Clinical Insights to Complete and Incomplete Surgical Revascularization in Atrial Fibrillation and Multivessel Coronary Disease

Abstract

ObjectivesAlthough endorsed by international guidelines, complete revascularization (CR) with Coronary Artery Bypass Grafting (CABG) remains underused. In higher-risk patients such as those with pre-operative atrial fibrillation (AF), the effects of CR are not well studied.MethodsWe analyzed patients’ data from the HEIST (HEart surgery In AF and Supraventricular Tachycardia) registry. Between 2012 and 2020 we identified 4770 patients with pre-operative AF and multivessel coronary artery disease who underwent isolated CABG. We divided the cohort according to the completeness of the revascularization and used propensity score matching (PSM) to minimize differences between baseline characteristics. The primary endpoint was all-cause mortality.ResultsMedian follow-up was 4.7 years [interquartile range (IQR) 2.3–6.9]. PSM resulted in 1,009 pairs of complete and incomplete revascularization. Number of distal anastomoses varied, accounting for 3.0 + –0.6 vs. 1.7 + –0.6, respectively. Although early (< 24 h) and 30-day post-operative mortalities were not statistically different between non-CR and CR patients [Odds Ratio (OR) and 95% Confidence Intervals (CIs): 1.34 (0.46–3.86); P = 0.593, Hazard Ratio (HR) and 95% CIs: 0.88 (0.59–1.32); P = 0.542, respectively] the long term mortality was nearly 20% lower in the CR cohort [HR (95% CIs) 0.83 (0.71–0.96); P = 0.011]. This benefit was sustained throughout subgroup analyses, yet most accentuated in low-risk patients (younger i.e., < 70 year old, with a EuroSCORE II < 2%, non-diabetic) and when off-pump CABG was performed.ConclusionComplete revascularization in patients with pre-operative AF is safe and associated with improved survival. Particular survival benefit with CR was observed in low-risk patients undergoing off-pump CABG.

2023 KASNet Guidelines on Atrial Fibrillation Surgery

“…Finally, it is worth noting that there may be a significant association between complete revascularization and long-term mortality in patients with preexisting AF. A database extracted from the multinational registry Heart Surgery in Atrial Fibrillation and Supraventricular Tachycardia (HEIST) [ 64 ] showed that complete revascularization resulted in a 20% lower long-term mortality rate than incomplete revascularization. Therefore, in non-prohibited risk patients with preexisting AF, it would be beneficial to aim for both SA and complete revascularization, even if this takes longer to perform.…”