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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Surgical Ablation of Atrial Fibrillation in High-Risk Patients: Success versus Risk
Bernd Niemann1, Nicolas Doll2, Herko Grubitzsch3
1Justus-Liebig-Universität Giessen, UKGM - Klinik für Herz-, Kinderherz- und Gefäßchirurgie, Giessen, Hessen, Germany.
Insights
Surgical atrial ablation in high-risk patients (HRPs) does not escalate mortality or stroke risk. Ablation offers freedom from atrial fibrillation (AF) and symptom relief, proving beneficial even for complex cases.
Area of Science:
- Cardiovascular Surgery
- Electrophysiology
- Cardiac Arrhythmias
Background:
- Surgical atrial ablation is a procedure evaluated based on estimated surgical risk.
- The study investigates whether high-risk patients (HRPs) experience increased risk following ablation procedures.
Purpose of the Study:
- To analyze the 1-year outcomes of atrial ablation in high-risk patients compared to low-risk patients.
- To determine if ablation procedures escalate risks in patients with pre-existing comorbidities.
Main Methods:
- Analysis of the prospective, multicenter CASE-Atrial Fibrillation (AF) registry.
- Inclusion of 1,000 consecutive patients undergoing atrial ablation in cardiac surgery.
- Patient stratification based on EuroSCORE II (≤2 vs. >2) to define HRPs and LRPs.
Main Results:
- HRPs had higher rates of comorbidities (e.g., heart failure, stroke history, renal insufficiency, COPD, diabetes) and lower ejection fraction.
- Despite increased complexity (e.g., combination surgeries, CABG, mitral valve procedures), mortality and stroke rates in HRPs did not exceed their baseline risk.
- Similar rates of freedom from AF and symptom relief were observed between HRPs and LRPs, with lower long-term symptoms in HRPs.
Conclusions:
- Underlying disease, not ablation, determines long-term mortality in HRPs.
- Atrial ablation is effective in achieving freedom from AF and symptom relief in HRPs.
- Preoperative risk scores should not preclude HRPs from undergoing ablation procedures.
Abstract:
Surgical atrial ablation is evaluated by surgeons in relation to the estimated surgical risk. We analyze whether high-risk patients (HRPs) experience risk escalation by ablation procedures.The CASE-Atrial Fibrillation (AF) registry is a prospective, multicenter, all-comers registry of atrial ablation in cardiac surgery. We analyzed the 1-year outcome regarding survival and rhythm endpoints of 1,000 consecutive patients according to the operative risk classification (EuroSCORE II ≤ 2 vs. >2).Higher NYHA (New York Heart Association) score, ischemic heart failure, status poststroke, renal insufficiency, chronic obstructive pulmonary disease, and diabetes mellitus were strongly represented in HRPs. HRPs exhibit more left ventricular ejection fraction < 40% (19.2 vs. 8.8%; p < 0.001) but identical left atrial diameter and left ventricular end-diastolic diameter compared with low-risk patients (LRPs). CHA2DS-Vasc-score (2.4 ± 1 vs. 3.6 ± 1.5; p < 0.001), sternotomies, combination surgeries, coronary artery bypass graft, and mitral valve procedures were increased in HRPs. LRPs underwent stand-alone ablations as well. Ablation energy did not differ. Left atrial appendage closure was performed in up to 86.1% (mainly cut-and-sew procedures). Mortality corresponded to the original risk class without an escalation that may be related to ablation, stroke rate, or myocardial infarction. A total of 60.6% of HRPs versus 75.1% of LRPs were discharged in sinus rhythm. Long-term EHRA (European Heart Rhythm Association) score symptoms were lower in HRPs. Repeated rhythm therapies were rare. Additional antiarrhythmics received a minority without group dependency. A total of 1.6 versus 4.1% of HRPs (p = 0.042) underwent long-term stroke; excess mortality was not observed. Anticoagulation remained common in HRPs.Surgical risk and long-term mortality are determined by the underlying disease. In HRPs, freedom from AF and symptom relief can be achieved. Preoperative risk scores should not lead to withholding an ablation procedure.
