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Treat paroxysmal atrial fibrillation during cardiac surgery: study

NEW YORK (Reuters Health) – Like permanent atrial fibrillation, paroxysmal atrial fibrillation (PAF) should be treated when patients undergo cardiac surgery, a retrospective study suggests.

“Preoperative paroxysmal AF reduces long-term survival after cardiac surgery, and the addition of AF surgery is safe and may restore overall survival,” Dr. Chris Malaisrie from Northwestern University, Feinberg School of Medicine, Chicago, Illinois, told Reuters Health. “The question of whether the addition of AF surgery improves survival will need to be validated further in larger national datasets.”

Even though AF ablation adds only nine minutes of cross-clamp and cardiopulmonary bypass time, only 38% of patients with preoperative AF undergoing cardiac surgery are treated at surgery, he and his colleagues say in their report.

Using data from the Bluhm Cardiovascular Institute’s Clinical Trial Units Cardiovascular Research Database, they investigated whether treating PAF during cardiac surgery might improve freedom from AF compared with untreated PAF.

Of 552 PAF patients, 423 (77%) were treated concomitant to other cardiac operations, according to the report online July 29 in The Journal of Thoracic and Cardiovascular Surgery.

The treated PAF group had fewer perioperative complications (28% vs 43% in the untreated PAF group), lower 30-day mortality (2% vs 6% for untreated PAF), and a higher rate of freedom from AF at follow-up (85% vs 66%). The treated group also had a higher rate of late ablation (9% vs 5%).

After propensity score matching, the treated PAF group spent significantly less time in the intensive care unit and had significantly fewer total complications, a significantly lower risk of all-cause overall mortality, and significantly higher freedom from AF at the last follow-up visit.

Compared to patients with no AF before surgery, the treated PAF group had longer perfusion and cross-clamp times, longer hospital stays, and fewer complications overall, but the operative, 30-day, and all-cause mortality rates did not differ significantly.

Survival in the treated PAF and no AF groups was lower for patients in AF at the last follow-up visit, whereas overall survival in the untreated PAF group did not differ between those in AF and those with freedom from AF.

“When considering the risk-to-benefit ratio of adding PAF surgery, no concerns were raised that it would add to the perioperative risk,” the researchers note, “a similar observation to that from the randomized trials and the Society of Thoracic Surgeons database report.”

“We strongly believe that patients with preoperative AF (either paroxysmal or permanent) should have their AF ablated at the time of cardiac surgery,” Dr. Malaisrie advises.

But, he added, “The older, sicker patient who is undergoing reoperative cardiac surgery…(such as CABG or AVR) would be the typical patient that we may decline concomitant AF surgery.”

Dr. Petr Budera from Charles University, Prague, Czech Republic, told Reuters Health, “This published article has a limitation, that the study was not randomized. However, the message about safety of adding AF ablation procedure to cardiac surgery is very convincing.”

“I think that concomitant AF ablation should be performed routinely,” said Dr. Budera, who recently completed a similar study in AF patients. “I would not favor the ablation in extremely high-risk patient, who needs just a ‘simple, quick surgery,’ for example, palliative off-pump monobypass on (the left anterior descending artery) and in patients with extremely large left atrium, over 55 mm.”


J Thorac Cardiovasc Surg 2013.