Concomitant atrial fibrillation surgery for people undergoing cardiac surgery

Abstract

Background People with atrial fibrillation (AF) often undergo cardiac surgery for other underlying reasons and are frequently offered concomitant AF surgery to reduce the frequency of short- and long-term AF and improve short- and long-term outcomes. Objectives To assess the effects of concomitant AF surgery among people with AF who are undergoing cardiac surgery on short-term and long-term (12 months or greater) health-related outcomes, health-related quality of life, and costs. Search methods Starting from the year when the first “maze” AF surgery was reported (1987), we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (March 2016), MEDLINE Ovid (March 2016), Embase Ovid (March 2016), Web of Science (March 2016), the Database of Abstracts of Reviews of Effects (DARE, April 2015), and Health Technology Assessment Database (HTA, March 2016). We searched trial registers in April 2016. We used no language restrictions. Selection criteria We included randomised controlled trials evaluating the effect of any concomitant AF surgery compared with no AF surgery among adults with preoperative AF, regardless of symptoms, who were undergoing cardiac surgery for another indication. Data collection and analysis Two review authors independently selected studies and extracted data. We evaluated the risk of bias using the Cochrane ‘Risk of bias’ tool. We included outcome data on all-cause and cardiovascular-specific mortality, freedom from atrial fibrillation, flutter, or tachycardia off antiarrhythmic medications, as measured by patient electrocardiographic monitoring greater than three months after the procedure, procedural safety, 30-day rehospitalisation, need for post-discharge direct current cardioversion, health-related quality of life, and direct costs. We calculated risk ratios (RR) for dichotomous data with 95% confidence intervals (CI) using a fixed-effect model when heterogeneity was low (I2 ≤ 50%) and random-effects model when heterogeneity was high (I2 > 50%). We evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to create a ‘Summary of findings’ table. Main results We found 34 reports of 22 trials (1899 participants) with five additional ongoing studies and three studies awaiting classification. All included studies were assessed as having high risk of bias across at least one domain. The effect of concomitant AF surgery on all-cause mortality was uncertain when compared with no concomitant AF surgery (7.0% versus 6.6%, RR 1.14, 95% CI 0.81 to 1.59, I2 = 0%, 20 trials, 1829 participants, low-quality evidence), but the intervention increased freedom from atrial fibrillation, atrial flutter, or atrial tachycardia off antiarrhythmic medications > three months (51.0% versus 24.1%, RR 2.04, 95% CI 1.63 to 2.55, I2 = 0%, eight trials, 649 participants, moderate-quality evidence). The effect of concomitant AF surgery on 30-day mortality was uncertain (2.3% versus 3.1%, RR 1.25 95% CI 0.71...

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…W przeglądzie systematycznym zamówionym na potrzeby niniejszych wytycznych stwierdzono, że chirurgiczne leczenie AF przy okazji innej operacji kardiochirurgicznej zwiększało odsetek pacjentów bez AF, trzepotania przedsionków lub częstoskurczu przedsionkowego w porównaniu z niestosowaniem takiego leczenia (RR 1,94; 95% CI 1,51-2,49; n = 554 w 7 RCT) (dodatkowa ryc. 3) [1040]. Pacjenci poddawani zabiegowi labiryntowania według Coxa czę-www.kardiologiapolska.pl ściej wymagali wszczepienia stymulatora (RR 1,69; 95% CI 1,12-2,54; n = 1631 w 17 RCT), ale nie stwierdzono różnic pod względem innych wyników leczenia lub powikłań.…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…461,466,784 -798 In a systematic review commissioned for these guidelines, performing concomitant AF surgery resulted in increased freedom from AF, atrial flutter, and atrial tachycardia compared to no concomitant AF surgery (RR 1.94; 95% CI 1.51-2.49; n ¼ 554 from seven RCTs) (Web Figure 3). 1040 Patients undergoing the Cox maze procedure required pacemaker implantation more often (RR 1.69 799 Predictors of AF recurrence after surgery include left atrial dilatation, older age, .10-year history of AF, and non-paroxysmal AF. 800 -804 Regarding AF type, surgical PVI seems effective in paroxysmal AF.…”

Minimally invasive epicardial posterior left atrial wall isolation: technique and results

“…After thoracoscopic offpump radiofrequency pulmonary vein isolation plus left atrial appendage exclusion 60% to 80% of patients obtain sinus rhythm [23][24][25][26]. Moreover one systematic review suggested that the efficacy of stand-alone surgical ablation by bipolar radiofrequency is equivalent to the cut-and-sew maze III technique [4].…”

“…There are three limitations to doing this on the full beating heart: visualization behind the full beating heart's left atrium is very limited; circumflex coronary artery overlying the mitral valve could be damage, and the coronary sinus is unreliable, and may leave a gap [4].…”

“…For patients with AF undergoing cardiac surgery, there is moderate-quality evidence that concomitant AF surgery approximately doubles the percentage of freedom from AF, atrial flutter, or atrial tachycardia off antiarrhythmic drugs while increasing the risk of permanent pacemaker implantation [4]. However, due to the need for open-heart surgery and the morbidity associated with the surgical Cox-Maze procedure, minimally invasive and epicardial-endocardial (hybrid) ablation procedures have been developed.…”