Commentary: Judgment day: Should you add atrial fibrillation ablation?

Abstract

Guideline Level 1 recommendations are intended as strong suggestions for how to treat the patient. For example, patients with degenerative mitral regurgitation with left ventricular dysfunction should have surgery unless there are unusual extenuating circumstances (eg, age/frailty or other life-limiting comorbidities), in which case the surgeon makes a judgment that the risk of surgery is higher than the benefit. In 2017, adding an atrial fibrillation (AF) ablation procedure for those patients with preexisting AF undergoing concomitant surgery was elevated to a Class 1 indication 1,2 even though none of the randomized clinical trials demonstrated an increase in survival or reduction in strokes compared with the control population. 3-7 But freedom from AF was always better in the treated group.Ad and coworkers 8 have demonstrated that the 5-year freedom from AF of patients treated with AF ablation with a mitral valve procedure is similar when compared with AF ablation with coronary artery bypass (CAB) or aortic valve replacement (AVR), procedures that do not otherwise require a left atriotomy. Historically, only 15% to 30% of preoperative nonmitral surgery AF cases are treated with concomitant AF ablation. 9 Will these data be enough to convince surgeons to add AF ablation to patients undergoing AVR or CAB? Probably not, because we need a wider context that is often missing from AF surgery reports: how often surgeons do not perform AF ablation. The 30-day morbidity and 5-year freedom from AF could be influenced by the patients that we choose not to treat with AF ablation. For instance, since 2013, I have performed AF ablation in 97% of patients undergoing mitral valve surgery with preoperative AF. I use cryoablation almost exclusively and therefore can quickly and effectively create the lesion set.