Abstract
Background
Surgical atrial ablation is evaluated by surgeons in relation to the estimated surgical
risk. We analyze whether high-risk patients (HRPs) experience risk escalation by ablation
procedures.
Methods
The CASE-Atrial Fibrillation (AF) registry is a prospective, multicenter, all-comers
registry of atrial ablation in cardiac surgery. We analyzed the 1-year outcome regarding
survival and rhythm endpoints of 1,000 consecutive patients according to the operative
risk classification (EuroSCORE II ≤ 2 vs. >2).
Results
Higher NYHA (New York Heart Association) score, ischemic heart failure, status poststroke,
renal insufficiency, chronic obstructive pulmonary disease, and diabetes mellitus
were strongly represented in HRPs. HRPs exhibit more left ventricular ejection fraction < 40%
(19.2 vs. 8.8%; p < 0.001) but identical left atrial diameter and left ventricular end-diastolic diameter
compared with low-risk patients (LRPs). CHA2DS-Vasc-score (2.4 ± 1 vs. 3.6 ± 1.5;
p < 0.001), sternotomies, combination surgeries, coronary artery bypass graft, and
mitral valve procedures were increased in HRPs. LRPs underwent stand-alone ablations
as well. Ablation energy did not differ. Left atrial appendage closure was performed
in up to 86.1% (mainly cut-and-sew procedures). Mortality corresponded to the original
risk class without an escalation that may be related to ablation, stroke rate, or
myocardial infarction. A total of 60.6% of HRPs versus 75.1% of LRPs were discharged
in sinus rhythm. Long-term EHRA (European Heart Rhythm Association) score symptoms
were lower in HRPs. Repeated rhythm therapies were rare. Additional antiarrhythmics
received a minority without group dependency. A total of 1.6 versus 4.1% of HRPs (p = 0.042) underwent long-term stroke; excess mortality was not observed. Anticoagulation
remained common in HRPs.
Conclusion
Surgical risk and long-term mortality are determined by the underlying disease. In
HRPs, freedom from AF and symptom relief can be achieved. Preoperative risk scores
should not lead to withholding an ablation procedure.
Keywords
arrhythmia therapy - outcomes - surgery - complications
