fibrillation in a more minimally invasive manner in these patients, while still preserving treatment efficacy. Surgical ablation at the time of coronary artery bypass grafting surgery could be as important as complete revascularization. Bi-atrial ablation provides superior rhythm control compared to left-sided ablation only. We highlight various options for surgical ablation at the time of coronary artery bypass grafting surgery, and provide an algorithm for ablation in individual patients.

Perioperative and mid-term outcomes of mitral valve surgery with and without concomitant surgical ablation for atrial fibrillation: a retrospective analysis.

We retrospectively analysed perioperative and mid-term outcomes for patients undergoing mitral valve surgery with and without atrial fibrillation. Patients who underwent mitral valve surgery between January 2018 and February 2023 were included and categorized into 3 groups: 'No AF' (no documented atrial fibrillation), 'AF no SA' (atrial fibrillation without surgical ablation) and 'AF and SA' (atrial fibrillation with concomitant surgical ablation). Groups were compared for perioperative and mid-term outcomes, including mortality, stroke, bleeding and pacemaker implantation. A P-value <0.05 was considered statistically significant. Of the 400 patients included, preoperative atrial fibrillation was present in 43%. Mean follow-up was 1.8 (standard deviation: 1.1) years. The patients who underwent surgical ablation for atrial fibrillation exhibited similar overall outcomes compared to patients without preoperative atrial fibrillation. Patients with untreated atrial fibrillation showed higher mortality ('No AF': 2.2% versus 'AF no SA': 8.3% versus 'AF and SA': 3.2%; P-value 0.027) and increased postoperative pacemaker implantation rates ('No AF': 5.7% versus 'AF no SA': 15.6% versus 'AF and SA': 7.9%, P-value: 0.011). In a composite analysis of adverse events (Mortality, Bleeding, Stroke), the highest incidence was observed in patients with untreated atrial fibrillation, while patients with treated atrial fibrillation had similar outcomes as those without preoperative documented atrial fibrillation ('No AF': 9.6% versus 'AF no SA': 20.2% versus 'AF and SA' 3: 9.5%, P-value: 0.018). Concomitant surgical ablation should be considered in mitral valve surgery for atrial fibrillation, as it leads to similar mid-term outcomes compared to patients without preoperative documented atrial fibrillation.

Concomitant Surgical Ablation in Paroxysmal vs Persistent Atrial Fibrillation During Mitral Surgery

BackgroundDespite prospective randomized evidence supporting concomitant treatment of atrial fibrillation (AF) during mitral valve (MV) surgery, variation in surgical management of AF remains. We assessed longitudinal outcomes after surgical treatment of persistent or paroxysmal AF during MV surgery in Medicare beneficiaries. MethodsAll Medicare beneficiaries with a diagnosis of AF undergoing MV surgery (2018-2020) were evaluated. Patients were stratified by no AF treatment, left atrial appendage obliteration (LAAO) alone, or surgical ablation and LAAO (SA+LAAO). Doubly robust risk adjustment and subgroup analysis by persistent or paroxysmal AF were performed. ResultsA total of 7517 patients with preoperative AF underwent MV surgery (32.1% no AF treatment, 23.1% LAAO alone, 44.7% SA+LAAO). After doubly robust risk adjustment, AF treatment with SA+LAAO or LAAO alone were associated with lower 3-year readmission for stroke or bleeding. However, SA+LAAO was associated with reduced 3-year mortality and readmission for AF or heart failure compared with no AF treatment or LAAO alone. Compared with no AF treatment or LAAO alone, SA+LAAO was associated with lower composite end point of stroke (hazard ratio, 0.75) or death (hazard ratio, 0.83) at 3 years. Subgroup analysis identified similar longitudinal benefits of SA+LAAO in patients with persistent or paroxysmal AF. ConclusionsIn Medicare beneficiaries with AF undergoing MV surgery, SA+LAAO was associated with improved longitudinal outcomes compared with LAAO alone or no AF treatment in patients with paroxysmal or persistent AF. These contemporary real-world data further clarify the benefit of SA+LAAO during MV surgery across all types of AF.

Epicardial and endocardial surgical ablation of atrial fibrillation: outcomes from CASE-AF Registry.

The German CArdioSurgEry Atrial Fibrillation Registry is a prospective, multicentric registry analysing outcomes of patients undergoing surgical ablation for atrial fibrillation as concomitant or stand-alone procedures. This data sub-analysis of the German CArdioSurgEry Atrial Fibrillation Registry aims to describe the in-hospital and 1-year outcomes after concomitant surgical ablation, based on 2 different ablation approaches, epicardial and endocardial surgical ablation. Between January 2017 and April 2020, 17 German cardiosurgical units enrolled 763 consecutive patients after concomitant surgical ablation. In the epicardial group, 413 patients (54.1%), 95.6% underwent radiofrequency ablation. In the endocardial group, 350 patients (45.9%), 97.7% underwent cryoablation. 61.5% of patients in the epicardial group and 49.4% of patients in the endocardial group presenting with paroxysmal atrial fibrillation. Pre-, intra- and post-operative data were gathered. Upon discharge, 32.3% (n = 109) of patients after epicardial surgical ablation and 24.0% (n = 72) of patients after endocardial surgical ablation showed recurrence of atrial fibrillation. The in-hospital mortality rate was low, 2.2% (n = 9) in the epicardial and 2.9% (n = 10) in the endocardial group. The overall 1-year procedural success rate was 58.4% in the epicardial and 62.2% in the endocardial group, with significant symptom improvement in both groups. The 1-year mortality rate was 7.7% (n = 30) in epicardial and 5.0% (n = 17) in the endocardial group. Concomitant surgical ablation is safe and effective with significant improvement in patient symptoms and freedom from atrial fibrillation. Adequate cardiac rhythm monitoring should be prioritized for higher quality data acquisition.

Surgical Ablation for Atrial Fibrillation: Risk Factors for Recurrence and Long-Term Outcome

Atrial fibrillation (AF) is the most common cardiac arrhythmia. Due to the insufficient efficacy of antiarrhythmic drugs and their adverse side effects, there has been considerable interest in the interventional treatment of AF, including both catheter ablation and surgical ablation. Surgical ablation or the maze procedure is a treatment option for patients with AF undergoing concomitant or isolated cardiac surgery. We performed a retrospective study of prospectively collected data to investigate short- and long-term outcomes of patients who underwent the surgical ablation of AF. Outcome variables included freedom from recurrent atrial arrhythmias and mortality at 1-, 3-, 5-, and 7-year follow-ups. We also identified risk factors for arrhythmia recurrence and mortality. Israel's largest university tertiary care center. The study population comprised 668 patients operated on between January 1, 2006, and June 30, 2022. All patient data were extracted from our departmental database. Concomitant or stand-alone surgical AF ablation. The mean duration of follow-up was 106 ± 66.7 months. Freedom from AF was 97.6% (n = 615) and mortality was 3% (n = 20) at the 1-year follow-up, 95.3% (n = 574) and 6.1% (n = 45) at 3 years, 90.1% (n = 396) and 9.1% (n = 61) at 5 years, and 77.5% (n = 308) and 10.8% (n = 72) at 7 years. According to logistic regression analysis, age and female sex determined the 7-year freedom from AF, and risk factors for 7-year mortality included diabetes mellitus, age, and valve surgery. Surgical ablation had a high success rate, with freedom from recurrent atrial arrhythmia at 1-, 3-, 5-, and 7-year follow-ups. Age and female sex were factors determining the 5- and 7-year recurrence of AF.

Left atrial strain predicts the rhythm outcome in patients with persistent atrial fibrillation undergoing left atrial cryoablation during minimally invasive mitral valve repair.

Patients with atrial fibrillation (AF) have lower left atrial (LA) strain, which is a predictor for LA function. Here, we evaluated the prognostic value of LA strain to predict the rhythm outcome in patients with persistent AF undergoing LA cryoablation concomitant to minimally invasive mitral valve repair. Between 01/2016 and 12/2020, 72 patients with persistent AF underwent LA cryoablation during minimally invasive mitral valve surgery. All patients received a complete LA lesion set and left atrial appendage (LAA) closure with a clip. All patients received preoperative transthoracic echocardiography (TTE) with LA and left ventricular strain measurements. Preoperative LA and LV strain analysis was correlated with postoperative rhythm outcome. The mean age of the patients was 66.9 ± 7.2 years, of whom 42 (58%) were male patients. No major ablation-related complications occurred in any of the patients. Successful LAA closure was confirmed by intraoperative echocardiography in all patients. The 1-year survival rate was 97%. Freedom from AF at 12 months was 72% and 68% off antiarrhythmic drugs. Preoperative LA strain values were statistically significantly higher in patients with freedom from AF at 12 months of follow-up (12.7% ± 6.9% vs. 4.9% ± 4.1%, p = 0.006). Preoperative LV strain value was not associated with postoperative rhythm outcome. In multivariate logistic regression analysis, LA strain (p < 0.001) and AF duration (p = 0.017) were predictors for freedom from AF at 12 months of follow-up. In our study, LA strain analysis predicted the rhythm outcome in patients with persistent AF undergoing concomitant surgical AF ablation. In the future, LA strain might be a useful tool to guide decision-making on ablation strategies in patients with persistent AF.

One-year postprocedural quality of life following mitral valve surgery: data from The Netherlands heart registration.

The aim of surgical treatment of mitral valve disease is to reverse heart failure and to restore life expectancy and quality of life (QoL). In mitral valve surgery, QoL has not been studied extensively, especially regarding the surgical approach. The current study aimed to evaluate QoL after mitral valve surgery through full sternotomy and a minimally invasive approach (MIMVS). All patients undergoing mitral valve surgery between 2013-2018 through sternotomy or a MIMVS approach (right anterolateral mini-thoracotomy, sternal-sparing), with or without concomitant tricuspid valve surgery, surgical ablation, or atrial septal defect closure were eligible for inclusion in this multicentre nationwide registry in the Netherlands. Quality of life was measured using the 12- and 36-item short form surveys, before surgery and postoperatively at 1 year. Independent predictors for loss of QoL were evaluated. 485 patients were included (full sternotomy: n = 276, and MIMVS: n = 209). Overall, patients experienced a significant increase in physical component score (56 [42-75] vs 74 [57-88], p < 0.001) and mental component score at 1-year (63 [52-74] vs 70 [59-86], p < 0.001). Baseline QoL scores and new onset of atrial arrhythmia were independently associated with a clinically relevant reduction in physical and mental QoL. Mitral valve surgery is associated with significant improvement in physical and mental QoL. Baseline QoL scores and new onset of atrial arrhythmia are associated with a clinically relevant reduction in postoperative QoL.

Clinical benefits of surgical ablation during isolated aortic valve replacement: a nationwide study.

To compare the early- and long-term clinical outcomes of concomitant surgical ablation (SA) for atrial fibrillation (AF) during isolated aortic valve replacement (AVR) using data from the Korean National Health Insurance Service Database. Of 23,332 adult patients who underwent AVR between 2003 and 2019, those with underlying AF with or without concomitant SA were extracted, and propensity score matching analysis was performed. Overall, 1,741 patients with underlying AF with (n = 445, group A) or without (n = 1,296, group N) concomitant SA during isolated AVR were enrolled, from whom 435 pairs were matched in a 1:1 ratio using propensity score matching analysis. The operative mortality and early postoperative morbidities, including bleeding reoperation, stroke, permanent pacemaker implantation and acute kidney injury were comparable between the groups. The overall survival showed no differences between the groups. However, the cumulative incidence of new-onset late ischaemic stroke was significantly lower in group A than group N in propensity score-matched patients [2.3 vs 3.5 per 100 patient-years, adjusted hazard ratio (95% confidence interval) 0.64 (0.43-0.96), Group A versus Group N, respectively]. The cumulative incidence of other morbidities such as reoperation, permanent pacemaker implantation and progression to chronic renal failure showed no difference between groups. The incidence of late ischaemic stroke was significantly lower when concomitant SA was performed during isolated AVR in patients with underlying AF. Therefore, concomitant SA should be actively considered in patients with underlying AF undergoing isolated AVR to prevent the occurrence of late ischaemic stroke.

Surgical options for atrial fibrillation treatment during concomitant cardiac procedures.

Current guidelines recommend concomitant surgical ablation (SA) of atrial fibrillation (AF) in the context of mitral valve disease. A variety of energy sources have been tested for SA to perform effective transmural lesions reliably. To date, only radiofrequency and cryothermy energies are considered viable options. The gold standard for SA is the Cox-Maze ablation set, especially for non-paroxysmal AF (nPAF), with the aim of interrupting macro-reentrant drivers perpetuating AF, without hampering the sinus node activation of both atria, and to maintain the atrioventricular synchrony. Although the efficacy of SA in terms of early and late sinus rhythm restoration has been clearly demonstrated over the years, concomitant AF ablation is still underperformed in patients with AF undergoing cardiac surgery. From a surgical standpoint, concerns have been raised about whether a single (left) or double atriotomy would be justified in AF patients undergoing a "non-atriotomy" surgical procedure, such as aortic valve or revascularization surgery. Thus, an array of simplified lesion sets have been described in the last decade, which have unavoidably hampered procedural efficacy, somewhat jeopardizing the standardization process of ablation surgery. As a matter of fact, the term "Maze" has improperly become a generic term for SA. Surgical interventions that do not align with the principles of forming conduction-blocking lesions according to the Maze pattern, cannot be classified as Maze procedures. In this complex scenario, a tailored approach according to the different AF patterns has been proposed: for patients with concomitant nPAF, a biatrial Cox-Maze ablation is recommended. Conversely, it might be reasonable to limit lesions to the left atrium or the pulmonary veins in patients with paroxysmal AF (PAF) in some clinical scenarios. The aim of this review is to provide an overview of the current ablation strategies for patients with AF undergoing concomitant cardiac surgery.

Concomitant Surgical Ablation for Treatment of Atrial Fibrillation in Patients Undergoing Minimally Invasive Mitral Valve Surgery: A Single-Center Experience in Vietnam

Abstract Background This study presents the early and midterm outcomes of combining atrial fibrillation (AF) treatment with minimally invasive mitral valve surgery (MIMVS) at our center. Methods From January 2017 to June 2022, our center treated a total of 86 patients with both MIMVS and surgical AF ablation. The patient cohort included 62 women (72.1%) and 24 men (27.9%). The average EuroScore II was 2.64 ± 1.49%, and the patients were followed up for an average period of 46.31 ± 9.84 months. Results Postoperatively, 95.3% of patients experienced a change in sinus rhythm, and 86.2% were discharged in sinus rhythm. The hospital's mortality rate was 2.3%, with a late mortality rate of 3.5%. Survival analysis revealed an atrial fibrillation–free 5-year follow-up rate of 59.1 ± 9.1%. The 5-year survival rate was 92.7 ± 3.3%. Conclusion Our 5-year experience demonstrates that the combination of MIMVS and surgical AF ablation can be routinely performed with favorable peri- and postoperative outcomes. This reflects our hospital's culture and guidance on patient selection, particularly when adopting minimally invasive approaches for multiple procedures.

Postoperative atrial fibrillation (POAF) after cardiac surgery: clinical practice review.

Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with elevated morbidity and mortality. Although current prediction models have limited efficacy, several perioperative interventions can reduce patients' risk of POAF. These begin with preoperative medications, including beta-blockers and amiodarone. Moreover, patients should be screened for preexisting atrial fibrillation (AF) so that concomitant surgical ablation and left atrial appendage occlusion can be performed in appropriate candidates. Intraoperative interventions such as posterior pericardiectomy can reduce mediastinal fluid accumulation, which is a trigger for POAF. Furthermore, many preventive strategies for POAF are implemented in the immediate postoperative period. Initiating beta-blockers, amiodarone, or both is reasonable for most patients. Overdrive atrial pacing, colchicine, and steroids have been used by some, although the evidence base is less robust. For patients with POAF, rate-control and rhythm-control strategies have comparable outcomes. Decision-making regarding anticoagulation should recognize that the stroke risk associated with POAF appears to be lower than that for general nonvalvular AF. The evidence that oral anticoagulation reduces stroke risk is less clear for POAF patients than for patients with general nonvalvular AF. Given that POAF tends to be shorter-lived and is associated with greater bleeding risks in the perioperative period, decisions regarding anticoagulation should be individualized. Finally, wearable technology and machine learning algorithms for better predicting and managing POAF appear to be coming soon. These technologies and a comprehensive clinical program could meaningfully reduce the incidence of this common complication.

Additional bypass graft or concomitant surgical ablation? Insights from the HEIST registry

BackgroundSurgical ablation for atrial fibrillation at the time of isolated coronary artery bypass grafting is reluctantly attempted. Meanwhile, complete revascularization is not always possible in these patients. We attempted to counterbalance the long-term benefits of surgical ablation against the risks of incomplete revascularization. MethodsAtrial fibrillation patients undergoing isolated coronary artery bypass grafting for multivessel disease between 2012 to 2022 and included in the HEart surgery In atrial fibrillation and Supraventricular Tachycardia registry were divided into complete revascularization, complete revascularization with additional grafts, and incomplete revascularization cohorts; these were further split into surgical ablation and non-surgical ablation subgroups. ResultsA total of 8,405 patients (78% men; age 69.3 ± 7.9) were included; of those, 5,918 (70.4%) had complete revascularization, and 556 (6.6%) had surgical ablation performed. Number of anastomoses was 2.7 ± 1.2. The median follow-up was 5.1 [interquartile range 2.1–8.8] years. In patients in whom complete revascularization was achieved, surgical ablation was associated with long-term survival benefit: hazard ratio 0.69; 95% confidence intervals (0.50–0.94); P = .020 compared with grafting additional lesions. Similarly, in patients in whom complete revascularization was not achieved, surgical ablation was associated with a long-term survival benefit of 0.68 (0.49–0.94); P = .019. When comparing surgical ablation on top of incomplete revascularization against complete revascularization without additional grafts or surgical ablation, there was no difference between the 2: 0.84 (0.61–1.17); P = .307, which was also consistent in the propensity score–matched analysis: 0.75 (0.39–1.43); P = .379. ConclusionTo achieve complete revascularization is of utmost importance. However, when facing incomplete revascularization at the time of coronary artery bypass grafting in a patient with underlying atrial fibrillation, concomitant surgical ablation on top of incomplete revascularization is associated with similar long-term survival as complete revascularization without surgical ablation.

Surgical ablation, left atrial appendage occlusion or both? Nationwide registry analysis of cardiac surgery patients with underlying atrial fibrillation.

The aim of this study was to evaluate in-hospital outcomes and long-term survival of patients undergoing cardiac surgery with preoperative atrial fibrillation (AF). We compared different strategies, including no-AF treatment, left atrial appendage occlusion (LAAO) alone, concomitant surgical ablation (SA) alone or both. A retrospective analysis using the KROK registry included all patients with preoperative diagnosis of AF who underwent cardiac surgery in Poland between between January 2012 and December 2022. Risk adjustment was performed using regression analysis with inverse probability weighting of propensity scores. We assessed 6-year survival with Cox proportional hazards models. Sensitivity analysis was performed based on index cardiac procedure. Initially, 42510 patients with preoperative AF were identified, and, after exclusion, 33949 included in the final analysis. A total of 1107 (3.26%) received both SA and LAAO, 1484 (4.37%) received LAAO alone, 3921 (11.55%) SA alone and the remaining 27437 (80.82%) had no AF-directed treatment. As compared to no treatment, all strategies were associated with survival benefit over 6-year follow-up. A gradient of treatment was observed with the highest benefit associated with SA + LAAO followed by SA alone and LAAO alone (log-rank P < 0.001). Mortality benefits were reflected when stratified by surgery type with the exception of aortic valve surgery where LAAO alone fare worse than no treatment. Among patients with preoperative AF undergoing cardiac surgery, surgical management of AF, particularly SA + LAAO, was associated with lower 6-year mortality. These findings support the benefits of incorporating SA and LAAO in the management of AF during cardiac surgery.

Surgical ablation of atrial fibrillation during mitral valve surgery: a systematic review and meta-analysis.

Atrial fibrillation (AF) is a common tachyarrhythmia, affecting approximately 33 million people worldwide, and is frequently associated with mitral valve disease. Surgical ablation during mitral valve surgery provides an opportune circumstance for arrhythmia correction. The results of recent randomized trial data are promising, demonstrating both safety and efficacy. The aim of this systematic review is to report the efficacy and morbidity of concomitant surgical ablation for AF during mitral valve surgery. Five electronic databases were searched from inception to March 2023. All studies reporting the primary outcome, freedom from AF (FFAF), for patients with a history of AF undergoing concomitant mitral valve surgery were identified. Studies with patient cohorts less than 100 were excluded. Relevant data were extracted and a meta-analysis of proportions was conducted using a random-effects model. Survival data were pooled from original Kaplan-Meier curves and reconstructed, reporting aggregate FFAF and survival. Thirty-six studies with a total of 8,340 patients were included in the systematic review. All 36 papers reported postoperative FFAF with a pooled result of 76.9% [95% confidence interval (CI): 73.8-79.9%] at a weighted mean follow-up of 40.2 months, however this result was associated with significant heterogeneity (I2=89%). A total of 31 studies reported postoperative short-term mortality, with a pooled result of 1.68% (95% CI: 1.15-2.29%). Aggregate survival at 1 to 5 years was 93.7%, 92.5%, 91.3%, 89.4%, and 87%, respectively, and aggregate FFAF for 1 to 5 years was 90.2%, 83.5%, 79.5%, 76.4% and 73.2%, respectively. Evaluation of the evidence suggests that concomitant ablation for AF during mitral valve surgery is both safe and efficacious. The results were associated with significant heterogeneity, reflective of variable institutional protocols, patient characteristics, and lesion sets. Randomized data with longer term follow-up would help validate these results.

Trends in surgical ablation at the time of cardiac surgery among patients with atrial fibrillation

BackgroundThe 2017 American Association for Thoracic Surgery (AATS) guidelines support surgical ablation in patients undergoing cardiac surgery with preoperative atrial fibrillation (AF) owing to a reduction in early mortality and improved overall safety. We explored practice patterns changes and outcomes in patients undergoing concomitant surgical ablation following the guideline change. MethodsWe identified 19,246 patients with preoperative AF who underwent cardiac surgery between 2016 and 2019 from the Florida and Maryland State Inpatient Databases. Rates of surgical ablation by procedure type were temporally trended across years. Secondary outcomes included complications, inpatient mortality, and hospital readmissions. Using multivariable logistic regression, we identified patient variables associated with concomitant surgical ablation. ResultsA total of 2738 patients (14.3%) with AF underwent a concomitant surgical ablation. The rate of surgical ablation increased from 2.1% to 17.4% (P < .001) from 2016 to 2017 but remained unchanged thereafter. Postoperative mortality was lower in the surgical ablation cohort (2.7% vs 3.7%; P = .006), although with a higher rate of pacemaker insertion (11.8% vs 7.2%; P < .0001). Patients with a high-risk Elixhauser score (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.73-0.95), lower income (OR, 0.66; 95% CI, 0.57-0.75), or African American or Hispanic race/ethnicity (OR, 0.80; 95% CI, 0.67-0.96 and OR, 0.82; 95% CI, 0.71-0.96, respectively) had lower odds of undergoing concomitant surgical ablation. ConclusionsDespite a class I-2a recommendation by the AATS, surgical ablation continues to be underutilized in clinical practice, especially in patients with high-risk comorbidities, with lower incomes, or from minority populations. Surgeons should be mindful of guideline-directed AF management in these vulnerable populations.

Outcomes of concomitant surgical ablation in patients undergoing surgical myectomy for hypertrophic obstructive cardiomyopathy: A systematic review and meta-analysis

ObjectiveStudies investigating the efficacy of concomitant surgical atrial fibrillation (AF) ablation in hypertrophic obstructive cardiomyopathy (HOCM) patients undergoing myectomy are scarce and limited in terms of sample size. We aim to summarize current outcomes of concomitant surgical AF ablation in HOCM patients undergoing surgical myectomy. MethodsThis systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included all studies reporting any of the following outcomes of concomitant surgical AF ablation in HOCM patients: freedom from recurrence of AF, overall survival and complications. Outcomes were evaluated using traditional meta-analysis at given time-points and using pooled Kaplan-Meier curves. ResultsA total of 13 studies were included, resulting in a total of 616 individual patients available for analysis. AF was paroxysmal in 68.1% of the patients (95% CI 56.0–78.2%; I2 = 87.1%; 8 studies, 583 participants). The majority of patients (86.2%) underwent either conventional Cox Maze III or IV (95% CI 39.7–98.3%; I2 = 92.4%; 8 studies, 616 patients) procedure. The incidence of early post-operative pacemaker implantation was 6.1% (95% CI 3.1–11.8%). Overall survival at 3, 5 and 7 years was 95.6% (95% CI 93.4–97.9%), 93.6% (95% CI 90.8–96.5%) and 90.5% (95% CI 86.5–94.6%), respectively. Freedom from recurrent AF at 3, 5 and 7 years was 77.6% (95% CI 73.7–81.7%), 70.6% (95% CI 65.8–75.7) and 63.2% (95% CI 56.2–73.8%), respectively. ConclusionThis meta-analysis supports concomitant surgical AF ablation at the time of surgical myectomy in HOCM patients, as it seems to be safe and effective in terminating AF.

Surgical ablation of atrial fibrillation is associated with improved survival compared with appendage obliteration alone: An analysis of 100,000 Medicare beneficiaries

ObjectiveSocietal guidelines support the concomitant surgical ablation of atrial fibrillation in patients undergoing cardiac surgery. Recent evidence has highlighted the stroke reduction of left atrial appendage obliteration with or without surgical ablation in similar populations. To inform clinical decision-making, we evaluated real-world outcomes of patients with atrial fibrillation undergoing cardiac surgery by comparing no atrial fibrillation management with left atrial appendage obliteration alone versus surgical ablation + left atrial appendage obliteration. MethodsBy using the US Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all beneficiaries aged 65 years and older with a diagnosis of atrial fibrillation undergoing coronary artery bypass grafting or mitral/aortic/tricuspid valve repair or replacement between January 2018 and December 2020. Diagnosis-related group and International Classification of Diseases, 10th Revision procedure codes were used to define variables. Risk adjustment was performed with regression analysis using inverse probability weighting of propensity scores and Cox proportional hazards models. Subgroup analyses stratified patients by primary operation and paroxysmal or persistent atrial fibrillation. ResultsA total of 103,382 patients with preoperative atrial fibrillation were stratified by surgical ablation + left atrial appendage obliteration (10,437; 10.1%), left atrial appendage obliteration alone (12,901; 12.5%), or no atrial fibrillation management (80,044; 77.4%). Patients with persistent atrial fibrillation (21,076; 20.4%) received the highest proportion of surgical ablation + left atrial appendage obliteration (4661 19.4%) and left atrial appendage obliteration alone (3%724%; 15.4%) versus no atrial fibrillation management (15,688; 65.2%). Likewise, patients undergoing open atrial operations (mitral/tricuspid; 17,204; 16.6%) had higher proportions of atrial fibrillation treatment (surgical ablation + left atrial appendage obliteration 5267 30.6%; left atrial appendage obliteration alone 4259 24.8%; no atrial fibrillation management 7678 44.6%). After robust risk adjustment, surgical ablation + left atrial appendage obliteration was independently associated with reduced 3-year mortality compared with no atrial fibrillation treatment (hazard ratio, 0.68, P < .001) and left atrial appendage obliteration alone (hazard ratio, 0.90, P < .001). Compared with no atrial fibrillation treatment, readmissions for embolic stroke were lower with both surgical ablation + left atrial appendage obliteration (hazard ratio, 0.77, P = .009) and left atrial appendage obliteration alone (hazard ratio, 0.73, P < .001). Reduction in 3-year composite mortality or stroke after surgical ablation + left atrial appendage obliteration was superior to left atrial appendage alone (hazard ratio, 0.90, P = .035). ConclusionsIn Medicare beneficiaries with atrial fibrillation undergoing cardiac surgery, the surgical management of atrial fibrillation was associated with lower 3-year mortality and readmission for stroke, with surgical ablation + left atrial appendage obliteration being associated with higher survival compared with left atrial appendage obliteration alone.