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, Eugene H. Blackstone, Helena L. Chang, Jeevanantham Rajeswaran, Michael K. Parides, Hemant Ishwaran, Liang Li, John Ehrlinger, Annetine C. Gelijns, Alan J. Moskowitz, Michael Argenziano, Joseph DeRose, Jean Phillipe Couderc, Dan Balda, François Dagenais, Michael J. Mack, Gorav Ailawadi, Peter K. Smith, Michael A. Acker, Patrick T. O'Gara & 31 others A. Marc Gillinov, Marissa A. Miller, Wendy C. Taddei-Peters, Dennis Buxton, Amy Connolly, Nancy L. Geller, David Gordon, Neal O. Jeffries, Albert Lee, Claudia S. Moy, Ilana Kogan Gombos, Jennifer Ralph, Richard Weisel, Timothy J. Gardner, Patrick T. O'Gara, Eric A. Rose, Annetine C. Gelijns, Michael K. Parides, Deborah D. Ascheim, Alan J. Moskowitz, Emilia Bagiella, Ellen Moquete, Helena Chang, Melissa Chase, Seth Goldfarb, Lopa Gupta, Katherine Kirkwood, Edlira Kumbarce, Ron Levitan, Karen O'Sullivan, Jessica Overbey

Research output: Contribution to journalArticle

  • 4 Citations

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.

LanguageEnglish (US)
Pages234-243.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 Katherine Kirkwood and Edlira Kumbarce and Ron Levitan and Karen O'Sullivan and Jessica Overbey",
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TY - JOUR

T1 - Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery

T2 - Journal of Thoracic and Cardiovascular Surgery

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 - Kirkwood, Katherine

AU - Kumbarce, Edlira

AU - Levitan, Ron

AU - O'Sullivan, Karen

AU - Overbey, Jessica

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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