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Kumar NS, Khanji MY, Patel KP, Ricci F, Providencia R, Chahal A, Sohaib A, Awad WI. Surgical management of atrial fibrillation in patients undergoing cardiac surgery: a systematic review of clinical practice guidelines and recommendations. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:14-24. [PMID: 37873664 DOI: 10.1093/ehjqcco/qcad060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 09/20/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
AIMS Surgical ablation of atrial fibrillation (AF) has been demonstrated to be a safe procedure conducted concomitantly alongside cardiac surgery. However, there are conflicting guideline recommendations surrounding indications for surgical ablation. We conducted a systematic review of current recommendations on concomitant surgical AF ablation. METHODS AND RESULTS We identified publications from MEDLINE and EMBASE between January 2011 and December 2022 and additionally searched Guideline libraries and websites of relevant organizations in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of 895 studies screened, 4 were rigorously developed (AGREE-II > 50%) and included. All guidelines agreed on the definitions of paroxysmal, persistent, and longstanding AF based on duration and refraction to current treatment modalities. In the Australia-New Zealand (CSANZ) and European (EACTS) guidelines, opportunistic screening for patients >65 years is recommended. The EACTS recommends systematic screening for those aged >75 or at high stroke risk (Class IIa, Level B). However, this was not recommended by American Heart Association or Society of Thoracic Surgeons guidelines. All guidelines identified surgical AF ablation during concomitant cardiac surgery as safe and recommended for consideration by a Heart Team with notable variation in recommendation strength and the specific indication (three guidelines fail to specify any indication for surgery). Only the STS recommended left atrial appendage occlusion (LAAO) alongside surgical ablation (Class IIa, Level C). CONCLUSION Disagreements exist in recommendations for specific indications for concomitant AF ablation and LAAO, with the decision subject to Heart Team assessment. Further evidence is needed to develop recommendations for specific indications for concomitant AF procedures and guidelines need to be made congruent.
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Affiliation(s)
- Niraj S Kumar
- Barts Heart Centre, St. Bartholomew's Hospital, London, UK
- National Medical Research Association, London, UK
| | - Mohammed Y Khanji
- Barts Heart Centre, St. Bartholomew's Hospital, London, UK
- Newham University Hospital, Barts Health NHS Trust, London, UK
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Kush P Patel
- Barts Heart Centre, St. Bartholomew's Hospital, London, UK
- Institute of Cardiovascular Sciences, University College London, UK
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, G.d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Rui Providencia
- Department of Cardiac Electrophysiology, Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Anwar Chahal
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Wael I Awad
- Barts Heart Centre, St. Bartholomew's Hospital, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
- University of South Wales, Cardiff, UK
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Hanafy DA, Erdianto WP, Husen TF, Nathania I, Vidya AP, Angelica R, Suwatri WT, Lintangella P, Prasetyo P, Sugisman. Three Ablation Techniques for Atrial Fibrillation during Concomitant Cardiac Surgery: A Systematic Review and Network Meta-Analysis. J Clin Med 2023; 12:5716. [PMID: 37685784 PMCID: PMC10488688 DOI: 10.3390/jcm12175716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/19/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Atrial fibrillation (AF) ablation is a frequent procedure used in concomitant cardiac surgery. However, uncertainty still exists concerning the optimal extent of lesion sets. Hence, the objective of this study was to assess the results of various ablation techniques, aiming to offer a reference for clinical decision making. This review is listed in the prospective register of systematic reviews (PROSPERO) under ID CRD42023412785. A comprehensive search was conducted across eight databases (Scopus, Google Scholar, EBSCOHost, PubMed, Medline, Wiley, ProQuest, and Embase) up to 18 April 2023. Studies were critically appraised using the Cochrane Risk of Bias 2.0 for randomized control trials (RCTs) and the Newcastle Ottawa Scale adapted by the Agency for Healthcare Research and Quality (AHRQ) for cohort studies. Forest plots of pooled effect estimates and surface under the cumulative ranking (SUCRA) were used for the analysis. Our analysis included 39 studies and a total of 7207 patients. Both bi-atrial ablation (BAA) and left atrial ablation (LAA) showed similar efficacy in restoring sinus rhythm (SR; BAA (77.9%) > LAA (76.2%) > pulmonary vein isolation (PVI; 66.5%); LAA: OR = 1.08 (CI 0.94-1.23); PVI: OR = 1.36 (CI 1.08-1.70)). However, BAA had higher pacemaker implantation (LAA: OR = 0.51 (CI 0.37-0.71); PVI: OR = 0.52 (CI 0.31-0.86)) and reoperation rates (LAA: OR = 0.71 (CI 0.28-1.45); PVI: OR = 0.31 (CI 0.1-0.64)). PVI had the lowest efficacy in restoring SR and a similar complication rate to LAA, but had the shortest procedure time (Cross-clamp (Xc): PVI (93.38) > LAA (37.36) > BAA (13.89)); Cardiopulmonary bypass (CPB): PVI (93.93) > LAA (56.04) > BAA (0.03)). We suggest that LAA is the best surgical technique for AF ablation due to its comparable effectiveness in restoring SR, its lower rate of pacemaker requirement, and its lower reoperation rate compared to BAA. Furthermore, LAA ranks as the second-fastest procedure after PVI, with a similar CPB time.
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Affiliation(s)
- Dudy Arman Hanafy
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Faculty of Medicine, University of Indonesia, Jl. Salemba Raya No. 6, Kenari, Jakarta 10430, Indonesia; (D.A.H.)
- Division of Adult Cardiac Surgery, Department of Surgery, National Cardiovascular Center, Harapan Kita, Jakarta 11420, Indonesia;
| | - Wahyu Prima Erdianto
- Division of Adult Cardiac Surgery, Department of Surgery, National Cardiovascular Center, Harapan Kita, Jakarta 11420, Indonesia;
| | - Theresia Feline Husen
- Faculty of Medicine, University of Indonesia, Pondok Cina, Beji, Depok 16424, Indonesia
| | - Ilona Nathania
- Faculty of Medicine, University of Indonesia, Pondok Cina, Beji, Depok 16424, Indonesia
| | - Ananda Pipphali Vidya
- Faculty of Medicine, University of Indonesia, Pondok Cina, Beji, Depok 16424, Indonesia
| | - Ruth Angelica
- Faculty of Medicine, University of Indonesia, Pondok Cina, Beji, Depok 16424, Indonesia
| | - Widya Trianita Suwatri
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Faculty of Medicine, University of Indonesia, Jl. Salemba Raya No. 6, Kenari, Jakarta 10430, Indonesia; (D.A.H.)
- Division of Adult Cardiac Surgery, Department of Surgery, National Cardiovascular Center, Harapan Kita, Jakarta 11420, Indonesia;
| | - Pasati Lintangella
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Faculty of Medicine, University of Indonesia, Jl. Salemba Raya No. 6, Kenari, Jakarta 10430, Indonesia; (D.A.H.)
| | - Priscillia Prasetyo
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Faculty of Medicine, University of Indonesia, Jl. Salemba Raya No. 6, Kenari, Jakarta 10430, Indonesia; (D.A.H.)
| | - Sugisman
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Faculty of Medicine, University of Indonesia, Jl. Salemba Raya No. 6, Kenari, Jakarta 10430, Indonesia; (D.A.H.)
- Division of Adult Cardiac Surgery, Department of Surgery, National Cardiovascular Center, Harapan Kita, Jakarta 11420, Indonesia;
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