International Society for Minimally Invasive Cardiothoracic Surgery

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Cha2ds2-vasc To Guide Surgical Ablation for Atrial Fibrillation during Minimally Invasive Mitral Valve Surgery
Mariusz Kowalewski1, Lukasz Kuzma2, Karol Gostomczyk1, Radoslaw Litwinowicz3, Emil J. Dabrowski2, Michal Swieczkowski2, Marek Jasinski4, Kazimierz Widenka5, Tomasz Hirnle6, Marek Deja7, Krzysztof Bartus8, Zdzislaw Tobota9, Bohdan Maruszewski9, Piotr Suwalski1.
1Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, WARSAW, Poland, 2Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland, 3Department of Cardiac Surgery, Regional Specialist Hospital, Grudzi?dz, Poland, 4Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroc?aw, Poland, 5Clinical Department of Cardiac Surgery, District Hospital No. 2, Rzeszów, Poland, 6Department of Cardiosurgery, Medical University of Bialystok, Bia?ystok, Poland, 7Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice,, Katowice, Poland, 8Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital,, Kraków, Poland, 9Department of Pediatric Cardiothoracic Surgery, The Children’s Memorial Health Institute, Warsaw, WARSAW, Poland.

Background: This study aimed to evaluate the impact of concomitant atrial fibrillation (AF) ablation during minimally invasive mitral valve surgery (MIMVS) on long-term survival, particularly focusing on patients with varying preoperative risks. Additionally, we sought to address discrepancies in outcomes between MIMVS and sternotomy approaches, emphasizing the importance of the left atrial appendage (LAA) closure in MIMVS and its potential influence on the benefits of ablation.Methods: A comprehensive analysis was conducted on patients undergoing MIMVS and included in the nationwide KROK registry (between 2006 and 2021), comparing those with concurrent AF ablation (MIMVS + ablation) to those without (MIMVS alone). We assessed patient outcomes, complications, and long-term survival, stratifying the results based on preoperative risk factors, EuroSCORE II, and CHA2DS2-VASc scores. The study also examined the utility of risk assessment scales in predicting outcomes for both MIMVS and MIMVS + ablation groups. We performed propensity score matching for the comparison of MIMVS + SA versus MIMVS alone. Propensity score matching resulted in 365 pairs with similar baseline characteristics.
Results: In the adjusted population median age was 65 (IQR 58-70), median EuroSCORE II 2.2 [IQR 1.4-3.4]. Left atrium appendage occlusion was performed in 37.5% and 35.3% in SA vs no-SA group (p=0.590). We observed no differences in 48-hour mortality (MIMVS with SA vs MIMVS alone; 0.3% vs 0, p=0.999). Most common post-operative complications including respiratory, kidney injury, return to intensive care unit, post-operative myocardial infarction and permanent pacemaker implantation were reported with similar frequencies between groups. Neurological complications were reported less frequently in the SA group (2.7 vs 8.2%, p=0.002). Unadjusted hazard ratios demonstrated improved remote survival with surgical ablation, especially for patients with both mitral and tricuspid valve (MV + TV) interventions and isolated MV interventions. The benefits of surgical ablation were more pronounced in higher-risk patients (Figure) especially those with increasing CHA2DS2-VASc scores challenging the notion of limiting ablation procedures to low-risk cases.

Conclusions: This study challenges the conventional wisdom surrounding the safety and efficacy of combining AF ablation with MIMVS, particularly in patients with elevated EuroSCORE II and CHA2DS2-VASc scores. The findings underscore the improved long-term survival associated with the concomitant approach, even in high-risk patients. Notably, the study highlights the importance of LAA closure in MIMVS and its potential impact on AF ablation benefits. The analysis supports the notion that ablation procedures can be safely performed in MIMVS patients, challenging the existing trend of avoiding such interventions in higher-risk individuals. Further research is needed to explore the recurrence of AF after ablation during MIMVS and refine risk assessment tools for this specific patient population.

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