Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery: New analytical approaches and end points.
Publication/Presentation Date
1-1-2019
Abstract
OBJECTIVE: To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation during mitral valve surgery (MVS).
METHODS: Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P < .001) by 72-hour Holter monitoring, without evident difference between lesion sets (for which the trial was underpowered).
RESULTS: Estimated freedom from AF/AFL/AT on any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95-5.65; P = .07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57-1.43; P = .6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P < .02).
CONCLUSIONS: Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.
Volume
157
Issue
1
First Page
234
Last Page
243
ISSN
1097-685X
Published In/Presented At
Blackstone, E. H., Chang, H. L., Rajeswaran, J., Parides, M. K., Ishwaran, H., Li, L., Ehrlinger, J., Gelijns, A. C., Moskowitz, A. J., Argenziano, M., DeRose, J. J., Jr, Couderc, J. P., Balda, D., Dagenais, F., Mack, M. J., Ailawadi, G., Smith, P. K., Acker, M. A., O'Gara, P. T., Gillinov, A. M., … Cardiothoracic Surgical Trials Network Investigators (2019). Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery: New analytical approaches and end points. The Journal of thoracic and cardiovascular surgery, 157(1), 234–243.e9. https://doi.org/10.1016/j.jtcvs.2018.06.093
Disciplines
Medicine and Health Sciences
PubMedID
30557941
Department(s)
Department of Surgery
Document Type
Article