2023 APHRS expert consensus statements on surgery for <scp>AF</scp>

摘要

A variety of surgical procedures for atrial fibrillation (AF) with different approaches have become available during the last quarter century, starting with the Maze procedure to the minimally invasive procedures. Asia-Pacific region is an active region in surgical treatment of AF; however, there is a diversity in the region in terms of health care and insurance systems, which can affect the indication and outcome of surgery for AF. The Asia Pacific Heart Rhythm Society (APHRS) and the surgery subcommittee organized a task force group to develop the APHRS Expert Consensus Statement on Surgery for AF (hereafter Statement). The purpose of the Statement is to describe the evidence and recommendation of various surgical treatments for AF patients with or without structural heart disease. Contents in each chapter include a brief outline of the procedure, followed by a comparative outcome of the procedure based on clinical evidence. The evidence includes freedom from AF, short- and long-term survivals, and morbidities or complications. Freedom from AF is a function of time after intervention. Clinical studies do not necessarily come into the line align with guidelines in regard to the timing and method for evaluation of postoperative arrhythmia, which may influence the objective assessment of surgical procedures.1-4 A classified recommendation of the procedure is described with a level of evidence. A recommended lesion set and a device is also described, if appropriate. Definitions of classes of recommendations and levels of evidence are referred to the ESC Guidelines.5 Patients undergoing LA open procedures, such as mitral valve surgery, frequently have atrial fibrillation (AF). Untreated AF has been shown to increase the risk of morbidities, such as stroke, and affect the long-term survival. Therefore, concomitant procedures for AF have been recommended to improve the postoperative outcomes.6-8 Meta-analyses of randomized controlled trials (RCT) and non-RCTs showed concomitant AF surgery to be safe without increasing operative mortality.1, 9-23 The analyses of the United States (US) Society of Thoracic Surgeons (STS) AF database21 with a propensity matching showed that surgical ablation was associated with a reduction of 30-day mortality. Previous studies,8-21 including several meta-analyses, RCT and non-RCT clinical trials and the US STS AF database, on patients undergoing surgical AF ablation concomitant with LA open procedures, demonstrated a superior sinus rhythm restoration and maintenance rates than those without undergoing AF ablation. A meta-analysis of several nonrandomized1, 22, 23 clinical trials and one RCT24 of concomitant surgical AF ablation in patients undergoing LA open procedures showed a reduction of stroke rate at 5-year postoperatively. Although there has been no RCT examining the long-term (>12 months) outcome after concomitant surgical AF ablation, several retrospective and propensity-matched studies25-27 have demonstrated the performance of surgical AF ablation concomitant with other cardiac procedures, such as valve surgery or combined valve surgery and CABG, were associated with improved long-term survival. An LA open procedure was performed in the majority of the patients in these studies, and two studies25, 26 demonstrated not only the improved survival in the treated AF group compared to the untreated AF group without treating AF, but also showed similar survival to the group of patients without a history of AF. Besides the common complications of cardiac surgical procedures, there are two specific complications potentially related to surgical procedures for AF: postoperative atrial tachycardia (AT) and new permanent pacemaker (PPM) implantation. Inappropriate lesion sets or surgical techniques, including inappropriate use of ablation devices, have been shown to be the mechanism for a part of postoperative AF recurrence and the majority of AT.32 Even in the original cut-and-sew maze procedure, incomple