New Practice Guidelines for Surgical Treatment of Atrial Fibrillation

12/23/16

By Will Boggs MD

NEW YORK (Reuters Health) - A new set of clinical practice guidelines from The Society of Thoracic Surgeons includes eight recommendations regarding the surgical treatment of atrial fibrillation (AF).

"These guidelines provide surgeons and cardiologists with renewed understanding how surgical ablation may play an enhanced role in the therapy," Dr. Vinay Badhwar from West Virginia University in Morgantown told Reuters Health by email. "Joining catheter ablation, surgical ablation provides an evidence-based continuum for the most comprehensive approach to our patients with atrial fibrillation."

Surgical ablation has been used to treat atrial fibrillation for more than three decades, and many advances have been made.

Dr. Badhwar and colleagues assessed the optimal application of surgical ablation to provide recommendations for three operation categories in clinical practice: primary open atrial operations, primary closed atrial operations, and standalone operations for AF.

According to the new guidelines, surgical ablation for AF can be performed to restore sinus rhythm without additional risk of operative mortality or major morbidity at the time of concomitant mitral operations and at the time of concomitant isolated aortic valve replacement (AVR), isolated coronary artery bypass graft surgery (CABG), and aortic valve replacement plus CABG.

Surgical ablation is reasonable as a primary standalone procedure for symptomatic AF in the absence of structural heart disease when it is refractory to other therapies.

Pulmonary vein isolation alone is not recommended as surgical ablation, however, for symptomatic AF in the setting of left atrial enlargement or more than moderate mitral regurgitation.

Left atrial appendage excision or exclusion is reasonable for longitudinal thromboembolic morbidity prevention in conjunction with surgical ablation for AF or at the time of concomitant cardiac operations in patients with AF.

Finally, multidisciplinary heart team assessment, treatment planning, and long-term follow-up are recommended as useful and beneficial to optimize patient outcomes in the treatment of AF.

"The evidence for surgical ablation has changed over the last five years," Dr. Badhwar said. "The 2017 STS Guidelines compartmentalize concomitant cardiac operations by categories commonly approached by surgeons. These include closed atrial operations, or cases where the left atrium would not otherwise be opened (i.e., isolated CABG, isolated AVR, or AVR+CABG), open atrial operations such as mitral valve operations, and standalone operations. Given the substantial evidence now available, STS for the first time has made surgical ablation for AF at the time of open atrial mitral operations a Class I, Level of Evidence A recommendation."

"Surgical ablation can now be performed safely and effectively to restore sinus rhythm at minimal to no added morbidity," Dr. Badhwar concluded.

Dr. Benedict Glover from Queen's University, Kingston, Ontario, Canada, who recently reviewed current approaches and future directions for hybrid ablation for AF, told Reuters Health by email, "Although there is reasonable evidence that a surgical approach can be performed in patients undergoing mitral valve surgery with no overall significant increase in complication rates, the evidence for performing this procedure in patients undergoing either isolated aortic valve surgery, coronary artery bypass grafting, or a combination of the two procedures is lacking and, therefore, we should consider this procedure carefully in these patients. It would be useful to acquire further clinical evidence to support this particular strategy."

"I feel that these guidelines further consolidate our clinical practice," he said. "Unfortunately, many trials in this area do not involve large numbers of patients, which always has its own inherent limitations, but we appear to be evolving into an era where there is increasing collaboration between percutaneous and surgical options for the management of atrial fibrillation."

"Although there is limited evidence for a surgical approach for atrial fibrillation as a standalone procedure, this is an evolving area and further work is required in assessing a hybrid approach combining percutaneous and surgical techniques which may help gain access to more regions of both atria," Dr. Glover concluded.

The December 19th Annals of Thoracic Surgery online report provides evidence and rationales for each of the recommendations included in the new clinical practice guidelines.

SOURCE: http://bit.ly/2hQGrZB

Ann Thorac Surg 2016.

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