Long-Term Outcomes of Paroxysmal and Persistent Atrial Fibrillation Management Strategy During Non-Emergent Coronary Artery Bypass Surgery

BACKGROUND: Management of atrial fibrillation (AF) at the time of coronary artery bypass grafting (CABG) is a Class 1 recommendation. This study evaluated trends in AF management and their association with long-term survival. METHODS: Patients with paroxysmal or persistent AF undergoing isolated CABG were identified from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2022) with linkage to Medicare claims for long-term outcomes. Patients were stratified by AF treatment: none, left atrial appendage occlusion (LAAO) only, epicardial ablation (EA), or intracardiac ablation (IA). Primary endpoint was all-cause mortality; secondary endpoints included permanent pacemaker placement, stroke, and readmission for AF, bleeding, or heart failure. Long-term mortality was assessed using Kaplan-Meier methods and Cox regression. Nonfatal outcomes were assessed using competing-risk regression with death as the competing event. RESULTS: Among 59,331 patients, 71.0% had paroxysmal AF, increasing from 56.6% (2011) to 79.6% (2022). AF treatment included none (51.0%), LAAO-only (15.3%), EA (25.4%), and IA (8.2%). AF treatment increased from 31.8% to 68.8%, driven by LAAO (1.2% to 30.8%). Patients with Persistent AF had higher mortality than those with paroxysmal AF (p<0.001). EA showed lower mortality compared to no treatment. Intracardiac ablation was associated with higher pacemaker implantation (6.0% vs. 3.2-3.4% in other groups, p<0.001). Compared with no treatment, all treatment groups had lower stroke risk (sHR 0.64-0.79, p<0.001) and lower AF readmission (sHR 0.85-0.89, p<0.05). CONCLUSIONS: Nearly half of AF patients undergoing CABG receive no treatment. Epicardial ablation was associated with superior long-term survival, and all strategies with lower stroke risk.