Surgical Ablation of Atrial Fibrillation in the United States: Trends and Propensity Matched Outcomes

Background Surgical ablation (SA) for atrial fibrillation (AF) effectively restores sinus rhythm. Incompletely defined risk has previously limited concomitant performance of SA during cardiac operations. The study goals were to define performance trends and risk-adjusted outcomes for contemporary SA. Methods From July 2011 to June 2014, 86,941 patients with AF, but without endocarditis, underwent primary nonemergent cardiac operations in The Society of Thoracic Surgeons (STS) database. Cochran-Armitage tests examined performance trends of SA for six operative categories: mitral valve repair or replacement (MVRR) with or without coronary artery bypass graft surgery (CABG), aortic valve replacement (AVR) with or without CABG, CABG, AVR with MVRR, stand-alone SA, and other concomitant operations. The risk of concomitant SA was analyzed by propensity matching 28,739 patient-pairs with and without SA by AF type, primary operation, and STS comorbid risk variables using greedy 1:1 matching algorithms. Results Among all patients with AF, 48.3% (42,066 of 86,941) underwent SA. Mitral operations had the highest rate of SA (MVRR ± CABG 68.4% [14,693 of 21,496]; MVRR + AVR 59.1% [1,626 of 2,750]). The AVR ± CABG and isolated CABG rates were 39.3% (6,816 of 17,349) and 32.8% (9,156 of 27,924), respectively. Nearly half of other concomitant operations underwent SA, 47.6% (6,939 of 14,586). Performance frequency increased throughout the study period. After propensity matching, SA was associated with a reduction in relative risk (RR) of 30-day mortality (RR 0.92, 95% confidence interval [CI]: 0.85 to 0.99) and stroke (RR 0.84, 95% CI: 0.74 to 0.94), but an increase in renal failure (RR 1.12, 95% CI: 1.03 to 1.22) and pacemaker implantation (RR 1.33, 95% CI: 1.24 to 1.43). Conclusions Contemporary utilization of SA is increasing across all operative categories. Performance of SA is accompanied by a 30-day reduction in mortality and stroke. These findings further refine our understanding of the role of SA in the treatment of AF.