Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery

New analytical approaches and end points

Cardiothoracic Surgical Trials Network Investigators

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

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.

Original languageEnglish (US)
Pages (from-to)234-243.e9
JournalJournal of Thoracic and Cardiovascular Surgery
Volume157
Issue number1
DOIs
StatePublished - Jan 1 2019

Fingerprint

Pulmonary Veins
Mitral Valve
Atrial Fibrillation
Atrial Flutter
Tachycardia
Ambulatory Electrocardiography
Odds Ratio
Confidence Intervals
Surgical Instruments

Keywords

  • ablation
  • atrial arrhythmia
  • Cardiothoracic Surgical Trials Network
  • postablation heart rhythm monitoring
  • transtelephonic monitoring

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery : New analytical approaches and end points. / Cardiothoracic Surgical Trials Network Investigators.

In: Journal of Thoracic and Cardiovascular Surgery, Vol. 157, No. 1, 01.01.2019, p. 234-243.e9.

Research output: Contribution to journalArticle

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title = "Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery: New analytical approaches and end points",
abstract = "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.",
keywords = "ablation, atrial arrhythmia, Cardiothoracic Surgical Trials Network, postablation heart rhythm monitoring, transtelephonic monitoring",
author = "{Cardiothoracic Surgical Trials Network Investigators} and Blackstone, {Eugene H.} and Chang, {Helena L.} and Jeevanantham Rajeswaran and Parides, {Michael K.} and Hemant Ishwaran and Liang Li and John Ehrlinger and Gelijns, {Annetine C.} and Moskowitz, {Alan J.} and Michael Argenziano and Joseph DeRose and Couderc, {Jean Phillipe} and Dan Balda and Fran{\cc}ois Dagenais and Mack, {Michael J.} and Gorav Ailawadi and Smith, {Peter K.} and Acker, {Michael A.} and O'Gara, {Patrick T.} and Gillinov, {A. Marc} and Miller, {Marissa A.} and Taddei-Peters, {Wendy C.} and Dennis Buxton and Amy Connolly and Geller, {Nancy L.} and David Gordon and Jeffries, {Neal O.} and Albert Lee and Moy, {Claudia S.} and Gombos, {Ilana Kogan} and Jennifer Ralph and Richard Weisel and Gardner, {Timothy J.} and O'Gara, {Patrick T.} and Rose, {Eric A.} and Gelijns, {Annetine C.} and Parides, {Michael K.} and Ascheim, {Deborah D.} and Moskowitz, {Alan J.} and Emilia Bagiella and Ellen Moquete and Helena Chang and Melissa Chase and Seth Goldfarb and Lopa Gupta and Michler, {Robert E.} and Goldstein, {Daniel J.} and Jakobleff, {William A.} and Taub, {Cynthia C.} and Spevack, {Daniel M.}",
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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

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

AU - Miller, Marissa A.

AU - Taddei-Peters, Wendy C.

AU - Buxton, Dennis

AU - Connolly, Amy

AU - Geller, Nancy L.

AU - Gordon, David

AU - Jeffries, Neal O.

AU - Lee, Albert

AU - Moy, Claudia S.

AU - Gombos, Ilana Kogan

AU - Ralph, Jennifer

AU - Weisel, Richard

AU - Gardner, Timothy J.

AU - O'Gara, Patrick T.

AU - Rose, Eric A.

AU - Gelijns, Annetine C.

AU - Parides, Michael K.

AU - Ascheim, Deborah D.

AU - Moskowitz, Alan J.

AU - Bagiella, Emilia

AU - Moquete, Ellen

AU - Chang, Helena

AU - Chase, Melissa

AU - Goldfarb, Seth

AU - Gupta, Lopa

AU - Michler, Robert E.

AU - Goldstein, Daniel J.

AU - Jakobleff, William A.

AU - Taub, Cynthia C.

AU - Spevack, Daniel M.

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 - ablation

KW - atrial arrhythmia

KW - Cardiothoracic Surgical Trials Network

KW - postablation heart rhythm monitoring

KW - transtelephonic monitoring

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DO - 10.1016/j.jtcvs.2018.06.093

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