Minimally Invasive Surgical Off-Pump Ablation and Sinus Rhythm Restoration in AF

Compared with catheter ablation, minimally invasive surgical off-pump ablation for atrial fibrillation (AF) may be associated with superior rhythm outcomes for freedom from AF, according to a study in the International Journal of Cardiology.

A meta-analysis compared the efficacy and safety of minimally invasive surgical off-pump ablation, including the thoracoscopic and transdiaphragmatic or subxiphoid approaches to CA.

Researchers conducted a search of multiple databases up to March 2022. Eligible studies were 2-armed studies published in English that compared minimally invasive surgical off-pump ablation, including the hybrid approach, and CA alone, and reported restoration to sinus rhythm (SR) as the primary outcome. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

The primary endpoint was freedom from AF based on reconstructed IPD.

A total of 21 studies with 2234 patients were included in the analysis. Of these patients there were 1070 in the minimally invasive surgical off-pump ablation group (mean age, 58.8±5.1 years; 78.6% men) and 1164 in the CA group (mean age, 59.3±5.0 years; 74% men). The studies were published from 2011 to 2021, 9 were randomized controlled trials, 4 were propensity-matched studies, and 8 were observational studies. The pooled mean follow-up was 16.8±7.5 months.

The minimally invasive surgical off-pump ablation and CA groups had similar outcomes for postoperative cerebrovascular accident (CVA) incidence (odds ratio [OR], 2.00; 95% CI, 0.91-4.40; P =.084), postoperative permanent pacemaker (PPM) implant (OR, 1.55; 95% CI, 0.61-3.95; P =.358), and 30-day mortality (OR, 1.96; 95% CI, 0.90-4.22; P =.087). The total number of postoperative adverse events was greater in the minimally invasive surgical off-pump ablation group vs the CA group (OR, 4.44; 95% CI, 2.38-8.27; P <.001).

Survival freedom from AF was analyzed in 19 studies, with 1021 patients in the CA group and 892 in the minimally invasive surgical off-pump ablation group. Freedom from AF at 4 years was 29.1%±3.5% in the CA group vs 52.1%±3.2% in the minimally invasive surgical off-pump ablation group (log-rank P <.001).

Significant improvement in survival freedom from AF was observed in the minimally invasive surgical off-pump ablation group vs the CA group after 5 months of follow-up in the landmark analysis (2 months from the blanking period; log-rank P-value =.044). Minimally invasive surgical off-pump ablation was a protective factor for AF in univariable weighted estimation Cox regression (hazard ratio, 0.60; 95% CI, 0.50-0.72; P <.001).

In the thoracoscopic subgroup, freedom from AF at 3 years was 48.4%±3.0% vs 66.9%±2.5% for CA and minimally invasive surgical off-pump ablation, respectively (log-rank P <.0001). For the transdiaphragmatic subgroup, freedom from AF at 3 years was 34.5%±4.2% vs 54.1%±4.2% for CA and minimally invasive surgical off-pump ablation, respectively (log-rank P =.00062).

Among several limitations, nonrandomized trials were included in the analysis, and the 2 patient groups significantly differ in the proportion of patients who had a history of a previous ablation and type of AF. In addition, most of the data are from centers that are highly experienced in performing minimally invasive surgical off-pump ablation, and the rhythm follow-up of the included studies was limited with few exceptions.

“Despite the superiority of the surgical approach for the primary endpoint, MISOA [minimally invasive surgical off-pump ablation] is associated [with] higher postoperative complications compared to CA,” stated the investigators. “However, postoperative CVA and PPM implantation did not significantly differ between the 2 groups.”

Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.