Prioritizing surgical ablation for atrial fibrillation during coronary artery bypass grafting: new evidence, old...

Atrial fibrillation (AF) affects 10-20% of patients undergoing coronary artery bypass grafting (CABG) and is associated with increased postoperative morbidity and mortality. Although studies support the safety and effectiveness of surgical ablation (SA), and guidelines recommend its use during CABG for patients with preexisting AF, clinical adoption remains limited.

In this review, we outline current guideline recommendations, evaluate the evidence base, highlight recent analyses, and examine persistent barriers to the adoption of SA during CABG, informed by studies identified through searches of PubMed and Google Scholar.

Small randomized studies demonstrate that SA restores sinus rhythm following CABG, while observational studies suggest rhythm restoration improves survival and reduces thromboembolic events. Recent national database analyses have lent further support, finding an association between SA and long-term survival. Analytic approaches included analysis by treatment type using propensity-score risk adjustment and, more recently, using surgeon frequency of SA as an instrumental variable. However, concerns about unmeasured confounding, sparse rhythm follow-up, and limited lesion-set granularity undermine confidence and contribute to underuse. A randomized trial comparing long-term outcomes between pulmonary vein isolation, left atrial, and bi-atrial lesion sets is critically needed to guide optimal implementation of SA during CABG.