Does Surgical Ablation of Atrial Fibrillation Benefit Patients Undergoing Bioprosthetic Valve Replacement?

      The benefit of avoiding lifelong anticoagulation therapy in patients with bioprosthetic heart valve implantation may potentially be offset by atrial fibrillation (AF); however, clinical impact of surgical AF ablation in such patients remains controversial. We enrolled 426 patients (aged 72.0 ± 7.8 years) with AF who underwent left-side valve replacement with bioprostheses between 2001 and 2018. Of these, 297 underwent concomitant surgical ablation (ablation group) and 129 underwent valve replacement alone (non-ablation group). Clinical outcomes were compared, and mortality was considered as a competing risk factor against valve-related complications. Inverse-probability weighting (IPTW) was adopted to reduce selection bias. The ablation group had lower baseline risk profiles than the non-ablation group. In crude analysis, early mortality rates were 3.4% and 7.0% in the ablation and non-ablation groups, respectively (P = 0.104). During follow-up (1521.9 patient-years), the ablation group showed lower AF-recurrence (P < 0.001) and anticoagulant medication rate (P = 0.021), and lower overall mortality risk (subdistribution hazard ratio [SHR], 0.63; 95% confidence interval [CI], 0.42–0.94), but higher risk of permanent pacemaker implantation (SHR, 4.67; 95% CI, 1.36–16.05). No significant difference in the risk of stroke (SHR, 1.27; 95% CI, 0.55–2.95) was observed between the groups. After baseline IPTW-adjustment, findings of the clinical outcomes were analogous to those from crude analyses. In patients undergoing bioprosthetic valve replacement, the addition of surgical ablation was associated with improved rhythm outcomes and survival but at the expense of a higher risk of pacemaker implantation. The underlying mechanism of improved survival by AF ablation needs further investigation.

      Graphical Abstract



      AF (atrial fibrillation), CI (confidence interval), SHR (subdistribution hazard ratio), IPTW (inverse-probability of treatment weighting), PS (propensity score), SMD (standardized mean difference)
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          In this issue of Seminars in Thoracic and Cardiovascular Surgery, Pyo et al address the question “Does surgical ablation of atrial fibrillation benefit patients undergoing bioprosthetic valve replacement?”1 They conclude that adding surgical ablation for atrial fibrillation reduces the prevalence of atrial fibrillation, decreases the need for anticoagulation, and improves long-term survival at the expense of an increased pacemaker requirement. There are reasons to question these conclusions, chiefly that the risk profiles were far more favorable in those who underwent ablation when compared to those who did not receive ablation.
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