Preexisting Atrial Fibrillation as Predictor for Late-Time Mortality in Patients with End-Stage Renal Disease Undergoing Cardiac Surgery - A Multicenter Study

Clinical Insights to Complete and Incomplete Surgical Revascularization in Atrial Fibrillation and Multivessel Coronary Disease

Objectives

Although endorsed by international guidelines, complete revascularization (CR) with Coronary Artery Bypass Grafting (CABG) remains underused. In higher-risk patients such as those with pre-operative atrial fibrillation (AF), the effects of CR are not well studied.

Methods

We analyzed patients’ data from the HEIST (HEart surgery In AF and Supraventricular Tachycardia) registry. Between 2012 and 2020 we identified 4770 patients with pre-operative AF and multivessel coronary artery disease who underwent isolated CABG. We divided the cohort according to the completeness of the revascularization and used propensity score matching (PSM) to minimize differences between baseline characteristics. The primary endpoint was all-cause mortality.

Results

Median follow-up was 4.7 years [interquartile range (IQR) 2.3–6.9]. PSM resulted in 1,009 pairs of complete and incomplete revascularization. Number of distal anastomoses varied, accounting for 3.0 + –0.6 vs. 1.7 + –0.6, respectively. Although early (< 24 h) and 30-day post-operative mortalities were not statistically different between non-CR and CR patients [Odds Ratio (OR) and 95% Confidence Intervals (CIs): 1.34 (0.46–3.86); P = 0.593, Hazard Ratio (HR) and 95% CIs: 0.88 (0.59–1.32); P = 0.542, respectively] the long term mortality was nearly 20% lower in the CR cohort [HR (95% CIs) 0.83 (0.71–0.96); P = 0.011]. This benefit was sustained throughout subgroup analyses, yet most accentuated in low-risk patients (younger i.e., < 70 year old, with a EuroSCORE II < 2%, non-diabetic) and when off-pump CABG was performed.

Conclusion

Complete revascularization in patients with pre-operative AF is safe and associated with improved survival. Particular survival benefit with CR was observed in low-risk patients undergoing off-pump CABG.

Preoperative atrial fibrillation is an independent risk factor for mid-term mortality after concomitant aortic valve replacement and coronary artery bypass graft surgery

OBJECTIVES

Preoperative atrial fibrillation (PAF) has been associated with poorer early and mid-term outcomes after isolated valvular or coronary artery bypass graft surgery. Few studies, however, have evaluated the impact of PAF on early and mid-term outcomes after concomitant aortic valve replacement and coronary aortic bypass graft (AVR-CABG) surgery.

METHODS

Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program was retrospectively analysed. Patients who underwent concomitant atrial arrhythmia surgery/ablation were excluded. Demographic and operative data were compared between patients undergoing concomitant AVR-CABG who presented with PAF and those who did not using chi-square and t-tests. The independent impact of PAF on 12 short-term complications and mid-term mortality was determined using binary logistic and Cox regression, respectively.

RESULTS

Concomitant AVR-CABG surgery was performed in 2563 patients; 322 (12.6%) presented with PAF. PAF patients were generally older (mean age 76 vs 74 years; P < 0.001) and presented more often with comorbidities including congestive heart failure, chronic pulmonary disease and cerebrovascular disease (all P < 0.05). PAF was associated with 30-day mortality on univariate analysis (P = 0.019) but not multivariate analysis (P = 0.53). The incidence of early complications was not significantly higher in the PAF group. PAF was independently associated with reduced mid-term survival (HR, 1.58; 95% CI, 1.14-2.19; P = 0.006).

CONCLUSIONS

PAF is associated with reduced mid-term survival after concomitant AVR-CABG surgery. Patients with PAF undergoing AVR-CABG should be considered for a concomitant surgical ablation procedure.