Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
Semin Thorac Cardiovasc Surg. 2022 Autumn;34(3):906-915. doi: 10.1053/j.semtcvs.2021.05.015. Epub 2021 Jun 6.
The benefit of avoiding lifelong anticoagulation therapy in patients with bioprosthetic heart valve implantation may potentially be offset by atrial fibrillation (AF); however, clinical impact of surgical AF ablation in such patients remains controversial. We enrolled 426 patients (aged 72.0 ± 7.8 years) with AF who underwent left-side valve replacement with bioprostheses between 2001 and 2018. Of these, 297 underwent concomitant surgical ablation (ablation group) and 129 underwent valve replacement alone (non-ablation group). Clinical outcomes were compared, and mortality was considered as a competing risk factor against valve-related complications. Inverse-probability weighting (IPTW) was adopted to reduce selection bias. The ablation group had lower baseline risk profiles than the non-ablation group. In crude analysis, early mortality rates were 3.4% and 7.0% in the ablation and non-ablation groups, respectively (P = 0.104). During follow-up (1521.9 patient-years), the ablation group showed lower AF-recurrence (P < 0.001) and anticoagulant medication rate (P = 0.021), and lower overall mortality risk (subdistribution hazard ratio [SHR], 0.63; 95% confidence interval [CI], 0.42-0.94), but higher risk of permanent pacemaker implantation (SHR, 4.67; 95% CI, 1.36-16.05). No significant difference in the risk of stroke (SHR, 1.27; 95% CI, 0.55-2.95) was observed between the groups. After baseline IPTW-adjustment, findings of the clinical outcomes were analogous to those from crude analyses. In patients undergoing bioprosthetic valve replacement, the addition of surgical ablation was associated with improved rhythm outcomes and survival but at the expense of a higher risk of pacemaker implantation. The underlying mechanism of improved survival by AF ablation needs further investigation.
在植入生物瓣的患者中，避免终身抗凝治疗的益处可能会因心房颤动（AF）而抵消；然而，此类患者中外科房颤消融术的临床影响仍存在争议。我们纳入了 2001 年至 2018 年间接受左侧瓣膜置换术的 426 例 AF 患者（年龄 72.0 ± 7.8 岁），其中 297 例同时接受外科消融术（消融组），129 例仅接受瓣膜置换术（非消融组）。比较了临床结局，并将死亡率视为瓣膜相关并发症的竞争风险因素。采用逆概率加权（IPTW）减少选择偏倚。消融组的基线风险状况低于非消融组。在粗分析中，消融组和非消融组的早期死亡率分别为 3.4%和 7.0%（P = 0.104）。在随访期间（1521.9 患者年），消融组显示出较低的 AF 复发率（P < 0.001）和抗凝药物使用率（P = 0.021），以及较低的全因死亡率风险（亚分布风险比[SHR]，0.63；95%置信区间[CI]，0.42-0.94），但永久性起搏器植入的风险较高（SHR，4.67；95% CI，1.36-16.05）。两组间中风风险无显著差异（SHR，1.27；95% CI，0.55-2.95）。在基线 IPTW 调整后，临床结局的发现与粗分析相似。在接受生物瓣置换术的患者中，外科消融术的附加治疗与改善节律结果和生存率相关，但代价是起搏器植入的风险增加。AF 消融术改善生存率的潜在机制需要进一步研究。
