Impact of clinical presentation and surgeon experience on the decision to perform surgical ablation

Patients with atrial fibrillation (AF) undergoing cardiac surgery have higher morbidity and decreased survival. Recent data revealed that surgical ablation (SA) is performed in only 39% of these patients, with variability among surgeons. The aim of this study was to determine the impact of clinical presentation and surgeon experience when making the decision to treat AF concomitantly with another cardiac surgical procedure.

Since 2005, we identified 983 nonemergent patients with preoperative AF at our institution with 41% (n=401) having a concomitant SA. Logistic regression identified independent predictors for SA. The number of SAs performed captured surgeon experience in AF ablation.

Major growth in the percent of SA performed for AF was noted (31% in 2005 vs 49% in 2010; p<0.001). Independent predictors (χ2=283.5, p<0.001, area under the curve=0.80) for SA were found, including concomitant mitral valve surgery (odds ratio [OR]=5.81) and lower creatinine (OR=4.34). Surgeon experience predicted SA with 6% greater odds for every 10 SA cases performed (OR=1.06, p<0.001). The group of surgeons with 50 or greater SA cases ablated, 57% of AF patients (301 of 526), compared with those with less than 50 cases ablated, 22% (101 of 457; p<0.001).

We demonstrated that patient acuity and surgeon experience are significantly associated with the decision to perform concomitant SA for AF. Only the most experienced surgeons performed SA in patients with more complex clinical presentation. These findings, together with the negative impact of AF on patient outcomes, should prompt a comprehensive approach to educate and train surgeons in the performance of SA for AF when clinically justified.