title: Mitral Valve Surgery in The Elderly: Should We Treat Atrial Fibrillation Too?
abstract: BACKGROUND
  The study aim was to examine whether concomitant atrial fibrillation (AF) surgery at the time of mitral valve surgery in the elderly results in increased operative mortality (OM).
  
  
  METHODS
  Medicare beneficiaries aged ≥65 years undergoing primary mitral valve repair or replacement between 2004 and 2006 were included. The cohort was divided into three groups: Group 1, AF- (n = 2,705); group 2, AF+AF surgery- (n = 2,119), and group 3, AF+AF surgery+ (n = 1,832). The primary outcomes were OM and long-term survival. A secondary outcome was the association between hospital annual mitral procedure volume and OM.
  
  
  RESULTS
  The unadjusted OM was 6.4% for group 1 (AF-), 10.3% for group 2 (AF+AF surgery-), and 7.1% for group 3 (AF+AF surgery+) (p = 0.0001). Adjusted OM for AF+AF surgery+ patients was not significantly different from that of AF- patients (OR 1.16, 95% CI 0.90-1.48), or from AF+AF surgery patients (OR 0.83, 95% CI 0.66-1.06). When comparisons were adjusted for differences in baseline characteristics, AF+AF surgery- patients were more likely to experience long-term mortality than AF- patients (HR 1.30, 95% CI 1.17-1.45), as well as AF+AF surgery+ patients (HR 1.17, 95% CI 1.05-1.31). An annual average mitral procedure volume ≤40 was independently predictive of OM (OR 1.42, 95% CI 1.13-1.78). The effect of institutional volume on mortality was strongest in those who received AF surgery (AF+AF surgery+) (HR 1.75, 95% CI 1.15-2.65), compared to those who did not undergo surgery (AF+AF surgery-) (OR 1.20, 95% CI 0.86-1.67).
  
  
  CONCLUSIONS
  Elderly patients undergoing mitral valve surgery do not appear to have an increased mortality when clinical judgment favored the performance of concomitant AF surgery.
authors.affiliation: Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA.
authors.forename: Paige S
authors.initials: PS
authors.lastname: Tsuda
authors.affiliation: Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA.
authors.forename: Christian A
authors.initials: CA
authors.lastname: McNeely
authors.affiliation: Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Markwell
authors.affiliation: Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA.
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Hazelrigg
authors.affiliation: Division of Cardiothoracic Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, USA.
authors.forename: Christina M
authors.initials: CM
authors.lastname: Vassileva