Concomitant surgical ablation during cardiac surgery in patients with atrial fibrillation improves the achievement of sinus rhythm and increases ejection fraction (+4.1% more than control).
Does concomitant surgical ablation improve clinical and resource outcomes in adults with atrial fibrillation undergoing cardiac surgery compared to cardiac surgery alone?
Concomitant surgical ablation for AF during cardiac surgery is recommended to improve sinus rhythm maintenance and exercise tolerance without increasing perioperative risks.
Objective This purpose of this consensus conference was to determine whether surgical atrial fibrillation (AF) ablation during cardiac surgery improves clinical and resource outcomes compared with cardiac surgery alone in adults undergoing cardiac surgery for valve or coronary artery bypass grafting. Methods Before the consensus conference, the consensus panel reviewed the best available evidence, whereby systematic reviews, randomized trials, and nonrandomized trials were considered in descending order of validity and importance. Evidence-based statements were created, and consensus processes were used to determine the ensuing recommendations. The American Heart Association/American College of Cardiology system was used to label the level of evidence and class of recommendation. Results The consensus panel agreed on the following statements in patients with AF undergoing cardiac surgery concomitant surgical ablation: 1. Improves the achievement of sinus rhythm at discharge and 1 year (level A); this effect is sustained up to 5 years (level B). Does not reduce the use of antiarrhythmic drugs at 12 months after surgery (level A; 36.0% vs. 45.4%), although trials were not designed to answer this question. 2. Does not increase the requirement for permanent pacemaker implantation (4.4% vs. 4.8%; level A). 3. Does not increase the risk of perioperative mortality (level A), stroke (level A), myocardial infarction (level B), cardiac tamponade (level A), reoperative bleeding (level A), esophageal injury (level B), low cardiac output (level A), intraaortic balloon (level B), congestive heart failure (level B), ejection fraction (EF; level B), pleural effusion (level A), pneumonia (level A), renal dysfunction (level B), and mediastinitis (level A). The incidence of esophageal injury remains to be low (level B). 4. Does not reduce mortality at 1 year (level A). There is a possible reduction in mortality beyond 1 year (level B), but no difference in stroke (level A), myocardial infarction (level A), and heart failure (level B). EF is increased (+4.1% more than control; level A). 5. Has been shown to improve exercise tolerance at 1 year (level A), but no impact on quality of life at 3 months and 1 year (level A); however, the methodology used and the number of trials studying these outcomes are insufficient. 6. Increases cardiopulmonary bypass and cross-clamp times (level A), with no difference in intensive care unit and hospital length of stay (level A). Overall costs were not reported. Conclusions Given these evidence-based statements, the consensus panel stated that, in patients with persistent and permanent AF undergoing cardiac surgery, concomitant surgical ablation is recommended to increase incidence of sinus rhythm at short- and long-term follow-up (class 1, level A); to reduce the risk of stroke and thromboembolic events (class 2a, level B); to improve EF (class 2a, level A); and to exercise tolerance (class 2a, level A) and long-term survival (class 2a, level B).
Ad et al. (Mon,) conducted a review in Atrial fibrillation in adults undergoing cardiac surgery. Concomitant surgical ablation vs. Cardiac surgery alone was evaluated on Clinical and resource outcomes. Concomitant surgical ablation during cardiac surgery in patients with atrial fibrillation improves the achievement of sinus rhythm and increases ejection fraction (+4.1% more than control).