Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
J Thorac Cardiovasc Surg. 2024 May;167(5):1766-1775. doi: 10.1016/j.jtcvs.2023.04.020. Epub 2023 May 7.
Atrial fibrillation (AF), if left untreated, is associated with increased intermediate and long-term morbidity/mortality. Surgical treatment for AF is lacking standardization in patient selection and lesion set, despite clear support from multi-society guidelines. The aim of this study was to analyze a statewide cardiac surgery registry to establish whether or not there is an association between center volume and type of index procedure with performance of surgical ablation (SA) for AF, the lesion set chosen, and ablation technology used.
Adult, first-time, nonemergency patients with preoperative AF between 2014 and 2022 excluding standalone SA procedures from a statewide registry of Society of Thoracic Surgeons data were included (N = 4320). AF treatment variability by hospital volume (ordered from smallest to largest) and surgery type were examined with χ analyses. Hospital-level Spearman correlations compared hospital volume with proportion of AF patients treated with SA.
Overall, 37% of patients with AF were ablated at the time of surgery (63% of mitral procedures, 26% of non-mitrals) and 15% had left atrial appendage management only. There was a significant temporal trend of increasing performance of SA for AF over time (Cochran-Armitage = 27.8; P < .001). Hospital cardiac surgery volume did not correlate with the proportion of AF patients treated with SA (r = 0.19; P = .603) with a rate of SA below the state average for academic centers. Of cases with SA (n = 1582), only 43% had a biatrial lesion set. Procedures that involved mitral surgery were more likely to include a biatrial lesion set (χ = 392.3; P < .001) for both paroxysmal and persistent AF. Similarly, ablation technology use was variable by type of concomitant operation (χ = 219.0; P < .001) such that radiofrequency energy was more likely to be used in non-mitral procedures.
These results indicate an increase in adoption of SA for AF over time. No association between greater hospital volume or academic status and performance of SA for AF was established. Similar to national data, the type of index procedure remains the most consistent factor in the decision to perform SA with a disconnect between AF pathophysiology and decision making on the type of SA performed. This analysis demonstrates a gap between evidence-based guidelines and real-world practice, highlighting an opportunity to confer the benefits of concomitant SA to more patients.
如果不进行治疗，心房颤动（AF）会导致中期和长期发病率/死亡率增加。尽管多学会指南明确支持，但 AF 的手术治疗在患者选择和病变部位设置方面缺乏标准化。本研究旨在分析全州心脏手术登记处，以确定中心容量与索引手术类型是否与 AF 的手术消融（SA）的执行、选择的病变部位和使用的消融技术相关。
纳入 2014 年至 2022 年期间来自胸外科医师学会数据全州登记处的术前有 AF 的成年首次非紧急患者（不包括单独的 SA 手术）（N=4320）。使用 χ 检验检查医院容量（从小到大排序）和手术类型的 AF 治疗变异性。医院水平的 Spearman 相关性比较了医院容量与接受 SA 治疗的 AF 患者比例。
总体而言，37%的 AF 患者在手术时进行了消融（63%的二尖瓣手术，26%的非二尖瓣手术），15%仅进行了左心耳管理。随着时间的推移，AF 的 SA 执行率呈显著的时间趋势（Cochran-Armitage=27.8；P<.001）。医院心脏手术量与接受 SA 治疗的 AF 患者比例无相关性（r=0.19；P=.603），学术中心的 SA 率低于州平均水平。在接受 SA（n=1582）的病例中，只有 43%的患者进行了双心房病变部位设置。涉及二尖瓣手术的患者更有可能进行双心房病变部位设置（χ=392.3；P<.001），无论是阵发性还是持续性 AF。同样，消融技术的使用因伴随手术类型而异（χ=219.0；P<.001），因此非二尖瓣手术更可能使用射频能量。
这些结果表明，随着时间的推移，SA 治疗 AF 的采用率有所增加。没有发现医院容量或学术地位与 AF 的 SA 执行之间存在关联。与全国数据类似，索引手术的类型仍然是决定是否进行 SA 的最一致因素，而 AF 病理生理学与所进行的 SA 类型之间存在脱节。这项分析表明，证据基础指南和实际实践之间存在差距，突显了为更多患者带来 SA 获益的机会。
