Atrial fibrillation in coronary artery bypass patients: what should be offered

Of patients undergoing coronary artery bypass grafting (CABG), 10-20% have preexisting atrial fibrillation (AF), which remains undertreated at the time of surgery. With rapidly evolving data, interest and enthusiasm for concomitant surgical management of AF have grown concurrently. This review summarizes the contemporary evidence, techniques, and approaches for surgical management of AF in patients undergoing CABG and proposes tailored operative strategies for these patients at the time of surgery.

Concomitant surgical management of AF at the time of CABG is underutilized, with only 30-40% of eligible patients receiving concomitant AF treatment. Surgeons can offer a spectrum of options to concurrently treat AF, from left atrial appendage occlusion (LAAO) to a full biatrial Cox-maze iteration without significant additional perioperative risk. Contemporary large-scale observational analyses suggest concomitant surgical ablation improves rhythm outcomes and is associated with improved survival, and lower risk of stroke long-term.

Concomitant LAAO is essential. Ablation techniques can be tailored based on the patient's burden of AF, clinical complexity, and surgeon expertise. A robust randomized trial is needed to convince clinicians to expand adoption.