Increasing but Variable Use of Surgical Treatment of Atrial Fibrillation: An Update from The STS Adult Cardiac Surgery Database.

Overview

abstract

BACKGROUND: The Society of Thoracic Surgeons (STS) 2023 Guidelines for the Surgical Treatment of Atrial Fibrillation (AF) established concomitant surgical ablation (SA) and left atrial appendage occlusion (LAAO) as class I recommendations. This study uses the STS Adult Cardiac Surgery Database (STS-ACSD) to quantify trends in adherence. METHODS: Patients undergoing primary coronary artery bypass grafting (CABG), aortic valve replacement or repair (AVRr) surgery, and/or mitral valve replacement or repair (MVRr) surgery from July 2017 through December 2023 were analyzed. Data were analyzed for frequency trends for SA and LAAO in all patients with preoperative AF and stratified by surgical subcohorts (isolated CABG, AVRr ± CABG, or MVRr ± CABG). Variability in rates of SA and LAAO was also analyzed by patient characteristics, surgeon, program, and geographic region. RESULTS: The study included 1,242,607 patients, of whom 11.8% had preoperative AF. During the study period, the rate of no AF treatment decreased from 42.4% to 24.8%, whereas the rate of isolated LAAO increased from 14.7% to 30.1%. The rate of any SA remained stagnant at ∼45%. Patients with medical comorbidities and those undergoing nonelective surgery, isolated CABG, or surgery in the Middle Atlantic region were less likely to receive surgical AF treatment, especially SA. AF treatment by surgeon was highly variable, and program volume of cases with preoperative AF was correlated with rate of surgical treatment for AF. CONCLUSIONS: Despite increasing application of surgical treatment of preoperative AF in the United States, variability and undertreatment persist. Concerted efforts at education, monitoring adoption, and the potential establishment of quality metrics should be considered.