Atrial Fibrillation Ablation During Cardiac Surgery Linked to Improved Long-Term Survival

Surgical ablation for atrial fibrillation (AF) concomitant to other cardiac procedures, including mitral valve repair/replacement plus tricuspid intervention or coronary artery bypass graft (CABG), is associated with significantly improved long-term survival regardless of an individual’s baseline surgical risk. These findings were published in The Journal of Thoracic and Cardiovascular Surgery.

A multicenter, retrospective, propensity-matched study (ClinicalTrials.gov Identifier: NCT04860882) was conducted among patients from the HEart Surgery In Atrial Fibrillation and Supraventricular Tachycardia (HEIST) registry. It is well known that the presence of preoperative AF increases a patient’s risk for stroke, heart failure (HF), and all-cause mortality following cardiac procedures. Investigators sought to evaluate long-term mortality following surgical ablation that precedes a cardiac procedure.

All consecutive adult patients with presurgical AF who had received a conventional sternotomy heart procedure between 2010 and 2021 at 8 tertiary centers in Poland, the Netherlands, and Italy were enrolled in the study. The primary study endpoint was mortality at follow-up after cardiac procedure alone compared with cardiac procedure and concomitant surgical ablation. Secondary outcomes included early mortality (<48 hour and 30-day rates), in-hospital complications, and intensive care unit length of stay (LOS) and hospital LOS.

A total of 20,765 patients with AF receiving cardiac procedure were identified. Overall, 62% of them were men. Participants’ mean age was 68.2±15.3 years and the average European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was 5.48%±8.28%.

Results of the study showed that 2755 patients received surgical ablation for AF and 18,010 did not. The highest rates of surgical ablation were observed among those who received mitral interventions (mitral valve repair or replacement plus tricuspid intervention; 25.2%). The lowest rates were among patients who received isolated CABG (6.2%). Patients in the surgical-ablation group were significantly younger than those in the nonsurgical-ablation group (mean age, 64.5±9.0 years vs 68.7±16.0 years, respectively; P <.001) and had a significantly lower mean EuroSCORE II (4.1 vs 5.7, respectively; P <.001).

Throughout the 11-year study, a significant decrease in mortality was associated with the use of surgical ablation (hazard ratio [HR], 0.57; 95% CI, 0.52-0.62; P <.001). Following propensity matching, a total of 2750 pairs with similar baseline characteristics were identified and were assigned to the surgical-ablation arm or nonsurgical-ablation arms. The performance of concomitant surgical ablation was associated with a 16% decline in mortality compared with no use of surgical ablation (HR, 0.84; 95% CI, 0.75-0.94; P =.003).

Limitations of the study include that the registry did not collect data on long-term outcomes other than all-cause mortality, which might further enhance the registry and influenced the remote outcome. Further, certain detailed baseline and operative data, including AF type and duration, ablation energy source, and ablation duration, were not recorded. Although propensity score matching accounted for all of the variables included in EuroSCORE II, unmeasured biases and confounders may remain.

“In this multicenter, retrospective, propensity-matched study [surgical ablation] concomitant to other cardiac surgery was associated with a significantly improved long-term survival regardless of baseline surgical risk,” the study authors wrote.

Reference 

Kowalewski M, Pasierski M, Kołodziejczak M, et al. Atrial fibrillation ablation improves late survival after concomitant cardiac surgery. J Thorac Cardiovasc Surg. Published online May 14, 2022. doi:10.1016/j.tcvs.2022.04.035