Inova Heart and Vascular Institute, Falls Church, Virginia 22042, USA.
Ann Thorac Surg. 2013 Sep;96(3):763-8; discussion 768-9. doi: 10.1016/j.athoracsur.2013.03.066. Epub 2013 May 20.
Patients with atrial fibrillation (AF) undergoing cardiac surgery have higher morbidity and decreased survival. Recent data revealed that surgical ablation (SA) is performed in only 39% of these patients, with variability among surgeons. The aim of this study was to determine the impact of clinical presentation and surgeon experience when making the decision to treat AF concomitantly with another cardiac surgical procedure.
Since 2005, we identified 983 nonemergent patients with preoperative AF at our institution with 41% (n=401) having a concomitant SA. Logistic regression identified independent predictors for SA. The number of SAs performed captured surgeon experience in AF ablation.
Major growth in the percent of SA performed for AF was noted (31% in 2005 vs 49% in 2010; p<0.001). Independent predictors (χ2=283.5, p<0.001, area under the curve=0.80) for SA were found, including concomitant mitral valve surgery (odds ratio [OR]=5.81) and lower creatinine (OR=4.34). Surgeon experience predicted SA with 6% greater odds for every 10 SA cases performed (OR=1.06, p<0.001). The group of surgeons with 50 or greater SA cases ablated, 57% of AF patients (301 of 526), compared with those with less than 50 cases ablated, 22% (101 of 457; p<0.001).
We demonstrated that patient acuity and surgeon experience are significantly associated with the decision to perform concomitant SA for AF. Only the most experienced surgeons performed SA in patients with more complex clinical presentation. These findings, together with the negative impact of AF on patient outcomes, should prompt a comprehensive approach to educate and train surgeons in the performance of SA for AF when clinically justified.
接受心脏手术的心房颤动（AF）患者发病率更高，生存率降低。最近的数据显示，这些患者中只有 39%（n=401）进行了手术消融（SA），且不同外科医生之间存在差异。本研究旨在确定在决定同时治疗 AF 与另一种心脏手术时临床表型和外科医生经验的影响。
自 2005 年以来，我们在本机构确定了 983 例非紧急术前 AF 患者，其中 41%（n=401）同时进行了 SA。Logistic 回归确定了 SA 的独立预测因素。SA 数量的增加反映了外科医生在 AF 消融方面的经验。
我们注意到，AF 患者进行 SA 的比例显著增加（2005 年为 31%，2010 年为 49%；p<0.001）。发现了 SA 的独立预测因素（χ2=283.5，p<0.001，曲线下面积=0.80），包括同期二尖瓣手术（优势比[OR]=5.81）和较低的肌酐（OR=4.34）。外科医生经验可预测 SA，每进行 10 例 SA 手术，其可能性增加 6%（OR=1.06，p<0.001）。进行了 50 例或更多 SA 手术的外科医生组中，57%（301/526）的 AF 患者进行了 SA，而进行少于 50 例 SA 手术的外科医生组中，22%（101/457；p<0.001）。
我们证明了患者的病情严重程度和外科医生的经验与决定同时进行 AF 合并 SA 显著相关。只有最有经验的外科医生才会对临床表现更为复杂的患者进行 SA。这些发现，加上 AF 对患者预后的负面影响，应该促使我们全面采取措施，在临床上有理由时，对外科医生进行 AF 行 SA 的教育和培训。
