Combined surgical atrial fibrillation (AF) ablation and surgical left atrial appendage closure (LAAC): a systematic review and meta-analysis protocol

Atrial fibrillation (AF) is a common cardiac arrhythmia with an increasing prevalence and is associated with substantial clinical and societal burden. In patients undergoing cardiac surgery, AF is linked with a higher risk of morbidity and mortality compared with individuals without AF. Intraoperative management of AF usually involves surgical ablation or surgical left atrial appendage closure (LAAC); however, both procedures are used sparingly and the benefit of combining both procedures also remains uncertain. This systematic review and meta-analysis will assess the clinical outcomes of combining surgical AF ablation and LAAC in patients undergoing cardiac surgery. This protocol aligns with PRISMA-P guidelines and was registered on PROSPERO (CRD420251035845). Embase, MEDLINE and Scopus will be comprehensively searched from inception using terms for ‘atrial fibrillation’, ‘LAAC’ and ‘surgical ablation’. Results will be synthesized using STATA 18.0 using random-effects pairwise meta-analysis. If sufficient data are available across three intervention strategies (combined surgical AF ablation + LAAC, AF ablation alone, LAAC alone), an exploratory network meta-analysis will also be performed. The Cochrane Risk of Bias 2 tool will be used to assess risk of bias in randomized trials, and the ROBINS-I tool for non-randomized studies. The GRADE framework will be used to determine the certainty of evidence for each outcome. The findings will clarify the clinical impact of concomitant cardiac surgery involving surgical ablation, and LAAC. It will help determine whether the combined approach improves outcomes when compared to performing a single procedure.