Ablation of atrial fibrillation in high-risk patients during cardiac surgery: freedom from atrial fibrillation without risk escalation, data from the CASE-AF registry

Bernd Niemann (Gießen)1, U. Puvogel (Gießen)1, T. Ouarrak (Ludwigshafen am Rhein)2, J. Senges (Ludwigshafen am Rhein)2, T. Hanke (Hamburg)3, N. Doll (Bad Rothenfelde)4, H. Grubitzsch (Berlin)5, A. Rastan (Marburg)6, T. Walther (Frankfurt am Main)7, P. Massoudy (Passau)8, M. Vondran (Rotenburg an der Fulda)9, A. Böning (Gießen)1

1Universitätsklinikum Gießen und Marburg GmbH Klinik für Herz-, Kinderherz- und Gefäßchirurgie Gießen, Deutschland; 2Stiftung Institut für Herzinfarktforschung Ludwigshafen am Rhein, Deutschland; 3Asklepios Klinikum Harburg I. Medizinische Abteilung, Kardiologie Hamburg, Deutschland; 4Schüchtermann-Klinik Bad Rothenfelde Herzchirurgie Bad Rothenfelde, Deutschland; 5Charite Klinik für Herz-, Thorax- und Gefäßchirurgie Berlin, Deutschland; 6Universitätsklinikum Giessen und Marburg GmbH Klinik für Herz- und thorakale Gefäßchirurgie Marburg, Deutschland; 7Universitätsklinikum Frankfurt Klinik für Thorax-, Herz- und Thorakale Gefäßchirurgie Frankfurt am Main, Deutschland; 8Klinikum Passau Klinik für Herzchirurgie Passau, Deutschland; 9Herz-Kreislauf-Zentrum, Klinikum Hersfeld-Rotenburg GmbH Rotenburg an der Fulda, Deutschland



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.


The Case AF Registry is a prospective, multicenter, all-comers registry of lonestanding 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 versus >2; ASA ScoreI/II versus III-IV).Higher NYHA score, ischemic heart failure, status post stroke, renal insufficiency, COPD and diabetes mellitus were strongly represented in HRP.


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 frequnet 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. Longterm 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 recieved 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% versus 60.1% HRP (p<0.001) showed SR , anticoagulation remained common in HRP.


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. Pre-operative risk scores should not lead to withholding an ablation procedure

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