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