Graham R McClure1,2, Emilie P Belley-Cote2,3,4,5, Iqbal H Jaffer6,7, Nazari Dvirnik2,4,7, Kevin R An1, Gabriel Fortin5, Jessica Spence2,8, Jeff Healey3,4, Rohit K Singal9,10, Richard P Whitlock2,4,7. 1. Michael G. DeGroote School of Medicine, McMaster University, 1280 Main St W, Hamilton, ON, Canada. 2. Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St W, Hamilton, ON, Canada. 3. Department of Medicine, McMaster University, 1280 Main St W, Hamilton, ON, Canada. 4. Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada. 5. Department of Medicine, Université de Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, Canada. 6. Thrombosis & Atherosclerosis Research Institute (TaARI), McMaster University, 20 Copeland Ave, Hamilton, ON, Canada. 7. Department of Cardiac Surgery, McMaster University, 1280 Main St W, Hamilton, ON, Canada. 8. Department of Anesthesia, McMaster University, 1280 Main St W, Hamilton, ON, Canada. 9. Department of Surgery, University of Manitoba, 66 Chancellors Cir, Winnipeg, MB, Canada. 10. I.H. Asper Clinical Research Institute, St. Boniface General Hospital, 69 Taché Avenue, Winnipeg, MB, Canada.
Abstract
Aims: The aim of this review was to assess the effect of concomitant surgical atrial fibrillation (AF) ablation on postoperative freedom from AF and patient-important outcomes. Methods and results: We searched Cochrane CENTRAL, MEDLINE, and EMBASE databases from inception to May 2016 for randomized controlled trials (RCTs) evaluating surgical AF ablation using any lesion set vs. no surgical AF ablation in adults with AF undergoing cardiac surgery. We performed screening, risk-of-bias evaluation, and data collection independently and in duplicate. We evaluated risk of bias with the modified Cochrane tool, quality of evidence using GRADE framework, and pooled data with a random-effects model. Of the 23 included studies, only one was considered at low risk of bias. Surgical AF ablation was associated with more freedom from AF at 12 months [relative risk (RR) = 2.32, 95% confidence interval (CI) 1.92-2.80; P < 0.001, low quality]. However, no significant difference was seen in mortality (RR = 1.07, 95% CI 0.72-1.52; P = 0.41, moderate quality), stroke (RR = 1.19, 95% CI 0.59-2.39; P = 0.63, moderate quality), or pacemaker implantation (RR = 1.28, 95% CI 0.85-1.95; P = 0.24, high quality). Comparing biatrial and left-sided lesion sets showed no difference in mortality (P-interaction = 0.60) or stroke (P-interaction = 0.12). At 12 months, biatrial procedures led to more freedom from AF (RR = 2.80, 95% CI 2.13-3.68; P < 0.0001) when compared with left-sided ablation (RR = 2.00, 95% CI 1.68-2.39; P < 0.0001) (P-interaction = 0.04) Biatrial procedures appear to increase the risk for pacemaker (RR = 2.68, 95% CI 1.41-5.11; P = 0.002) compared with no ablation while left-sided ablation does not (RR = 1.08, 95% CI 0.67-1.74; P = 0.76) (P-interaction = 0.03). Conclusion: Surgical AF ablation during cardiac surgery improves freedom from AF. However, impact on patient-important outcomes including mortality and stroke has not shown statistical significance in current RCT evidence. Biatrial compared with left-sided lesion sets showed no difference in mortality or stroke but were associated with significantly increased freedom from AF and risk for pacemaker requirement.
Aims: The aim of this review was to assess the effect of concomitant surgical atrial fibrillation (AF) ablation on postoperative freedom from AF and patient-important outcomes. Methods and results: We searched Cochrane CENTRAL, MEDLINE, and EMBASE databases from inception to May 2016 for randomized controlled trials (RCTs) evaluating surgical AF ablation using any lesion set vs. no surgical AF ablation in adults with AF undergoing cardiac surgery. We performed screening, risk-of-bias evaluation, and data collection independently and in duplicate. We evaluated risk of bias with the modified Cochrane tool, quality of evidence using GRADE framework, and pooled data with a random-effects model. Of the 23 included studies, only one was considered at low risk of bias. Surgical AF ablation was associated with more freedom from AF at 12 months [relative risk (RR) = 2.32, 95% confidence interval (CI) 1.92-2.80; P < 0.001, low quality]. However, no significant difference was seen in mortality (RR = 1.07, 95% CI 0.72-1.52; P = 0.41, moderate quality), stroke (RR = 1.19, 95% CI 0.59-2.39; P = 0.63, moderate quality), or pacemaker implantation (RR = 1.28, 95% CI 0.85-1.95; P = 0.24, high quality). Comparing biatrial and left-sided lesion sets showed no difference in mortality (P-interaction = 0.60) or stroke (P-interaction = 0.12). At 12 months, biatrial procedures led to more freedom from AF (RR = 2.80, 95% CI 2.13-3.68; P < 0.0001) when compared with left-sided ablation (RR = 2.00, 95% CI 1.68-2.39; P < 0.0001) (P-interaction = 0.04) Biatrial procedures appear to increase the risk for pacemaker (RR = 2.68, 95% CI 1.41-5.11; P = 0.002) compared with no ablation while left-sided ablation does not (RR = 1.08, 95% CI 0.67-1.74; P = 0.76) (P-interaction = 0.03). Conclusion: Surgical AF ablation during cardiac surgery improves freedom from AF. However, impact on patient-important outcomes including mortality and stroke has not shown statistical significance in current RCT evidence. Biatrial compared with left-sided lesion sets showed no difference in mortality or stroke but were associated with significantly increased freedom from AF and risk for pacemaker requirement.
Authors: Scott C Brancato; Mansen Wang; Kateri J Spinelli; Maheer Gandhavadi; Neil K Worrall; Eric J Lehr; Zach M DeBoard; Torin P Fitton; Alison Leiataua; Jonathan P Piccini; Ty J Gluckman Journal: Heart Rhythm O2 Date: 2021-12-24