AATS releases guidelines on concomitant surgical ablation in AFib patients

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 - guidelines, directions, advice

Patients with atrial fibrillation (AFib) who undergo concomitant surgical ablation have an improvement in 30-day operative mortality, long-term survival and health-related quality of life, according to new expert consensus guidelines from the American Association for Thoracic Surgery (AATS).

The authors also found that concomitant surgical ablation in AFib patients does not increase the risk of perioperative morbidity, stroke or transient ischemic attack. In addition, they recommended that physicians should undergo training before performing surgical ablation.

The guidelines were published online in The Journal of Thoracic and Cardiovascular Surgery on April 19.

“Clinical practice regarding surgical ablation of [AFib] varies widely,” study co-author Marc Gillinov, MD, of the Cleveland Clinic, said in a news release. “This consensus statement should guide surgeons to provide the best therapy for their patients who have [AFib].”

A group of six cardiac surgeons, two biostatisticians and one electrophysiologist developed the guidelines based on a literature review of studies published from 2000 to 2015. All of the studies evaluated concomitant surgical ablation procedures in adults and included a comparison group of patients.

The panel graded the class of recommendation and the level of evidence for each of seven research questions. The five classes of recommendation are Class I (strong), IIa (moderate), IIb (weak), III (no benefit, moderate) and Class III (harm, strong). The five levels of evidence are Level A, B-R (randomized), B-NR (nonrandomized), C-LD (limited data) and Level C-EO (expert opinion).

The authors noted that the guidelines are intended for cardiothoracic surgeons performing operations in patients with AFib and cardiologists and electrophysiologists who refer patients for surgeries. They added that physicians treat AFib as a stand-alone procedure or concomitantly with valve, coronary bypass or other types of cardiac surgical procedures.

“It is clear that the success of any ablation procedure is dependent on the lesion pattern and the quality of the lesion,” the researchers wrote. “Surgeons should be familiar with the different lesion set options and the efficacy of the ablation tool in use.”

The authors mentioned that bipolar radiofrequency clamps or reusable/disposable cryoprobes are the best ablation devices, although they added that physicians should avoid coronary arteries when ablating. They also recommended training and mentoring protocols for surgeons interested in surgical ablation and trials that use standard time points and outcomes.

“These guidelines are extremely important for a few reasons,” lead author Niv Ad, MD, a cardiothoracic surgeon and professor at the West Virginia University School of Medicine, said in a news release. “This consensus statement demonstrates the safety of the procedure and the clear association with reduced early death compared to patients who were left with atrial fibrillation. It also clearly states that there is a reduction in late stroke and better long term survival with improved quality of life.”