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Management of Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Grafting

Review of the Literature

Khiabani, Ali J., MD; Adademir, Taylan, MD; Schuessler, Richard B., PhD; Melby, Spencer J., MD; Moon, Marc R., MD; Damiano, Ralph J. Jr, MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: November/December 2018 - Volume 13 - Issue 6 - p 383–390
doi: 10.1097/IMI.0000000000000570
Review Articles

Untreated atrial fibrillation is associated with an increased risk of all-cause mortality and morbidity. Despite the current guidelines recommending surgical ablation of atrial fibrillation at the time of coronary artery bypass surgery, most patients with concomitant atrial fibrillation and coronary artery disease do not receive surgical ablation for their atrial fibrillation. This review reports the efficacy of different surgical ablation techniques used for the treatment of atrial fibrillation during coronary artery bypass. PubMed was systematically searched for studies reporting outcomes of concomitant surgical ablation in coronary artery bypass patients between January 2002 and March 2018. Data were independently extracted and analyzed by two investigators. Twenty-four studies were included. Twelve studies exclusively reported outcomes of surgical ablation in patients undergoing coronary artery bypass, whereas the remaining 12 reported outcomes of concomitant cardiac surgery with subgroup analysis. Only four studies performed the concomitant Cox-Maze procedure. Freedom from atrial tachyarrhythmia was reported as high as 98% at 1 year and 76% at 5 years with Cox-Maze procedure, whereas lesser lesion sets had more variable outcomes, ranging from 35% to 93%. In most studies, the addition of surgical ablation was not associated with increased morbidity and mortality. Although the Cox-Maze procedure had the greatest short- and long-term success rates, most studies comprising the evidence documenting the safety and efficacy of adding surgical ablation were of low or moderate quality. There was a great deal of heterogeneity among study populations, follow-up times, methods, and definition of failure. To establish a consensus regarding a surgical ablation technique for atrial fibrillation in coronary artery bypass population, larger multicenter randomized controlled studies need to be designed.

From the Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO USA.

Accepted for publication October 29, 2018.

Ali J. Khiabani, MD, and Taylan Adademir, MD, contributed equally to this study.

Supported by the National Institutes of Health R01-HL032257 to Ralph J. Damiano, Jr, MD, and Richard B. Schuessler, PhD, and T32-HL007776 to Ralph J. Damiano, Jr, MD, and Ali J. Khiabani, MD. Taylan Adademir, MD, received the American Association for Thoracic Surgery's Evarts A. Graham Memorial Traveling Fellowship.

Disclosures: Ralph J. Damiano, Jr, MD, is a speaker and receives research funding from AtriCure, Inc, Mason, OH USA, is a speaker for LivaNova, London, UK, and Edwards Lifesciences, Irvine, CA USA, and is a consultant for Medtronic, Inc, Minneapolis, MN USA. Ali J. Khiabani, MD, Taylan Adademir, MD, Richard B. Schuessler, PhD, Spencer J. Melby, MD, and Marc R. Moon, MD, declare no conflicts of interest.

Address correspondence and reprint requests to Ralph J. Damiano, Jr, MD, Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Campus Box 8234, 660 S Euclid Ave, St. Louis, MO 63110 USA. E-mail:

©2018 by the International Society for Minimally Invasive Cardiothoracic Surgery