Page 80 - ADD-ON ABLATION SURGERY IN PATIENTS WITH ATRIAL FIBRILLATION

Chapter 9
ablation was not executed according to a predefined protocol.The high number of AF patients undergoing mitral surgery without an associated Maze procedure may be explained in part by surgeons’ hesitation to extend the cardiopulmonary bypass time, by the still existing concerns about the effectiveness of the procedure, by the lack of surgeons’ experience and little knowledge of the surgical lesion sets. Nonetheless, this drawback is shared by most of the published studies on this topic50.
Add-on surgery and oral anticoagulation: A still unanswered matter.
We investigated the real-life anticoagulation treatment after ablation surgery and examined whether this treatment adhered to current guidelines. Additionally, we explored factors related to oral anticoagulation (OAC) use preoperatively and at follow-up (Chapter 6).
The main finding of the study was that OAC before and after AF surgical ablation is hardly guided by the patient’s individual stroke risk. Contrary to current recommendations, the rate of OAC remains high even in patients with a low stroke risk.The most important factor that influences the use of anticoagulants seems to be age > 75 years and type of AF > paroxysmal at inclusion and “preoperative OAC use” and “other indications for OAC use than AF” at follow-up.This results in possible over-treatment of low-risk patients and under-treatment of high-risk patients. Indeed, one year after the procedure, 96% of patients (47/49) with a low stroke risk (CHADS2 51,52 [congestive heart failure, hypertension, age ≥ 75 years, diabetes {1 point each}, and prior stroke or transient ischaemic attack {2 points}) score ≤ 1) were still receiving OAC. In addition, this is in contrast with the current guidelines, which advocate basing decisions regarding OAC treatment after surgical and catheter ablation on the patient’s risk factors, and not on the presence or type of AF53, 54, and to continue anticoagulation treatment in patients with a high stroke risk as expressed by a CHADS2 score ≥ 2. Indeed, the results of our study show that real-life anticoagulation practice does not adhere to these recommendations and the rate of anticoagulation remained very high at 12-month follow-up irrespective of the patient’s stroke risk. Indeed, we found only a moderate overall guideline adherence of 62% at inclusion with an even distribution in low- and high-risk AF patients (p=. 13). Total guideline adherence for patients still in AF follow-up fell to 55% at 12-months with no statistical difference between high-risk and low-risk groups (p=0.12). In addition, a high percentage of low-risk patients were over-treated (41% at inclusion 42% at 12
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