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Surgical Ablation for Atrial Fibrillation in Cardiac Surgery: A Consensus Statement of the International Society of Minimally Invasive Cardiothoracic Surgery (ISMICS) 2009

Ad, Niv MD*; Cheng, Davy C. H. MD; Martin, Janet PharmD, MSc (HTA&M)†‡; Berglin, Eva E. MD, PhD§; Chang, Byung-Chul MD; Doukas, George MD; Gammie, James S. MD**; Nitta, Takashi MD, PhD††; Wolf, Randall K. MD‡‡; Puskas, John D. MD§§

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: March-April 2010 - Volume 5 - Issue 2 - p 74-83
doi: 10.1097/IMI.0b013e3181d72939
Consensus Statement

Objective: This purpose of this consensus conference was to determine whether surgical atrial fibrillation (AF) ablation during cardiac surgery improves clinical and resource outcomes compared with cardiac surgery alone in adults undergoing cardiac surgery for valve or coronary artery bypass grafting.

Methods: Before the consensus conference, the consensus panel reviewed the best available evidence, whereby systematic reviews, randomized trials, and nonrandomized trials were considered in descending order of validity and importance. Evidence-based statements were created, and consensus processes were used to determine the ensuing recommendations. The American Heart Association/American College of Cardiology system was used to label the level of evidence and class of recommendation.

Results: The consensus panel agreed on the following statements in patients with AF undergoing cardiac surgery concomitant surgical ablation:

  1. Improves the achievement of sinus rhythm at discharge and 1 year (level A); this effect is sustained up to 5 years (level B). Does not reduce the use of antiarrhythmic drugs at 12 months after surgery (level A; 36.0% vs. 45.4%), although trials were not designed to answer this question.
  2. Does not increase the requirement for permanent pacemaker implantation (4.4% vs. 4.8%; level A).
  3. Does not increase the risk of perioperative mortality (level A), stroke (level A), myocardial infarction (level B), cardiac tamponade (level A), reoperative bleeding (level A), esophageal injury (level B), low cardiac output (level A), intraaortic balloon (level B), congestive heart failure (level B), ejection fraction (EF; level B), pleural effusion (level A), pneumonia (level A), renal dysfunction (level B), and mediastinitis (level A). The incidence of esophageal injury remains to be low (level B).
  4. Does not reduce mortality at 1 year (level A). There is a possible reduction in mortality beyond 1 year (level B), but no difference in stroke (level A), myocardial infarction (level A), and heart failure (level B). EF is increased (+4.1% more than control; level A).
  5. Has been shown to improve exercise tolerance at 1 year (level A), but no impact on quality of life at 3 months and 1 year (level A); however, the methodology used and the number of trials studying these outcomes are insufficient.
  6. Increases cardiopulmonary bypass and cross-clamp times (level A), with no difference in intensive care unit and hospital length of stay (level A). Overall costs were not reported.

Conclusions: Given these evidence-based statements, the consensus panel stated that, in patients with persistent and permanent AF undergoing cardiac surgery, concomitant surgical ablation is recommended to increase incidence of sinus rhythm at short- and long-term follow-up (class 1, level A); to reduce the risk of stroke and thromboembolic events (class 2a, level B); to improve EF (class 2a, level A); and to exercise tolerance (class 2a, level A) and long-term survival (class 2a, level B).

From the *Department of Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA USA; †Department of Anesthesia and Perioperative Medicine, Evidence-Based Perioperative Clinical Outcomes Research Group (EPiCOR), London Health Sciences Centre, The University of Western Ontario, London, ON, Canada; ‡High Impact Technology Evaluation Centre, London Health Sciences Centre, London, ON, Canada; §Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Goteborg, Sweden; ¶Department of Cardiac Surgery, Yonsei University College of Medicine, Seoul, Korea; ∥Department of Cardiothoracic Surgery, Glenfield Hospital, Leicester, UK; **Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; ††Department of Cardiac Surgery, Nippon Medical School Main Hospital, Tokyo, Japan; ‡‡Deaconess Hospital, Cincinnati, OH USA; and §§Division of Cardiothoracic Surgery, Emory University, Atlanta, GA USA.

Accepted for publication February 1, 2010.

Supported by the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS), which has received unrestricted educational grants from industries that produce surgical technologies.

Disclosures: Eva E. Berglin, MD, PhD is a consultant for ATS Medical, Inc., Minneapolis, MN USA. James S. Gammie, MD is a consultant for ATS Medical, Inc., Minneapolis, MN USA. Randall K. Wolf, MD is a consultant and receives royalties from AtriCure, West Chester, OH USA. John D. Puskas, MD is a consultant for MAQUET, Wayne, NJ USA, and Medtronic, Inc., Minneapolis, MN USA.

Address correspondence and reprint requests to Niv Ad, MD, Department of Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA 22042 USA. E-mail:

© 2010 Lippincott Williams & Wilkins, Inc.