TY - JOUR
T1 - Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery
T2 - New analytical approaches and end points
AU - Cardiothoracic Surgical Trials Network Investigators
AU - Blackstone, Eugene H.
AU - Chang, Helena L.
AU - Rajeswaran, Jeevanantham
AU - Parides, Michael K.
AU - Ishwaran, Hemant
AU - Li, Liang
AU - Ehrlinger, John
AU - Gelijns, Annetine C.
AU - Moskowitz, Alan J.
AU - Argenziano, Michael
AU - DeRose, Joseph J.
AU - Couderc, Jean Phillipe
AU - Balda, Dan
AU - Dagenais, François
AU - Mack, Michael J.
AU - Ailawadi, Gorav
AU - Smith, Peter K.
AU - Acker, Michael A.
AU - O'Gara, Patrick T.
AU - Gillinov, A. Marc
N1 - Publisher Copyright:
© 2018 The American Association for Thoracic Surgery
PY - 2019/1/1
Y1 - 2019/1/1
N2 - Objective: To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation during mitral valve surgery (MVS). Methods: Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P <.001) by 72-hour Holter monitoring, without evident difference between lesion sets (for which the trial was underpowered). Results: Estimated freedom from AF/AFL/AT on any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95-5.65; P =.07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57-1.43; P =.6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P <.02). Conclusions: Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.
AB - Objective: To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation during mitral valve surgery (MVS). Methods: Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P <.001) by 72-hour Holter monitoring, without evident difference between lesion sets (for which the trial was underpowered). Results: Estimated freedom from AF/AFL/AT on any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95-5.65; P =.07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57-1.43; P =.6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P <.02). Conclusions: Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.
KW - Cardiothoracic Surgical Trials Network
KW - ablation
KW - atrial arrhythmia
KW - postablation heart rhythm monitoring
KW - transtelephonic monitoring
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U2 - 10.1016/j.jtcvs.2018.06.093
DO - 10.1016/j.jtcvs.2018.06.093
M3 - Article
C2 - 30557941
AN - SCOPUS:85058166328
SN - 0022-5223
VL - 157
SP - 234-243.e9
JO - Journal of Thoracic and Cardiovascular Surgery
JF - Journal of Thoracic and Cardiovascular Surgery
IS - 1
ER -