Surgical Ablation for Atrial Fibrillation During Minimally Invasive Mitral Valve Surgery: Risk Dependencies and Long-Term Survival

Objective: Atrial fibrillation (AF) is a common finding among patients with mitral valve disease, with a growing body of evidence showing survival benefits associated with surgical ablation (SA). However, a lack of data persists regarding the safety and survival after SA concomitant to minimally invasive mitral valve surgery (MIMVS). Methods: We retrospectively collected data from the Polish National Registry of Cardiac Surgery Procedures (Krajowy Rejestr Operacji Kardiochirurgicznych), searching for all adult patients with AF who underwent MIMVS between 2006 and 2021. Initially, 1,545 patients were identified; SA was performed on 512 patients (33.2%). Propensity score matching comparing MIMVS + SA versus MIMVS alone was performed. Results: Matching resulted in 365 pairs with similar baseline characteristics (median age = 65 years, interquartile range [IQR]: 58 to 70 years; median EuroSCORE II = 2.2%, IQR: 1.4 to 3.4). We observed no differences in 24 h mortality for MIMVS + SA versus MIMVS alone (0.3% vs 0.0%, P = 0.99). Although there was no difference in in-hospital complications, neurologic complications were reported less frequently in the SA group (2.7% vs 8.2%, P = 0.002). Unadjusted survival analysis favored MIMVS+SA (hazard ratio [HR] = 0.52, 95% confidence interval [CI]: 0.40 to 0.69, P < 0.001). However, after adjustment for baseline risk factors, the effect was no longer significant (HR = 0.85, 95% CI: 0.56 to 1.32, P = 0.48). When stratified on baseline CHA 2 DS 2 -VASc score, a gradient of benefit was seen, with patients at higher thromboembolic risk gaining the most benefits from concomitant SA. Conclusions: Patients with a higher thromboembolic risk gain the most benefits from concomitant SA. SA was associated with fewer neurologic complications.