Surgical Ablation of Atrial Fibrillation in High-risk Patients: High Success Rates without Risk Escalation, Data from the CASE-AF Registry

Background: Surgical atrial ablation is often evaluated by the treating physician in relation to the estimated surgical risk. We analyze whether high-risk patients (HRP) experience risk escalation by ablation procedures and degrees achieved for freedom from atrial fibrillation and symptomatic benefit.

Methods: The Case AF Registry is a prospective, multicenter, all-comers registry of lone standing and concomitant atrial ablation in cardiac surgery. We analyzed the 2-year outcome regarding survival and rhythm endpoints of 1000 consecutive patients according to the operative risk classification (EurocoreII≤2 vs. >2; ASA Score I/II vs. III-IV).Higher NYHA score, ischemic heart failure, status post stroke, renal insufficiency, COPD and diabetes mellitus were strongly represented in HRP.

Results: HRP exhibit more LVEF<40% (19.2 vs. 8.8%; p < 0.001), but identical LA diameter and LVEDD. In HRP CHA2DS-Vasc score (2.4 ± 1 vs. 3.6 ± 1.5; p < 0.001), not HAS-BLED score was increased. Preoperative rhythm medication or anticoagulation were balanced. Sternotomies, combination surgeries, coronary revascularizations were more frequent in HRP . Low-risk groups underwent stand-alone ablations (p < 0.001) as well. Mitral valve procedures were increased in HRP (p = 0.002). Ablation energy did not differ. LAA closure was performed in up to 86.1%, mainly as cut and sew procedure followed by clip application procedures. Mortality corresponded to the original risk class in all groups without an ablation-associated escalation, stroke rate or myocardial infarction. 60.6% of HRP vs. 75.1% (p < 0.001) were discharged in sinus rhythm (SR), remaining atrial fibrillation entities were balanced. Long-term EHRA - symptoms tended to be lower in HRP. Repeated rhythm therapies were rare and balanced. Long term additional therapies were balanced (pacemaker/bleeding). Beta-blockers (76.6 vs. 72.8; p = 0.19) as indicated according to primary diagnosis and class III antiarrhythmics received a minority of patients without group dependency (p = 0.29). 1.6 vs. 4.1% p = 0.042, of HRP showed stroke in the long-term (12 month), excess mortality was not observed. 75.1% vs. 60.1% HRP (p < 0.001) showed SR, anticoagulation remained common in HRP.

Conclusion: Surgical risk and long-term mortality is determined by the underlying disease and not by the ablation. Even in HRP high rates of freedom from atrial fibrillation and symptom relief can be achieved. Preoperative risk scores should not lead to withholding an ablation procedure.

Publication History

Article published online:
13 February 2024