Surgical Ablation of Atrial Fibrillation During Mitral-Valve Surgery | Clinical Trial - Surgical Ablation for Afib

Description:

The goal of the trial was to evaluate treatment with mitral valve surgery plus ablation compared with mitral valve surgery alone among patients with mitral valve disease and persistent atrial fibrillation undergoing open heart surgery.

Contribution to the Literature: This trial showed that mitral valve surgery plus atrial fibrillation ablation was effective at improving freedom from atrial fibrillation.


Study Design

  • Randomized
  • Parallel
  • Stratified

Patients with mitral valve disease and persistent atrial fibrillation were randomized to mitral valve surgery plus ablation (n = 133) versus mitral valve surgery alone (n = 127). Patients in the ablation group underwent further randomization to pulmonary vein isolation (PVI) versus biatrial maze procedure. All patients underwent closure of the left atrial appendage.

Inclusion criteria:

  • Patients with mitral valve disease undergoing open heart surgery
  • Persistent (>7 days) or long-standing persistent (>1 year) atrial fibrillation

Patient population:

  • Total number of enrollees: 260
  • Duration of follow-up: 12 months
  • Mean patient age: 70 years
  • Percentage female: 43%
  • Percentage diabetics: 22%

Other salient features/characteristics:

  • Type of atrial fibrillation: persistent 47%, long-standing persistent 53%
  • Mitral valve surgery: replacement 41%, repair 59%

Principal Findings:

The primary outcome of freedom from atrial fibrillation at 12 months occurred in 63% of the mitral valve surgery plus ablation group versus 29% of the mitral valve surgery alone group (p < 0.001). Among the ablation group, freedom from atrial fibrillation occurred in 61% with PVI vs. 66% with biatrial maze (p = 0.60).

Secondary outcomes:

  • Mortality: 6.8% vs. 8.7% (p = 0.55), respectively, for ablation vs. control
  • Major adverse cardiac or cerebrovascular events: 23.3% vs. 20.5% (p = 0.58), respectively, for ablation vs. control
  • Permanent pacemaker: 21.5 vs. 8.1 per 100 patient-years (p = 0.01), respectively, for ablation vs. control

Interpretation:

Among patients with mitral valve disease and persistent atrial fibrillation, mitral valve surgery plus atrial fibrillation ablation was effective at improving freedom from atrial fibrillation at 6 and 12 months. There was no difference between ablation techniques on freedom from atrial fibrillation. Major adverse cardiac and cerebrovascular events were similar between the groups.

References:

Gillinov AM, Gelijns AC, Parides MK, et al., on behalf of the CTSN Investigators. Surgical ablation of atrial fibrillation during mitral-valve surgery. N Engl J Med 2015;Mar 16:[Epub ahead of print].

Presented by Dr. A. Marc Gillinov at ACC.15, San Diego, CA, March 16, 2015.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias

Keywords: ACC Annual Scientific Session, Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Electrocardiography, Ambulatory, Heart Atria, Heart Conduction System, Mitral Valve, Patient Readmission, Pulmonary Veins, Stroke, Cardiac Surgical Procedures


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