Long-Term Outcomes of Paroxysmal and Persistent Atrial Fibrillation Management Strategy During Nonemergent Coronary Artery Bypass Surgery.

Abstract

Management of atrial fibrillation (AF) at the time of coronary artery bypass grafting (CABG) is a class 1 recommendation. This study evaluated trends in AF management and their association with long-term survival. Patients with paroxysmal or persistent AF who underwent isolated CABG were identified from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2022) with linkage to Medicare claims for long-term outcomes. Patients were stratified by AF treatment: none, left atrial appendage occlusion (LAAO) only, epicardial ablation (EA), or intracardiac ablation (IA). The primary end point was all-cause mortality; secondary end points included permanent pacemaker placement, stroke, and readmission for AF, bleeding, or heart failure. Long-term mortality was assessed using Kaplan-Meier methods and Cox regression. Nonfatal outcomes were assessed using competing-risk regression with death as the competing event. Among 59,331 patients, 71.0% had paroxysmal AF, increasing from 56.6% (2011) to 79.6% (2022). AF treatment included none (51.0%), LAAO only (15.3%), EA (25.4%), and IA (8.2%). AF treatment increased from 31.8% to 68.8%, driven by LAAO (1.2%-30.8%). Patients with persistent AF had higher mortality than patients with paroxysmal AF (P < .001). EA showed lower mortality compared with no treatment. IA was associated with higher pacemaker implantation (6.0% vs 3.2%-3.4% in other groups; P < .001). Compared with no treatment, all treatment groups had lower stroke risk (subdistribution hazard ratio, 0.64-0.79; P < .001) and lower AF readmission (subdistribution hazard ratio, 0.85-0.89; P < .05). Nearly one-half of patients with AF who underwent CABG receive no treatment. Epicardial ablation was associated with superior long-term survival, and all strategies with were associated lower stroke risk.