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The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation incorporate the most recent evidence for surgical ablation and left atrial appendage occlusion in different clinical scenarios. Substantial new evidence regarding the risks and benefits of surgical left atrial appendage occlusion and the long-term benefits of surgical ablation has been produced in the last 5 years. Compared with the 2017 clinical practice guideline, the current update has an emphasis on surgical ablation in first-time, nonemergent cardiac surgery and its long-term benefits, an extension of the recommendation to perform surgical ablation in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery, and a new class I recommendation for left atrial appendage occlusion in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery. Further guidance is provided for patients with structural heart disease and atrial fibrillation being considered for transcatheter valve repair or replacement, as well as patients in need of isolated left atrial appendage management who are not candidates for surgical ablation. The importance of a multidisciplinary team assessment, treatment planning, and long-term follow-up are reiterated in this clinical practice guideline with a class I recommendation, along with the other recommendations from the 2017 guidelines that remained unchanged in their class of recommendation and level of evidence., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG). Currently, there is no reliable way to determine preoperatively which patients will develop POAF following CABG. The aim of this study was to determine whether preoperative left atrial (LA) strain analysis might identify patients destined to develop POAF following CABG., Methods: From 2016 to 2018, 211 patients who had a preoperative left ventricular ejection fraction >50% and adequate preoperative, predischarge, and follow-up echo images for interpretation underwent isolated CABG surgery. Postoperatively, patients had continuous rhythm monitoring until hospital discharge. Retrospective speckle-tracking analysis of preoperative echocardiograms was performed to calculate preoperative left ventricular global longitudinal strain and LA compliance and contraction strains in 92 matched patients. Multivariate logistic regression and Cox proportional hazards models were used to determine the predictors of POAF after CABG., Results: POAF occurred in 50 patients (24%). They were older, had longer intensive care unit and hospital stays, and a slightly greater 30-day mortality (P = .07). Preoperative LA volume index was larger in the patients with POAF but still "normal" as defined by current guidelines. However, preoperative LA compliance and contraction strains were significantly lower in patients who developed POAF after CABG., Conclusions: Decreased preoperative LA strain measurements, especially LA-fractional area change, LA-emptying fraction, and LA-reservoir strain, taken jointly, are more specific and sensitive than other preoperative parameters in identifying patients who will develop POAF following CABG. The ability to identify patients preoperatively who are destined to develop POAF following CABG provides a basis for limiting POAF prophylactic therapy to only those patients undergoing CABG who are most likely to benefit from it rather than to all patients undergoing CABG., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The notion that medically-refractory arrhythmias might one day be amenable to interventional therapy slowly began to appear in the early 1960's. At that time, there were no "interventional electrophysiologists" or "arrhythmia surgeons" and there was little appreciation of the relationship between anatomy and electrophysiology outside the heart's specialized conduction system., Methods: In this review, we describe the evolution of collaboration between electrophysiologists and surgeons., Results: Although accessory atrio-ventricular (AV) connections were first identified in 1893 and the Wolff-Parkinson-White (WPW) syndrome was described 37 years later (1930), it was another 37 years (1967) before those anatomic AV connections were proven to be responsible for the clinical syndrome. The success of the subsequent surgical procedures for the WPW syndrome, AV node reentry tachycardia, automatic atrial tachycardias, ischemic and non-ischemic ventricular tachycardias and atrial fibrillation over the next two decades depended on a close, sometimes daily, collaboration between electrophysiologists and surgeons. In the past two decades, that tight collaboration was largely abandoned until the recent introduction of "hybrid procedures" for the treatment of atrial fibrillation., Conclusions: A retrospective assessment of the 50 years of interventional therapy for arrhythmias clearly demonstrates the clinical benefits of a close collaboration between electrophysiologists and arrhythmia surgeons, regardless of which one is actually performing the intervention., (© 2022 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Objectives: The aim of this study was to assess the incidence and prognostic impact of early and late postoperative atrial fibrillation or flutter (POAF) in patients with severe aortic stenosis (AS) treated with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR)., Background: There is an ongoing controversy regarding the incidence, recurrence rate, and prognostic impact of early (in-hospital) POAF and late (postdischarge) POAF in patients with AS undergoing TAVR or SAVR., Methods: In the PARTNER (Placement of Aortic Transcatheter Valve) 3 trial, patients with severe AS at low surgical risk were randomized to TAVR or SAVR. Analyses were performed in the as-treated population excluding patients with preexistent atrial fibrillation or flutter., Results: Among 781 patients included in the analysis, early POAF occurred in 152 (19.5%) (18 of 415 [4.3%] and 134 of 366 [36.6%] following TAVR and SAVR, respectively). Following discharge, 58 new or recurrent late POAF events occurred within 1 year following the index procedure in 55 of 781 patients (7.0%). Early POAF was not an independent predictor of late POAF following discharge (odds ratio: 1.04; 95% CI: 0.52-2.08; P = 0.90). Following adjustment, early POAF was not an independent predictor of the composite outcome of death, stroke, or rehospitalization (hazard ratio: 1.10; 95% CI: 0.64-1.92; P = 0.72), whereas late POAF was associated with an increased adjusted risk for the composite outcome (hazard ratio: 8.90; 95% CI: 5.02-15.74; P < 0.0001), irrespective of treatment modality., Conclusions: In the PARTNER 3 trial, early POAF was more frequent following SAVR compared with TAVR. Late POAF, but not early POAF, was significantly associated with worse outcomes at 2 years, irrespective of treatment modality., Competing Interests: Funding Support and Author Disclosures The PARTNER 3 trial was funded by Edwards Lifesciences. Dr Malaisrie is a consultant for Edwards Lifesciences, Medtronic, and Abbott. Dr George is a consultant for Edwards Lifesciences. Dr Thourani does research and is a consultant for Abbott Vascular, Allergen, Boston Scientific, CryoLife, Edwards Lifesciences, Gore Vascular, and JenaValve. Dr Babaliaros has received institutional research funding from Abbott, Edwards Lifesciences, and Medtronic; has received consulting fees from Edwards Lifesciences; and holds equity in Transmural Systems. Dr Kodali has received institutional research grants from Edwards Lifesciences, Medtronic, and Abbott; has received consulting fees from Abbott, Admedus, and Meril Life; and holds equity options from Biotrace Medical and Thubrikar Aortic Valve. Dr Nazif is a consultant for Edwards Lifesciences, Medtronic, and Boston Scientific. Dr Genereux has received consulting fees from Abbott Vascular, Abiomed, Boston Scientific, Cardinal Health, Cardiovascular Systems, Edwards Lifesciences, Medtronic, Opsens, Siemens, SoundBite Medical Solutions, Sig.Num, Saranas, Teleflex, and Tryton Medical; and has equity in Pi-Cardia, Sig.Num, SoundBite Medical Solutions, Saranas, and Puzzle Medical. Drs Lu and Yu are employees of Edwards Lifesciences. Ms Alu has received institutional research support (no direct compensation) from Abbott and Edwards Lifesciences. Dr Webb is a proctor and consultant for Edwards Lifesciences. Dr Mack has received institutional research support (no direct physician compensation) from Edwards Lifesciences. Dr Leon has received institutional research support from Edwards Lifesciences, Medtronic, Boston Scientific, and Abbott; and is a consultant or advisory board member for Medtronic, Boston Scientific, Gore, Meril Life, and Abbott. Dr Kosmidou has received institutional research support from Amgen; and is a consultant for Sanofi. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

The prognostic impact of preexisting atrial fibrillation or flutter (AF) in low-risk patients with severe aortic stenosis treated with transcatheter (TAVR) or surgical aortic valve replacement (SAVR) remains unknown. In this sub-analysis of the PARTNER 3 trial of patients with severe aortic stenosis at low surgical risk randomized 1:1 to TAVR versus SAVR, clinical outcomes were analyzed at 2 years according to AF status. Among 948 patients included in the analysis (452 [47.7%] in the SAVR vs 496 [52.3%] in the TAVR arm), 168 (17.6%) patients had AF [88/452 (19.5%) and 80/496 (16.1%) treated with SAVR and TAVR, respectively]. At 2 years, patients with AF had higher unadjusted rates of the composite outcome of death, stroke or rehospitalization (21.2% vs 12.9%, p = 0.007) and rehospitalization alone (15.3% vs 9.4%, p = 0.03) but not all cause death (3.8% vs 2.6%, p = 0.45) or stroke (4.8% vs 2.6%, p = 0.12). In adjusted analyses, patients with AF had a higher risk for the composite outcome of death, stroke or rehospitalization (hazard ratio [HR] 1.80, 95% confidence interval [CI] 1.20-2.71, p = 0.0046) and rehospitalization alone (HR 1.8, 95% CI 0.12-2.9, p = 0.015), but not death or stroke. There was no interaction between treatment modality and AF on the composite outcome (Pinter = 0.83). In conclusion, preexisting AF in patients with severe AS at low surgical risk was associated with increased risk of the composite outcome of death, stroke or rehospitalization at 2 years, irrespective of treatment modality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background The impact of atrial fibrillation (AF) in intermediate surgical risk patients with severe aortic stenosis who undergo either transcatheter or surgical aortic valve replacement (AVR) is not well established. Methods and Results Data were assessed in 2663 patients from the PARTNER (Placement of Aortic Transcatheter Valve) 2A or S3i trials. Analyses grouped patients into 3 categories according to their baseline and discharge rhythms (ie, sinus rhythm [SR]/SR, SR/AF, or AF/AF). Among patients with transcatheter AVR (n=1867), 79.2% had SR/SR, 17.6% had AF/AF, and 3.2% had SR/AF. Among patients with surgical AVR (n=796), 71.7% had SR/SR, 14.1% had AF/AF, and 14.2% had SR/AF. Patients with transcatheter AVR in AF at discharge had increased 2-year mortality (SR/AF versus SR/SR; hazard ratio [HR], 2.73; 95% CI, 1.68-4.44; P <0.0001; AF/AF versus SR/SR; HR, 1.56; 95% CI, 1.16-2.09; P =0.003); patients with SR/AF also experienced increased 2-year mortality relative to patients with AF/AF (HR, 1.77; 95% CI, 1.04-3.00; P =0.03). For patients with surgicalAVR, the presence of AF at discharge was also associated with increased 2-year mortality (SR/AF versus SR/SR; HR, 1.93; 95% CI, 1.25-2.96; P =0.002; and AF/AF versus SR/SR; HR, 1.67; 95% CI, 1.06-2.63; P =0.027). Rehospitalization and persistent advanced heart failure symptoms were also more common among patients with transcatheter AVR and surgical AVR discharged in AF, and major bleeding was more common in the transcatheter AVR cohort. Conclusions The presence of AF at discharge in patients with intermediate surgical risk aortic stenosis was associated with worse outcomes-especially in patients with baseline SR-including increased all-cause mortality at 2-year follow-up. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01314313 and NCT03222128.

Background: This study compares outcomes of patients with preoperative atrial fibrillation undergoing coronary artery bypass grafting (CABG) with or without concomitant atrial fibrillation ablation in a nationally representative Medicare cohort., Objectives: This study examined early and late outcomes in CABG patients with a preoperative history of atrial fibrillation to determine the correlation between surgical atrial fibrillation ablation to mortality and stroke or systemic embolization., Methods: In the Medicare-linked Society of Thoracic Surgeons database, 361,138 patients underwent isolated CABG from 2006 to 2013; 34,600 (9.6%) had preoperative atrial fibrillation; 10,541 (30.5%) were treated with surgical ablation (ablation group), and 23,059 were not (no ablation group). Propensity score matching was performed using a hierarchical mixed model. Long-term survival was summarized using Kaplan-Meier curves and Cox regression models with robust variance estimation. The stroke or systemic embolization incidence was modeled using the Fine-Gray model. Median follow-up was 4 years., Results: Long-term mortality in propensity score-matched CABG patients (mean age 74 years; Society of Thoracic Surgeons risk score, 2.25) receiving ablation versus no ablation was similar (log-rank P = .30). Stroke or systemic embolization occurred in 2.2% versus 2.1% at 30 days and 9.9% versus 12.0% at 5 years (Gray P = .0091). Landmark analysis from 2 to 5 years showed lower mortality (hazard ratio, 0.89; 95% confidence interval 0.82-0.97; P = .0358) and lower risk of stroke or systemic embolization (hazard ratio, 0.73; 95% confidence interval, 0.61-0.87; P = .0006) in the ablation group., Conclusions: Concomitant ablation in CABG patients with preoperative atrial fibrillation is associated with lower stroke or systemic embolization and mortality in patients who survive more than 2 years., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgical ablation of atrial fibrillation (AF) concomitant with cardiac surgery is a Society of Thoracic Surgeons (STS) class I recommendation, although the AF is frequently ignored. Analysis of the STS Database 30-day outcomes of isolated surgical aortic valve replacement (AVR) with and without AF ablation is presented., Methods: Data on 87,426 surgical aortic valve replacement patients were extracted from the STS database (version 2.81, 2014-2017) and patients were divided into 3 groups: (1) No preoperative AF, (2) Preoperative AF with concomitant ablation, and (3) Preoperative AF without ablation. The latter 2 groups were propensity score-matched in 1-(up)-to-2 ratio to alleviate covariate imbalances and reduce bias. Thirty-day outcomes were evaluated and compared., Results: Preoperative AF was present in 17.8% (15,596 of 87,426 patients). Ablation was performed in 33.1% (5,167 of 15,596), and 57.7% (2,983) had left atrial appendage closure. Propensity score matching (AF ablated n = 3692; AF non-ablated n = 5724), revealed that there was no difference between the AF ablated and AF non-ablated groups in mortality (2.8% vs 3.0%, respectively; P = .65) or for stroke (1.6% vs 1.7%, respectively; P = .82), but postoperative pacemaker implantation was higher in the AF ablated patients (6.8% AF ablated vs 5.0% AF non-ablated, P < .001)., Conclusions: Despite being a class I recommendation, AF ablation concomitantly with other cardiac surgical procedures remains lower than current guideline recommendation in surgical aortic valve replacement patients. Ablation for AF does not increase the 30-day operative mortality or perioperative morbidity compared with non-ablated patients, although new pacemaker requirements were higher in the AF ablated group., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Patients with atrial fibrillation (AF) undergoing cardiac surgery are at substantially increased risk for stroke. Increasing evidence has suggested that surgical left atrial appendage occlusion (S-LAAO) may have the potential to substantially mitigate this stroke risk; however, S-LAAO is performed in a minority of patients with AF undergoing cardiac surgery. We sought to identify factors associated with usage of S-LAAO., Methods: In a nationally-representative, contemporary cohort (07/2011-06/2012) of older patients undergoing cardiac surgery with preoperative AF (n = 11,404) from the Medicare-linked Society of Thoracic Surgeons Adult Cardiac Surgery Database, we evaluated patient and hospital characteristics associated with S-LAAO use by employing logistic and linear regression models., Results: In this cohort (average age, 76 years; 39% female), 4177 (37%) underwent S-LAAO. Neither S-LAAO nor discharge anticoagulation was used in 25% ("unprotected" patients). The overall propensity for S-LAAO decreased significantly with increasing CHA 2 DS 2 -VASc (congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; stroke, transient ischemic attack, or thromboembolism; vascular disease; age 65 to 74 years; sex category (female)) score (p trend  < 0.001). There was substantial variability in S-LAAO use across geographic regions, and S-LAAO was more commonly performed at academic and higher-volume valve surgery centers., Conclusions: Substantial variability in use of S-LAAO exists. In many instances, the procedure is being deferred in the patients that may be poised to benefit the most (i.e., those with increased CHA 2 DS 2 -VASc score-defined stroke risk).

Background: Catheter ablation (CA) for long-standing persistent atrial fibrillation (LSPAF) is suboptimal, and open surgical ablation, although more successful, is too invasive to be a first-line therapy. Less invasive hybrid procedures that combine thoracoscopic surgery (TS) with CA have been only marginally more successful for LSPAF than CA alone., Methods: Joint hybrid procedures for LSPAF are based on the assumption that AF surgery and CA procedures can be guided by intraoperative mapping. However, intraoperative mapping is not always dependable because of the transient nature of the sustaining reentrant drivers. The best results in patients with LSPAF have been attained with the non-guided, anatomy-based surgical Maze-III and Maze-IV procedures. Likewise, a staged TS/CA hybrid procedure that creates a combination of lesions that adhere to the concept of a Maze pattern, that is, a Hybrid Maze-IV procedure, should be more effective for LSPAF., Results: Initial TS includes all lesions of the Maze-IV procedure except the mitral line, coronary sinus lesion, and one right atrial lesion. Follow-up CA at 3 months includes touching up any incomplete TS lesions, a cavotricuspid isthmus lesion, and a mitral line/coronary sinus lesion in the 10% to 15% of patients with post-TS perimitral flutter. This combination of TS and CA lesions creates a complete Maze-IV procedure., Conclusions: It is possible to create the complete lesion pattern of a Maze-IV procedure with a staged TS/CA hybrid procedure. The success of this Hybrid Maze procedure in patients with LSPAF should be the same as that attained with an open surgical Maze-IV procedure., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: There is concern that the right atrial lesions of the maze procedure lead to more permanent pacemakers postoperatively and that they provide little therapeutic advantage over left atrial lesions alone., Methods: A discussion of the pertinent anatomy related to atrial fibrillation and the performance of the maze procedure, the potential ways that the specialized conduction system could theoretically be damaged by the procedure, non-procedure-related causes for increased postoperative pacemaker requirements, and the basis for the efficacy of the right atrial lesions of the maze procedure are presented. Several factors that can lead to a dysfunctional sinoatrial node preoperatively in patients with atrial fibrillation are also discussed., Results: The reasons new permanent pacemakers are required after a maze procedure include the high success rates of the surgery with subsequent unmasking of preoperative sick sinus syndrome, excessive extracardiac dissection that damages the autonomic nerve input to the heart, premature pacemaker implantation for a temporary junctional rhythm immediately postoperatively, surgical error, and patient selection., Conclusions: There are numerous reasons why patients need new pacemakers after a maze procedure, but the right atrial lesions of the procedure rarely, if ever, are the cause., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The initial surgical attempts to treat atrial fibrillation (AF) were isolation procedures designed to confine the arrhythmia to a specific area of the heart for relief of symptoms. The first surgical attempt to ablate AF was unsuccessful but was quickly followed by the Maze-I procedure on September 25, 1987. Because of several adverse sequelae of the Maze-I procedure, it was sequentially modified to the Maze-II and then Maze-III procedures. The Maze-IV procedure was introduced some 10 years later; these are the only 4 procedures that adhere to the concept of a maze pattern of lesions to ablate AF and leave both atria capable of being activated during normal sinus rhythm. The term maze procedure has become generic for virtually any operation designed to treat AF, but procedures that do not adhere to the concept of creating lesions of conduction block in the pattern of a maze are not maze procedures. These include, among others, the Wolf Mini-Maze, the Left-Sided Maze, and the 5-Box Maze, none of which are truly based on the maze-pattern concept. The cardinal feature of maze procedures that is necessary for both effectiveness and comparability to classical maze procedures includes lines of conduction block that preclude macro-reentry anywhere in either atrium while leaving both atria capable of activation by a sinus-generated impulse. Components essential to achieving this include appropriate lesions in both atria, the absence of gaps that allow electrical activity to bypass an intended line of block, and the absence of alternate pathways by which impulses can reach the intended maze exit., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objectives: We sought to determine the incidence and risk factors for de novo atrial fibrillation (>90 days after surgery) in patients without preoperative atrial fibrillation., Methods: From 2004 to 2014, 2261 patients underwent mitral valve surgery; 1288 patients (57%) did not have a history of atrial fibrillation, and 930 patients had rhythm information more than 90 days after surgery. De novo atrial fibrillation and death probabilities were estimated using a semi-competing risks, multi-state model. Univariable and multivariable risk factors for developing atrial fibrillation were identified using the Fine-Gray model., Results: The 5- and 10-year incidences of de novo atrial fibrillation were 14% and 23%, respectively. Univariable risk factors were older age, more complex operations, more tricuspid regurgitation, and congestive heart failure (all P < .05). Patients with degenerative mitral regurgitation were less likely to develop atrial fibrillation (hazard ratio [HR], 0.4; 95% confidence interval [CI], 0.24-0.65; P < .001). Multivariable risk factors for de novo atrial fibrillation were tricuspid valve surgery (HR, 1.80; 95% CI, 1.22, 2.65; P = .003), aortic valve surgery (HR, 1.49; 95% CI, 1.03-2.17; P = .035), and older age (HR, 1.03; 95% CI, 1.02-1.05; P < .001). De novo atrial fibrillation did not affect overall survival (P = .41). Among patients who developed de novo atrial fibrillation, we observed increased use of warfarin (P < .001) and a strong trend toward an increased risk of stroke (P = .055)., Conclusions: De novo atrial fibrillation develops progressively after mitral surgery and is associated with a strong trend toward stroke. Patients at high risk could be studied in a trial to reduce atrial fibrillation., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: This study compares early and late outcomes in patients undergoing coronary artery bypass grafting with and without preoperative atrial fibrillation in a contemporary, nationally representative Medicare cohort., Methods: In the Medicare-Linked Society of Thoracic Surgeons database, 361,138 patients underwent isolated coronary artery bypass from 2006 to 2013, of whom 37,220 (10.3%) had preoperative atrial fibrillation; 13,161 (35.4%) were treated with surgical ablation and were excluded. Generalized estimating equations were used to compare 30-day mortality and morbidity. Long-term survival was summarized using Kaplan-Meier curves and Cox regression models. Stroke and systemic embolism incidence was modeled using the Fine-Gray model and the CHA 2 DS 2 -VASc score was used to analyze stroke risk. Median follow-up was 4 years., Results: Preoperative atrial fibrillation was associated with a higher adjusted in-hospital mortality (odds ratio [OR], 1.5; P < .0001) and combined major morbidity including stroke, renal failure, prolonged ventilation, reoperation, and deep sternal wound infection (OR, 1.32; P < .0001). Patients with preoperative atrial fibrillation experienced a higher adjusted long-term risk of all-cause mortality and cumulative risk of stroke and systemic embolism compared to those without atrial fibrillation. At 5 years, the survival probability in the preoperative atrial fibrillation versus no atrial fibrillation groups stratified by CHA 2 DS 2 -VASc scores was 74.8% versus 86.3% (score 1-3), 56.5% versus 73.2% (score 4-6), and 41.2% versus 57.2% (score 7-9; all P < .001)., Conclusions: Preoperative atrial fibrillation is independently associated with worse early and late postoperative outcomes. CHA 2 DS 2 -VASc stratifies risk, even in those without preoperative atrial fibrillation., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: The left atrial appendage is a key site of thrombus formation in atrial fibrillation (AF) and can be occluded or removed at the time of cardiac surgery. There is limited evidence regarding the effectiveness of surgical left atrial appendage occlusion (S-LAAO) for reducing the risk of thromboembolism., Objective: To evaluate the association of S-LAAO vs no receipt of S-LAAO with the risk of thromboembolism among older patients undergoing cardiac surgery., Design, Setting, and Participants: Retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2012). Patients aged 65 years and older with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery with or without CABG, or aortic valve surgery with or without CABG) with and without concomitant S-LAAO were followed up until December 31, 2014., Exposures: S-LAAO vs no S-LAAO., Main Outcomes and Measures: The primary outcome was readmission for thromboembolism (stroke, transient ischemic attack, or systemic embolism) at up to 3 years of follow-up, as defined by Medicare claims data. Secondary end points included hemorrhagic stroke, all-cause mortality, and a composite end point (thromboembolism, hemorrhagic stroke, or all-cause mortality)., Results: Among 10 524 patients undergoing surgery (median age, 76 years; 39% female; median CHA2DS2-VASc score, 4), 3892 (37%) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4%, hemorrhagic stroke in 0.9%, all-cause mortality in 21.5%, and the composite end point in 25.7%. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2% vs 6.2%), all-cause mortality (17.3% vs 23.9%), and the composite end point (20.5% vs 28.7%) but no significant difference in rates of hemorrhagic stroke (0.9% vs 0.9%). After inverse probability-weighted adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (subdistribution hazard ratio [HR], 0.67; 95% CI, 0.56-0.81; P < .001), all-cause mortality (HR, 0.88; 95% CI, 0.79-0.97; P = .001), and the composite end point (HR, 0.83; 95% CI, 0.76-0.91; P < .001) but not hemorrhagic stroke (subdistribution HR, 0.84; 95% CI, 0.53-1.32; P = .44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among patients discharged without anticoagulation (unadjusted rate, 4.2% vs 6.0%; adjusted subdistribution HR, 0.26; 95% CI, 0.17-0.40; P < .001), but not among patients discharged with anticoagulation (unadjusted rate, 4.1% vs 6.3%; adjusted subdistribution HR, 0.88; 95% CI, 0.56-1.39; P = .59)., Conclusions and Relevance: Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO, compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over 3 years. These findings support the use of S-LAAO, but randomized trials are necessary to provide definitive evidence.

Background: Controversy exists when performing surgical atrial fibrillation ablation whether there is an increase in postoperative complications using biatrial (BA) lesions compared with only left atrial (LA) lesions, and some studies indicate similar efficacy. This study compares the clinical outcomes of BA and LA ablation lesions in mitral valve surgery patients., Methods: From 2004 through 2014, 2,137 patients had mitral valve surgery with or without other surgeries in a single center. Of those, 836 (39%) had preoperative atrial fibrillation, and of those, 724 (86%) underwent atrial fibrillation ablation surgery; 257 patients had BA lesion sets and 359 had LA lesion sets. Propensity score matching of BA and LA patients was performed., Results: Baseline differences included more postoperative complications in the BA group, specifically, permanent pacemaker placement (13% versus 7%; p = 0.006). Freedom from atrial fibrillation off antiarrhythmic drugs (72% BA versus 75% LA; p = 0.50), postoperative ablation (7% BA versus 5% LA; p = 0.20), stroke (0.11 versus 0.11 per 10 person-years; p = 0.91), and survival were similar between the groups. After matching, patients in the LA group had a higher freedom from postoperative ablation (p = 0.015), but no difference in freedom from atrial fibrillation off antiarrhythmic drugs (79% BA versus 69% LA; p = 0.09), and no difference in permanent pacemaker placement (10% versus 12%; p = 0.57)., Conclusions: Patients undergoing mitral surgery with LA or BA ablation had similar outcomes, survival, and complications. Limiting lesions to the LA is an effective alternative to BA ablation for patients undergoing ablation with concomitant mitral valve surgery., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Clinical Question: Should patients with preoperative atrial fibrillation who are undergoing cardiac surgery undergo concomitant atrial fibrillation surgery?, Bottom Line: There is moderate-quality evidence that concomitant atrial fibrillation surgery approximately doubles the likelihood of freedom from atrial fibrillation, atrial flutter, or atrial tachycardia while not receiving antiarrhythmic medications at least 3 months after the procedure with a small absolute increase in needing a permanent pacemaker.

Background: Elimination of the left atrial appendage (LAA) attempts to reduce stroke in patients with atrial fibrillation (AF). A retrospective review suggests that various surgical techniques are often unsuccessful and may leave a stump or gap. In a pilot study, we prospectively evaluated 3 surgical techniques with long-term follow up to define effectiveness., Methods: At a single institution, 28 patients undergoing concomitant AF surgery were randomized prospectively into 1 of 3 techniques of LAA elimination: internal suture ligation (IL), external stapled excision (StEx), and surgical excision (SxEx). The success of LAA elimination was assessed by transesophageal echocardiography (TEE) in all patients at the time of surgery. Failure of LAA closure consisted of either a stump (residual appendage tissue >1 cm in maximum length) or a gap (persistent flow between the left atrium [LA] and the LAA). Failure was treated intraoperatively when recognized. Late follow-up was obtained using a TEE at a mean of 0.4 years in 21/28 (75%) of patients., Results: Early failure was recognized and treated in 1 patient in the IL group (13%), 6 patients in the StEx group (60%), and 2 patients in the SxEx group (20%) (P = .06). On follow-up TEE, 4 of 7 patients in the IL group (57%) had developed gaps, 3 of whom (43%) with greater than mild flow. No patients in the StEx or SxEx groups had a gap (P = .03). In late follow-up, 1 of 7 patients in the IL group (14%) had a stump, compared with 2 of 8 (25%) in the StEx group and 3 of 6 (50%) in the SxEx group (P = .35). The overall failure rate was 57%: 5 of 8 (63%) in the IL group, 6 of 10 (60%) in the StEx group, and 5 of 10 (50%) in the SxEx group (P = .85). No patient had a stroke at any time during follow-up., Conclusions: LAA elimination is often incomplete and goes undetected. If the LAA is eliminated at the time of surgery, then TEE should be used intraoperatively to assess effectiveness and reintervention performed if warranted. Late assessment for completeness of closure should be considered before cessation of anticoagulation until more effective LAA techniques can be developed., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Prosthetic valve replacement is performed in several hundred thousand patients worldwide annually, and many of these patients have or will ultimately develop atrial fibrillation or flutter (AF). Novel oral anticoagulants (NOACs) are not recommended in patients with AF and mechanical valves but have not been evaluated in patients with bioprosthetic valves. This study sought to evaluate the efficacy and safety of NOACs in patients with AF and bioprosthetic valves., Methods: A retrospective single-center cohort study was performed on all patients with bioprosthetic valve implantation, for whom a NOAC was prescribed for the indication of AF. Patients were evaluated for thromboembolic events including imaging confirmed ischemic stroke, clinically suspected transient ischemic attack, and major bleeding events (according to International Society on Thrombosis and Hemostasis definition)., Results: In total, 73 patients (26 female, 35.6 %) were identified. NOAC therapy began, on average, 990.0 ± 1029.1 days after bioprosthetic valve implantation for an average duration of 511.8 ± 400.8 days. Aspirin was used concomitantly in a majority of patients (72.6 %). There were no ischemic strokes identified (0.0 %) and one possible TIA (1.4 %). There were 6 (8.2 %) minor and 5 (6.9 %) major bleeding events., Conclusion: The use of NOAC therapy for AF in patients with bioprosthetic valves appears safe and effective in the occurrence of thromboembolic events, however, at the expense of increased bleeding. Larger studies are necessary to confirm these findings.

Background: Gender disparities have been established in patients who have atrial fibrillation (AF), and in their outcomes after medical treatment for AF. This study evaluated differences in outcome by gender in patients who underwent surgical treatment for AF., Methods: From April 2004 to December 2012, a total of 936 patients had surgical treatment for AF. Outcomes were analyzed by gender using propensity score-matching methods., Results: Of the 936 subjects, 571 (61%) were men; women were older (aged 68.6 ± 11.3 vs 66.9 ± 11.9 years; P = .033), had more heart failure (44% vs 37%; P = .024), more mitral valve surgery (72% vs 50%; P < .001) and more tricuspid valve surgery (41% vs 18%; P < .001). Men underwent more coronary artery bypass surgery (37% vs 19%; P < .001) and aortic valve surgery (38% vs 31%; P = .029). Women had higher late stroke rate per 10 person-years (0.15 vs 0.07; P = .035), fewer catheter ablations (6.0% vs 9.8%; P = .017), and a trend toward fewer cardioversions for recurrent AF (15.7% vs 19.2%; P = .20). After propensity-score matching, late stroke rates per 10 person-years trended higher in women (0.12 vs 0.04; P = .13). No significant gender differences were found in overall survival (5-year survival: 78.8% in men, and 81.0% in women; P = .40) or freedom from AF without antiarrhythmic drugs at last follow-up (71.8% in men vs 73.6% in women, P = .59)., Conclusions: Women sought surgery treatment at older ages and with more heart failure. No gender-based differences were found in stroke, overall survival, or procedure success, after propensity-score matching., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Postsurgical late reinterventions for atrial fibrillation (AF) include cardioversions (CV) or catheter ablations (CA). Commonly used methods for reporting and modeling the frequency and timing of CA or CV have well-known shortcomings., Objective: The purpose of this study was to present intuitive and robust methods to visualize, summarize, and model late reinterventions type/timing and vital status simultaneously., Methods: We present (1) the SMART plot (Summary of Mortality And Outcomes Reported Over Time); (2) the reintervention mean cumulative function (MCF); and (3) the proportional means model and the proportional rates model. We illustrate these methods in 3 groups: patients age ≤60 years, 60-75 years (reference), and >75 years who underwent surgical AF ablation., Results: Patients age >75 years had a significantly lower MCF of CVs (hazard ratio [HR] 0.50, P <.001). MCF for CAs was not significantly lower for patients age >75 years (HR 0.57, P = .13). For combined reinterventions (CV or CA), the age group >75 years had a significantly lower MCF (HR 0.51, P <.001). There were no significant differences in late CV or CA reintervention patterns for patients age ≤60 years., Conclusion: The methods presented provide a comprehensive framework for displaying, summarizing, and modeling repeated late reinterventions after surgical AF ablation. Other areas of application are described, further emphasizing the potential for immediate use., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objectives: Randomized controlled trials of permanent atrial fibrillation ablation surgery have shown improved outcomes compared with control patients undergoing concomitant cardiac surgery. Little has been reported regarding patients with paroxysmal atrial fibrillation. We hypothesized that treating paroxysmal atrial fibrillation during cardiac surgery would not adversely affect the perioperative risk and would improve the midterm outcomes., Methods: From April 2004 to June 30 2012, 4947 patients (excluding those with transcatheter aortic valve implants, left ventricular assist devices, trauma, transplantation, and isolated atrial fibrillation surgery) underwent cardiac surgery, and 1150 (23%) had preoperative atrial fibrillation. Of these, 552 (48%) had paroxysmal atrial fibrillation. Three groups were compared using propensity score matching: treated (n = 423, 77%), untreated (n = 129, 23%), and no atrial fibrillation (n = 3797)., Results: The treated patients had 30-day mortality similar to that of the untreated patients and those without atrial fibrillation. They had fewer perioperative complications (26% vs 46%, P = .001), greater freedom from atrial fibrillation at the last follow-up visit (81% vs 60%, P = .007), and lower mortality (hazard ratio 0.47, P = .007) compared with the untreated patients. Compared with those without atrial fibrillation, the treated patients had fewer perioperative complications (25% vs 48%, P < .001), lower freedom from atrial fibrillation at the last follow-up visit (84% vs 93%, P = .001), and similar mortality., Conclusions: Concomitant surgical ablation of paroxysmal atrial fibrillation was not associated with increased perioperative risk. The treated patients had greater late freedom from atrial fibrillation and midterm survival compared with the untreated patients, and similar midterm survival compared with the patients without atrial fibrillation. These results suggest that paroxysmal atrial fibrillation warrants treatment consideration in select patients undergoing cardiac surgery., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The classic cut and sew maze is thought to reduce stroke, in part because of left atrial appendage (LAA) elimination. Multiple LAA elimination techniques have evolved with the introduction of new surgical treatment options for atrial fibrillation (AF), but the impact on stroke remains unknown. We studied the rate of late neurologic event (LNE) in the era of contemporary AF surgery., Methods: From April 21, 2004, to June 30, 2011, 773 patients underwent surgery for AF. In 131 patients, the LAA was excised. In 579, alternative elimination techniques were used (97 external ligation, 313 internal ligation, 126 stapled excision, 23 stapled excision plus internal ligation, 5 internal plus external ligations, and 15 that did not fit into any category); 63 LAAs were left intact and excluded from analyses. Complete follow-up was obtained by medical record review and phone call. Median survival follow-up was 3.3 years (first and third quartiles, 1.6 and 5.0). An LNE was defined as either a documented stroke or transient ischemic attack 30 or more days after surgery. Baseline characteristics and outcomes between LAA techniques were compared using χ(2), Fisher's exact tests, and Student's t tests., Results: There were 25 LNEs (3.5%) overall; the median occurrence time was 3.6 years (first and third quartiles, 1.9 and 5.4) after surgery. There were 17 strokes and 8 transient ischemic attacks. Of 45 demographic and surgical variables, only age, aortic valve surgery, and perioperative neurologic event (<30 days after cardiac surgery) independently predicted LNE (p = 0.003, 0.021, and 0.010, respectively). Late neurologic events occurred with an annual rate of 1.13% in patients with alternative elimination techniques, and 0.20% in patients with excised LAA (p = 0.001). Patients in AF at any time were more likely to have LNE, but this was not an independent predictor., Conclusions: After surgery for AF ablation, there is ongoing low risk of LNE even when the LAA is surgically excised. Further investigation should be pursued to clarify whether a difference exists with alternative elimination techniques and in patients in whom AF is successfully eliminated., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Patients undergoing cardiac surgery with a history of untreated atrial fibrillation have reduced survival compared with similar patients without atrial fibrillation. We sought to compare the midterm survival of patients who received concomitant surgical ablation treatment for atrial fibrillation (atrial fibrillation ablated) with that of matched patients without a history of atrial fibrillation (no atrial fibrillation)., Methods: We evaluated 3262 consecutive patients (813 [25%] with atrial fibrillation and 2449 [75%] without preoperative atrial fibrillation) undergoing cardiac surgery at a single institution from April 2004 to April 2009. Of patients with atrial fibrillation, 565 (70%) were treated with a concomitant surgical ablation procedure. Propensity scores were calculated on the basis of 37 known preoperative risk factors and yielded 744 patients. Midterm survival was compared between patients with atrial fibrillation ablation (n = 372) and patients without atrial fibrillation (n = 372). Survival was also compared between patients with successful vs unsuccessful ablation, and a matched analysis was performed at 1 year between the 2 groups., Results: Mean follow-up was 2.7 ± 1.6 years. Patients without atrial fibrillation and patients with treated atrial fibrillation had similar early 30-day mortality (1.2% vs 0.3%, P = .37) and overall mortality rates (11.6% vs 9.4%, P = .344), respectively. Survival analysis showed no differences at 1, 3, and 5 years between the 2 groups (log-rank P = .22). At last follow-up, 78% of treated patients were free of atrial fibrillation. At 1 year, 68% of patients were free of atrial fibrillation and antiarrhythmic medication. Freedom from atrial fibrillation and antiarrhythmic medication at 1 year predicted improved midterm survival (P = .03) compared with patients in atrial fibrillation or taking antiarrhythmic medication. Propensity-matched analysis after 1 year demonstrated improved survival for patients who were successfully treated (P = .016)., Conclusions: Patients undergoing surgical treatment of atrial fibrillation had survival similar to that of patients without a history of atrial fibrillation. Those with successful sinus restoration had improved survival compared with those who were treated but remained in atrial fibrillation., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background and Aim of the Study: Current guidelines suggest that the use of a mechanical prosthesis is favored when patients are already receiving long-term anticoagulation for conditions such as atrial fibrillation (AF). Surgical AF ablation can restore normal sinus rhythm (NSR) and obviate the need for anticoagulation. The study aim was to determine the impact of concomitant AF ablation in patients with AF undergoing aortic valve replacement (AVR) on the restoration of NSR and subsequent requirement for anticoagulation., Methods: Between April 2004 and December 2009, a total of 124 patients (mean age 74 +/- 12 years) with pre-existing AF underwent AVR with or without coronary artery bypass grafting. The documented preoperative rhythm was long-standing persistent AF in 39 patients (32%), persistent AF in five (4%), and paroxysmal AF in 80 (65%). Eighty patients (65%) had concomitant surgical AF ablation. In the ablation group, bilateral pulmonary vein isolation was performed in 55 cases (69%), left atrial-maze in 15 (19%), and Cox-maze in 10 (13%). A left atrial appendage closure was performed in 70 patients (88%). Sinus rhythm, in addition to anti-arrhythmic and warfarin use, were assessed between three and 15 months after surgery. Postoperatively, 13 patients died and 18 were lost to follow up during the three- to 15-month window; consequently, 71 patients were available for analysis in the ablation group, and 22 in the non-ablation group., Results: In-hospital mortality was 4% (the Ambler score predicted a median (IQR) of 6 (4-9)%). Freedom from AF when not receiving anti-arrhythmic drugs (AADs) occurred in 58 patients (82%) in the ablation group, compared to eight (36%) in the non-ablation group (p < 0.001). Fifty patients (70%) were free from warfarin in the ablation group, compared to six (27%) in the non-ablation group (p < 0.001). No differences were identified in freedom from AF between the surgical AF lesion sets. AF ablation, younger age, and paroxysmal AF were independently associated with freedom from AF when not receiving AADs., Conclusion: Surgical AF ablation is associated with an improved restoration of NSR in patients with AF requiring AVR. The need for anticoagulation is reduced in the majority of patients. A bioprosthetic valve may be an acceptable option for a patient with AF who requires AVR.

Atrial fibrillation (AF) is the most common of all cardiac arrhythmias, affecting roughly 1% of the general population in the Western world. The incidence of AF is predicted to double by 2050. Most patients with AF are treated with oral medications and only approximately 4% of AF patients are treated with interventional techniques, including catheter ablation and surgical ablation. The increasing prevalence and the morbidity/mortality associated with AF warrants a more aggressive approach to its treatment. It is the purpose of this invited editorial to describe the past, present, and anticipated future directions of the interventional therapy of AF, and to crystallize the problems that remain. [ABSTRACT FROM AUTHOR]