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Evidence summaries

Concomitant Atrial Fibrillation Surgery for People Undergoing Cardiac Surgery

For patients with atrial fibrillation (AF) undergoing cardiac surgery, concomitant AF surgery appears to increase freedom from atrial fibrillation, atrial flutter, or atrial tachycardia off anti-arrhythmic drugs, while increasing the risk of permanent pacemaker implantation. Level of evidence: "B"

The quality of evidence is downgraded by study limitations (unclear allocation concealment and lack of blinding).

Summary

A Cochrane review[Abstract] 1 included 22 studies with a total of 1 899 subjects. The studies assessed the effects of concomitant atrial fibrillation (AF) surgery among people with AF who were undergoing cardiac surgery for other underlying reasons; mitral valve surgery was the most common primary cardiac surgery (86%). Concomitant atrial fibrillation surgery (cut-and-sew maze, radiofrequency ablation, cryoablation, or high-intensity focused ultrasound with or without left atrial appendage excision or ligation) was compared with no AF surgery.

There was no difference in all-cause mortality between individuals who underwent AF surgery and those who did not, but AF surgery increased freedom from atrial fibrillation, atrial flutter (AFL), or atrial tachycardia (AT) off antiarrhythmic medications > 3 months after surgery. The rate of adverse of events defined by investigators were not routinely reported but were not different between the two groups. The only individual adverse event that appeared higher in the intervention group was the need for permanent pacemaker implantation (table T1).

There was uncertainty of any effect of concomitant AF surgery on cardiovascular mortality, other adverse events, fatal or non-fatal cardiovascular events, neurological or thromboembolic events, or health-related quality of life. Data on costs and cost-effectiveness were infrequently reported. One study reported results on costs and cost-effectiveness of AF surgery. The authors estimated that AF surgery costs an additional 74 724 € and was not considered cost-effective with an incremental cost-effectiveness ratio of 73 359 € per quality adjusted life year based on results from the EuroQoL instrument.

Concomitant atrial fibrillation surgery compared to no atrial fibrillation surgery for people undergoing cardiac surgery

OutcomeRelative effect (95% CI)Risk with no atrial fibrillation surgeryRisk with concomitant atrial fibrillation surgery (95% CI)Participants (studies)
All-cause mortalityRR 1.14(0.81 to 1.59)66 per 100075 per 1000(53 to 105)1 829(20 studies)
Freedom from AF/AFL/AT off antiarrhythmic medications > 3 monthsRR 2.04(1.63 to 2.55)241 per 1000492 per 1000(393 to 615)649(8 studies)
Investigator-defined adverse eventsRR 1.07(0.85 to 1.34)236 per 1000252 per 1000(201 to 316)858(9 studies)
Pacemaker implantationRR 1.69(1.12 to 2.54)41 per 100069 per 1000(46 to 104)1 726(18 studies)
30-day mortalityRR 1.25(0.71 to 2.20)23 per 100029 per 1000(16 to 51)1 566(18 studies)

Clinical comments

Note

Date of latest search:

References

  • Huffman MD, Karmali KN, Berendsen MA et al. Concomitant atrial fibrillation surgery for people undergoing cardiac surgery. Cochrane Database Syst Rev 2016;(8):CD011814. [PubMed]

Primary/Secondary Keywords