Society clinical practice guidelines have significant potential to change clinical practice ( Fig. 24.1 ). They are authored by experts in the field and undergo a rigorous development and review process to reach consensus, ideally reflecting the best and most recent information used to shape clinical practice. Guidelines are summarized in a concise format, with extensive supporting references, and are presented in a way that makes them easily accessible for busy clinicians. They focus on the latest information on a variety of issues facing clinicians, some of which are common and others that are rare and are updated periodically as clinical care evolves. Guidelines must be interpreted considering each patient’s clinical situation because they cover generalities, and individual patients may have comorbidities or other reasons that the guidelines may not be the “best” therapy for a particular patient.
Percentage of treatment of documented atrial fibrillation (AF) undergoing first-time, non-emergent cardiac surgery being treated with surgical ablation (SA) only, left atrial appendage occlusion (LAAO) alone, no treatment or surgical ablation plus LAAO. CPG, The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines on the Surgical Treatment of Atrial Fibrillation; STS, Society of Thoracic Surgeons.
(Reproduced from Wyler von Ballmoos MC, Hui DS, Mehaffey JH, et al. The Society of Thoracic Surgeons 2023 clinical practice guidelines for the surgical treatment of atrial fibrillation. Ann Thor Surg. 2024;118(2):291–310.)
Many societies have guidelines that cover various aspects of atrial fibrillation (AF) diagnosis, medical therapy, and interventional treatment, but not all are applicable to surgical patients. , , There are also various types of clinical practice documents ( Table 24.1 ). The most relevant of these to the surgical treatment of AF are the 2024 Society of Thoracic Surgeons (STS) Guidelines and the European Society of CardioThoracic Surgery Guidelines. , This chapter focuses on these two sets of guidelines and builds off Chapter 23 on the benefits of concomitant AF ablation. There are a few caveats. The guidelines in general are not specific to which technology, approach, or lesion set should be used. Randomized trials are typically the most definitive data, but often they are not available, so surgical guideline recommendations are often based on systematic reviews, meta-analyses, large database studies, multicenter trials, and single-center reports with a generous helping of expert opinion. There are more data available for concomitant mitral valve (MV) surgery than for concomitant aortic valve replacement (AVR) or coronary artery bypass graft (CABG) operations, and the Level of Evidence (LOE) behind these latter recommendations is more limited. There is even less information about many other important areas of care, including the various types of stand-alone and “hybrid” operations, best practices for postoperative care such as anticoagulation, and the ‘best” treatment for patients with aortic stenosis and AF, surgical AVR with concomitant ablation versus transcatheter AVR.
TABLE 24.1
Types of Clinical Practice Documents
| Clinical Practice Guidelines | Expert Consensus Statements | Clinical Statements or White Papers | |
|---|---|---|---|
| Definition | Evidence-based documents containing systematically developed recommendations with an explicit clinical scope and explicit consideration of benefits, harms, values, and preferences | Expert position on a controversial or specific clinical topic, formulated as a statement of facts based on available evidence and expert consensus in situations where high-level evidence is unavailable | Extensive reports outlining positions on critical clinical issues while highlighting areas of ongoing uncertainty or concern for patient safety |
| Source of evidence | Randomized controlled trials (RCTs) are available and serve as the primary source of information; observational data are used if considered robust. | Robust observational data are available and serve as the primary source of information in conjunction with a limited number of RCTs. | Any research and health care regulations |
| Number of writing committee members | ≤20 | ≤20 | ≤10 |
| Review | After the writing committee’s established composition principles, a lead reviewer and up to five anonymous reviewers from each participating entity in collaboration with the governing bodies | After the writing committee’s established composition principles, a lead reviewer and up to five anonymous reviewers from each participating entity in collaboration with the governing bodies | After the writing committee’s established composition principles, up to three anonymous reviewers from each participating entity |
| Length | ≤30,000 words and a total of 500 references | ≤15,000 words and a total of 300 references | ≤5000 words and a total of 50 references |
| Time frame (months) | 24 | 12 | 6 |
Reproduced from Milojevic M, Freemantle N, Hayanga JWA, et al. Harmonizing guidelines and other clinical practice documents: a joint comprehensive methodology manual by the American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), European Society of Thoracic Surgeons (ESTS), and Society of Thoracic Surgeons (STS). J Thorac Cardiovasc Surg . 2025;169(1):170–185.
Shared Decision Making and Heart Team Assessment
One principle common to all clinical practice guidelines is that the patient should be informed of options and have a role in decision making. As surgeons, we balance the risks and benefits of any procedure. Part of the informed consent of concomitant left atrial appendage occlusion (LAAO) and surgical ablation should include discussions of the potential near-term risks of adding LAAO and surgical ablation to what is almost always some other reason for undergoing cardiac surgery. The decision making for most patients is not complex because most patients are happy to have the AF and left atrial appendage (LAA) treated at the same time as the primary surgery. For “stand-alone” procedures, these discussions are more complex. The alternative treatments include continued medical therapy, or perhaps more catheter ablation. In the case of surgical AVR (SAVR) with LAAO and surgical ablation compared with transcatheter AVR (TAVR), the discussions can be quite extensive. These discussions typically center around improvement in symptoms and quality of life and reduction in stroke ( Table 24.2 ).
TABLE 24.2
Guideline Recommendations for a Team Approach to Treatment Decision Making
| Guideline | Recommendation: Team Approach | Class of Recommendation | Level of Recommendation |
|---|---|---|---|
| Wyler von Ballmoos et al., STS | Multidisciplinary heart team assessment and treatment planning and long-term follow-up with periodic continuous rhythm monitoring | I | C |
| Van Gelder et al., EACTS | Education directed to patients, family members, caregivers, and health care professionals is recommended to optimize shared decision-making, facilitating open discussion of both the benefits and risks associated with each treatment option | I | C |
| Van Gelder et al., EACTS | Access to patient-centered management according to the AF-CARE principles is recommended in all patients with AF, regardless of gender, ethnicity, and socioeconomic status, to ensure equality in health care provision and improve outcomes | I | C |
| Van Gelder et al., EACTS | Patient-centered AF management with a multidisciplinary approach should be considered in all patients with AF to optimize management and improve outcomes. | IIa | B |
AF, Atrial fibrillation; AF-CARE, Atrial fibrillation—[C] Comorbidity and risk factor management, [A] Avoid stroke and thromboembolism, [R] Reduce symptoms by rate and rhythm control, [E] Evaluation and dynamic reassessment; EACTS, European Association for Cardio-Thoracic Surgery; STS, Society of Thoracic Surgeons.
Heart transplantation always functioned as a team of surgeons, cardiologists, and associated specialists. Complex decision making and care are best addressed with the combined skills of a variety of subspecialists. The “heart team” concept entered the everyday lexicon of practice with the launch of the placement of aortic transcatheter valves (PARTNER) Trials and eventually expanded to include MV therapies, coronary artery disease, and the treatment of AF and other arrhythmias. The STS Guidelines recommend (Class 1; LOE C) using a multidisciplinary heart team approach to the patients covered in the Guidelines. The European Association for Cardio-Thoracic Surgery (EACTS) multidisciplinary team recommendation is Class IIA.
Guidelines for the Concomitant Ablation of Atrial Fibrillation
Mitral Valve Surgery
The STS and EACTS recommend concomitant AF ablation for patients undergoing first-time nonemergency MV surgery ( Table 24.3 ). , Reflecting the many randomized clinical trials, the recommendations are based on the success of restoring sinus rhythm compared with untreated patients with AF (see Table 23.1). Also, and importantly, they based this upon new information documenting improved long-term outcomes regarding survival and freedom from stroke ( Fig. 24.2 ). The data behind these recommendations are summarized in Chapter 23 . This recommendation has the highest rating from both STS and EACTS: Class I; LOE A. The EACTS document also gives its highest recommendation to concomitant surgical ablation with MV surgery. The EACTS guideline committee relied primarily on meta-analyses to support their recommendations.
TABLE 24.3
Society of Thoracic Surgeons, European Society of Cardiology, and European Association for Cardio-Thoracic Surgery Recommendations for Surgical Atrial Fibrillation Ablation During Mitral Operations
| Guideline: STS | Recommendations: Mitral Operations | Class of Recommendation | Level of Recommendation |
|---|---|---|---|
| Wyler von Ballmoos et al. | Surgical ablation for AF is recommended for first-time nonemergent concomitant mitral operations to restore sinus rhythm and improve long-term outcomes. | I | A |
| Guideline: ESC/EACTS | Recommendations: Mitral Operations | Class of Recommendation | Level of Recommendation |
| Van Gelder et al., EACTS | Concomitant surgical ablation is recommended in patients undergoing MV surgery and AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, with shared decision making supported by an experienced team of electrophysiologists and arrhythmia surgeons. | I | A |
AF, Atrial fibrillation; EACTS, European Association for Cardio-Thoracic Surgery; ESC, European Society of Cardiology; MV, mitral valve; STS, Society of Thoracic Surgeons.
Studies with a follow-up of 2 years or more (median follow-up range, 2.6–6.7 years; n = 8 studies) and the pooled effect estimates for all-cause mortality associated with surgical ablation of atrial fibrillation (hazard ratio, 0.77; 95% confidence interval [CI], 0.69–0.86). ES, estimate.
(Reproduced from Reproduced from Wyler von Ballmoos MC, Hui DS, Mehaffey JH, et al. The Society of Thoracic Surgeons 2023 clinical practice guidelines for the surgical treatment of atrial fibrillation. Ann Thor Surg. 2024;118(2):291–310.)
Non–Mitral Valve Surgery
The data for concomitant non-MV surgery in which the left atrium is normally not opened are not as robust as they are for MV surgery in which the left atrium is always open because concomitant surgery is performed far less often in non-MV surgery. As discussed in Chapter 23 , there are multiple STS database studies , and meta-analyses , focused on how to treat concomitant AF in patients undergoing CABG or AVR. The STS gave a Class 1 recommendation for concomitant AF surgical ablation in any first-time none-mergent non-mitral operation but an LOE B because the data supporting this recommendation are non-randomized ( Table 24.4 ). Surgical ablation for AF is recommended for any first-time non-emergent concomitant non-mitral operation to restore sinus rhythm and improve long-term outcomes. EACTS gave a more reserved recommendation of IIa in these patients and suggested that concomitant ablation “should be considered”. This conservative recommendation is LOE B because there are fewer studies of this combination. This recommendation is primarily based upon meta-analyses. , The STS apparently places more emphasis on the STS database studies of CABG patients that show reduced stroke and mortality rates in the treated group. More well-designed studies of AF ablation in patients undergoing CABG and AVR will be helpful for the formulation of the next guidelines.
TABLE 24.4
Society of Thoracic Surgeons, European Society of Cardiology, and European Association for Cardio-Thoracic Surgery Recommendations for Surgical Atrial Fibrillation Ablation During Nonmitral Operations
| Guideline: STS | Recommendations: Nonmitral Operations | Class of Recommendation | Level of Recommendation |
|---|---|---|---|
| Wyler von Ballmoos et al. | Surgical ablation for AF is recommended for any first-time nonemergent concomitant nonmitral operation to restore sinus rhythm and improve long-term outcomes. | I | B-NR |
| Guideline: ESC/EACTS | Recommendations: Nonmitral Operations | Class of Recommendation | Level of Recommendation |
| Van Gelder et al., EACTS | Concomitant surgical ablation should be considered in patients undergoing non–MV cardiac surgery and AF suitable for a rhythm control strategy to prevent symptoms and recurrence of AF, with shared decision making supported by an experienced team of electrophysiologists and arrhythmia surgeons. | IIa | B |
AF, Atrial fibrillation; EACTS, European Association for Cardio-Thoracic Surgery; ESC, European Society of Cardiology; MV, mitral valve; STS, Society of Thoracic Surgeons.
Left Atrial Appendage Management
Multiple studies supporting concomitant LAA closure for patients with preoperative AF to reduce the risk of stroke have created some of the most impressive datasets in cardiac surgery (see Chapter 23 ). Therefore, it was no surprise that both the STS and EACTS support this as a Class I recommendation. The American Heart Association gives this a Class 1 recommendation with LOE A on the strength of the LAAOS III randomized clinical trial ( Table 24.5 ). , , LAAO treatment should be considered the minimum treatment for any patient with AF undergoing cardiac surgery because of the high safety and late reduction in stroke. ,
TABLE 24.5
Guideline Recommendations for Left Atrial Appendage Management During Cardiac Surgery
| Guideline | Recommendations: Left Atrial Appendage | Class of Recommendation | Level of Recommendation |
|---|---|---|---|
| Wyler von Ballmoos et al. | LAAO for AF is recommended for all first-time nonemergent cardiac surgery procedures, with or without concomitant surgical ablation, to reduce morbidity from thromboembolic complications. | I | B-NR |
| Van Gelder et al., EACTS | Surgical closure of the LAA is recommended as an adjust to oral anticoagulation in patients with AF undergoing cardiac surgery to prevent ischemic stroke and thromboembolism | I | B |
| Joglar et al. | In patients with AF undergoing cardiac surgery with a CHA2DS2-VASc score of ≥2 or equivalent stroke risk, surgical LAA exclusion, in addition to continued anticoagulation, is indicated to reduce the risk of stroke and systemic embolism. | I | A |
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