Surgical ablation of long-standing persistent atrial fibrillation: 1-year outcomes from the CArdioSurgEry Atrial Fibrillation (CASE-AF) registry

Herko Grubitzsch; Etem Caliskan; Taoufik Ouarrak; Jochen Senges; Nicolas Doll; Michael Knaut; Thorsten Lewalter; Walter Eichinger; Bernd Niemann; Ivar Friedrich; Torsten Hanke; Volkmar Falk; CASE-AF Investigators

doi:10.1093/icvts/ivad203

Surgical ablation of long-standing persistent atrial fibrillation: 1-year outcomes from the CArdioSurgEry Atrial Fibrillation (CASE-AF) registry

Interdiscip Cardiovasc Thorac Surg. 2023 Dec 5;37(6):ivad203. doi: 10.1093/icvts/ivad203.

Authors

Herko Grubitzsch^{1

2}, Etem Caliskan^{1

2}, Taoufik Ouarrak³, Jochen Senges³, Nicolas Doll⁴, Michael Knaut⁵, Thorsten Lewalter⁶, Walter Eichinger⁷, Bernd Niemann⁸, Ivar Friedrich⁹, Torsten Hanke¹⁰, Volkmar Falk^{1

2

11}; CASE-AF Investigators

Collaborators

Affiliations

¹ Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany.
² Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
³ Institut für Herzinfarktforschung, Ludwigshafen, Germany.
⁴ Department of Cardiac Surgery, Schüchtermann-Klinik Bad Rothenfelde, Bad Rothenfelde, Germany.
⁵ Department of Cardiac Surgery, Herzzentrum Dresden GmbH Universitätsklinik an der Technischen Universität Dresden, Dresden, Germany.
⁶ Department of Cardiology, Internistisches Klinikum München Süd, München, Germany.
⁷ Department of Cardiac Surgery, München Klinik Bogenhausen, München, Germany.
⁸ Department of Cardiovascular Surgery, Universitätsklinikum Gießen, Gießen, Germany.
⁹ Department of Cardiac Surgery, Krankenhaus der Barmherzigen Brüder, Trier, Germany.
¹⁰ Department of Cardiac Surgery, Asklepios Klinikum Harburg, Hamburg, Germany.
¹¹ German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.

Abstract

Objectives: The CArdioSurgEry Atrial Fibrillation (CASE-AF) registry is a prospective, multicentre study for collecting and analysing real-world data of surgical atrial fibrillation (AF) treatment. This study aimed to evaluate outcomes of surgery for long-standing persistent AF at 1 year.

Methods: In total, 17 centres consecutively include all eligible patients with continuous AF lasting for ≥1 year. Exclusion criteria are missing informed consent or age <18 years. For patient-reported outcomes measures, the European Heart Rhythm Association score was used. No presence of AF (based on ECG findings including Holter ECG and/or implanted devices), no re-ablation, no further cardioversion and no rehospitalization due to AF after a 3-month blanking period defined no AF recurrence at 1 year.

Results: From January 2017 to January 2020, a total of 1115 patients were enrolled in CASE-AF. Of them, 202 patients (mean age 69.7 ± 7.8 years, 27.2% female) underwent surgical ablation of long-standing persistent AF (study cohort), mostly accompanied by left atrial appendage closure (n = 180 [89%], resection n = 75 [42%]) and predominantly performed as concomitant (n = 174 [86%]) and left atrial only procedure (n = 144 [71%]). Early mortality (30 days) was 2.0% and morbidity was low. At follow-up (median 14.4 months, interquartile range, 12.7-17.6 months, 100% complete), 106 patients (56%) had no AF recurrence and 93% of them were asymptomatic. AF recurrence was accompanied by AF-related rehospitalization (n = 12, P = 0.003), direct current shock cardioversion (n = 23, P < 0.001), AF ablation (n = 7, P = 0.003) and stroke (n = 3, P = 0.059). Multivariable analysis identified cryoablation, predominantly performed endocardially including additional left atrial (74%) and biatrial (42%) lesions, as a significant factor for freedom from AF recurrence (odds ratio 2.7, 95% confidence interval 1.07-6.79, P = 0.035).

Conclusions: According to CASE-AF, surgical ablation of long-standing persistent AF is most effective when concomitantly performed using endocardial cryoablation. Ongoing follow-up allows further elucidation of efficacious treatment strategies.

Keywords: Atrial fibrillation; Long-standing persistent; Registry; Surgical ablation.

Grants and funding

AtriCure Europe BV