title: Should paroxysmal atrial fibrillation be treated during cardiac surgery?
abstract: OBJECTIVE
  Randomized controlled trials of permanent atrial fibrillation ablation surgery have shown improved outcomes compared with control patients undergoing concomitant cardiac surgery. Little has been reported regarding patients with paroxysmal atrial fibrillation. We hypothesized that treating paroxysmal atrial fibrillation during cardiac surgery would not adversely affect the perioperative risk and would improve the midterm outcomes.
  
  
  METHODS
  From April 2004 to June 30 2012, 4947 patients (excluding those with transcatheter aortic valve implants, left ventricular assist devices, trauma, transplantation, and isolated atrial fibrillation surgery) underwent cardiac surgery, and 1150 (23%) had preoperative atrial fibrillation. Of these, 552 (48%) had paroxysmal atrial fibrillation. Three groups were compared using propensity score matching: treated (n = 423, 77%), untreated (n = 129, 23%), and no atrial fibrillation (n = 3797).
  
  
  RESULTS
  The treated patients had 30-day mortality similar to that of the untreated patients and those without atrial fibrillation. They had fewer perioperative complications (26% vs 46%, P = .001), greater freedom from atrial fibrillation at the last follow-up visit (81% vs 60%, P = .007), and lower mortality (hazard ratio 0.47, P = .007) compared with the untreated patients. Compared with those without atrial fibrillation, the treated patients had fewer perioperative complications (25% vs 48%, P < .001), lower freedom from atrial fibrillation at the last follow-up visit (84% vs 93%, P = .001), and similar mortality.
  
  
  CONCLUSIONS
  Concomitant surgical ablation of paroxysmal atrial fibrillation was not associated with increased perioperative risk. The treated patients had greater late freedom from atrial fibrillation and midterm survival compared with the untreated patients, and similar midterm survival compared with the patients without atrial fibrillation. These results suggest that paroxysmal atrial fibrillation warrants treatment consideration in select patients undergoing cardiac surgery.
authors.affiliation: Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, Ill. Electronic address: pmccart@nmh.org.
authors.forename: Patrick M
authors.initials: PM
authors.lastname: McCarthy
authors.forename: Adarsh
authors.initials: A
authors.lastname: Manjunath
authors.forename: Jane
authors.initials: J
authors.lastname: Kruse
authors.forename: Adin-Cristian
authors.initials: AC
authors.lastname: Andrei
authors.forename: Zhi
authors.initials: Z
authors.lastname: Li
authors.forename: Edwin C
authors.initials: EC
authors.lastname: McGee
authors.forename: S Chris
authors.initials: SC
authors.lastname: Malaisrie
authors.forename: Richard
authors.initials: R
authors.lastname: Lee
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000401:mortality / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D017115:Catheter Ablation / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006331:Heart Diseases / Q000401:mortality / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: 23; 23.1; 24; 35; AAD; AF; BA; CABG; FFAF; HR; HRS; Heart Rhythm Society; LA; NoAF; PAF; PS; PVI; STS; Society of Thoracic Surgeons; TrPAF; UntrPAF; antiarrhythmic drug; atrial fibrillation; biatrial; coronary artery bypass grafting; freedom from atrial fibrillation; hazard ratio; left atrial; paroxysmal AF; patients with PAF who did not receive AF treatment; patients with PAF who received AF treatment during cardiac surgery; patients without preoperative PAF who received no AF treatment; propensity score; pulmonary vein isolation