Temporal trends and predictors of surgical ablation for atrial fibrillation across a multistate healthcare system

Surgical Coronary Revascularization in Patients With Underlying Atrial Fibrillation: State-of-the-Art Review

The number of individuals referred for coronary artery bypass grafting (CABG) with preoperative atrial fibrillation (AF) is reported to be 8% to 20%. Atrial fibrillation is a known marker of high-risk patients as it was repeatedly found to negatively influence survival. Therefore, when performing surgical revascularization, consideration should be given to the concomitant treatment of the arrhythmia, the clinical consequences of the arrhythmia itself, and the selection of adequate surgical techniques. This state-of-the-art review aimed to provide a comprehensive analysis of the current understanding of, advancements in, and optimal strategies for CABG in patients with underlying AF. The following topics are considered: stroke prevention, prophylaxis and occurrence of postoperative AF, the role of surgical ablation and left atrial appendage occlusion, and an on-pump vs off-pump strategy. Multiple acute complications can occur in patients with preexisting AF undergoing CABG, each of which can have a significant effect on patient outcomes. Long-term results in these patients and the future perspectives of this scientific area were also addressed. Preoperative arrhythmia should always be considered for surgical ablation because such an approach improves prognosis without increasing perioperative risk. While planning a revascularization strategy, it should be noted that although off-pump coronary artery bypass provides better short-term outcomes, conventional on-pump approach may be beneficial at long-term follow-up. By collecting the current evidence, addressing knowledge gaps, and offering practical recommendations, this state-of-the-art review serves as a valuable resource for clinicians involved in the management of patients with AF undergoing CABG, ultimately contributing to improved outcomes and enhanced patient care.

Statewide data on surgical ablation for atrial fibrillation: The data provide a path forward

OBJECTIVE

Atrial fibrillation (AF), if left untreated, is associated with increased intermediate and long-term morbidity/mortality. Surgical treatment for AF is lacking standardization in patient selection and lesion set, despite clear support from multi-society guidelines. The aim of this study was to analyze a statewide cardiac surgery registry to establish whether or not there is an association between center volume and type of index procedure with performance of surgical ablation (SA) for AF, the lesion set chosen, and ablation technology used.

METHODS

Adult, first-time, nonemergency patients with preoperative AF between 2014 and 2022 excluding standalone SA procedures from a statewide registry of Society of Thoracic Surgeons data were included (N = 4320). AF treatment variability by hospital volume (ordered from smallest to largest) and surgery type were examined with χ2 analyses. Hospital-level Spearman correlations compared hospital volume with proportion of AF patients treated with SA.

RESULTS

Overall, 37% of patients with AF were ablated at the time of surgery (63% of mitral procedures, 26% of non-mitrals) and 15% had left atrial appendage management only. There was a significant temporal trend of increasing performance of SA for AF over time (Cochran-Armitage = 27.8; P < .001). Hospital cardiac surgery volume did not correlate with the proportion of AF patients treated with SA (rs = 0.19; P = .603) with a rate of SA below the state average for academic centers. Of cases with SA (n = 1582), only 43% had a biatrial lesion set. Procedures that involved mitral surgery were more likely to include a biatrial lesion set (χ2 = 392.3; P < .001) for both paroxysmal and persistent AF. Similarly, ablation technology use was variable by type of concomitant operation (χ2 = 219.0; P < .001) such that radiofrequency energy was more likely to be used in non-mitral procedures.

CONCLUSIONS

These results indicate an increase in adoption of SA for AF over time. No association between greater hospital volume or academic status and performance of SA for AF was established. Similar to national data, the type of index procedure remains the most consistent factor in the decision to perform SA with a disconnect between AF pathophysiology and decision making on the type of SA performed. This analysis demonstrates a gap between evidence-based guidelines and real-world practice, highlighting an opportunity to confer the benefits of concomitant SA to more patients.

Surgical options for atrial fibrillation treatment during concomitant cardiac procedures

Current guidelines recommend concomitant surgical ablation (SA) of atrial fibrillation (AF) in the context of mitral valve disease. A variety of energy sources have been tested for SA to perform effective transmural lesions reliably. To date, only radiofrequency and cryothermy energies are considered viable options. The gold standard for SA is the Cox-Maze ablation set, especially for non-paroxysmal AF (nPAF), with the aim of interrupting macro-reentrant drivers perpetuating AF, without hampering the sinus node activation of both atria, and to maintain the atrioventricular synchrony. Although the efficacy of SA in terms of early and late sinus rhythm restoration has been clearly demonstrated over the years, concomitant AF ablation is still underperformed in patients with AF undergoing cardiac surgery. From a surgical standpoint, concerns have been raised about whether a single (left) or double atriotomy would be justified in AF patients undergoing a "non-atriotomy" surgical procedure, such as aortic valve or revascularization surgery. Thus, an array of simplified lesion sets have been described in the last decade, which have unavoidably hampered procedural efficacy, somewhat jeopardizing the standardization process of ablation surgery. As a matter of fact, the term "Maze" has improperly become a generic term for SA. Surgical interventions that do not align with the principles of forming conduction-blocking lesions according to the Maze pattern, cannot be classified as Maze procedures. In this complex scenario, a tailored approach according to the different AF patterns has been proposed: for patients with concomitant nPAF, a biatrial Cox-Maze ablation is recommended. Conversely, it might be reasonable to limit lesions to the left atrium or the pulmonary veins in patients with paroxysmal AF (PAF) in some clinical scenarios. The aim of this review is to provide an overview of the current ablation strategies for patients with AF undergoing concomitant cardiac surgery.

Influence of concomitant ablation of nonparoxysmal atrial fibrillation during coronary artery bypass grafting on mortality and readmissions

Objective

We determined the utilization rate of surgical ablation (SA) during coronary artery bypass grafting (CABG) and compared outcomes between CABG with or without SA in a national cohort.

Methods

The January 2016 to December 2018 Nationwide Readmissions Database was searched for all patients undergoing isolated CABG with preoperative persistent or chronic atrial fibrillation by using the International Classification of Diseases, 10th Revision classification. Propensity score matching and multivariate logistic regressions were performed to compare outcomes, and Cox proportional hazards model was used to assess risk factors for 1-year readmission.

Results

Of 18,899 patients undergoing CABG with nonparoxysmal atrial fibrillation, 78% (n = 14,776) underwent CABG alone and 22% (n = 4123) underwent CABG with SA. In the propensity score-matched cohort (n = 8116), CABG with SA (n = 4054) (vs CABG alone [n = 4112]) was not associated with increased in-hospital mortality (3.4% [139 out of 4112] vs 3.9% [159 ut of 4054]; P = .4), index-hospitalization length of stay (10 days vs 10 days; P = .3), 30-day readmission (19.1% [693 out of 3362] vs 17.2% [609 out of 3537]; P = .2), or 90-day readmission (28.9% [840 out of 2911] vs 26.2% [752 out of 2875]; P = .1). Index hospitalization costs were significantly higher for those undergoing SA ($52,556 vs $47,433; P < .001). Rates of readmission at 300 days were similar between patients receiving SA (43.8%) and no SA (42.8%; log-rank P = .3). The 3 most common causes of readmission were not different between groups and included heart failure (24.3% [594 out of 2444]; P = .6), infection (16.8% [411 out of 2444]; P = .5), and arrhythmia (11.7% [286 out of 2444]; P = .2).

Conclusions

In patients with nonparoxysmal atrial fibrillation, utilization of SA during CABG remains low. SA during CABG did not adversely influence mortality or short-term readmissions. These findings support increased use of SA during CABG.

Nano drugs delivery system: A novel promise for the treatment of atrial fibrillation

Atrial fibrillation (AF) is one of the most common sustained tachyarrhythmias worldwide, and its prevalence is positively correlated with aging. AF not only significantly reduces the quality of life of patients but also causes a series of complications, such as thromboembolism, stroke, and heart failure, increases the average number of hospitalizations of patients, and places a huge economic burden on patients and society. Traditional drug therapy and ablation have unsatisfactory success rates, high recurrence rates, and the risk of serious complications. Surgical treatment is highly traumatic. The nano drug delivery system has unique physical and chemical properties, and in the application of AF treatment, whether it is used to assist in enhancing the ablation effect or for targeted therapy, it provides a safer, more effective and more economical treatment strategy.