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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 January 2, 2024 e91

Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation

Synopsis Among patients with AF or AFL, concomitant surgical ablation at the time of cardiac surgery has been shown to reduce the risk of recurrent atrial arrhythmia. However, it is associated with an increased risk of renal dysfunction and pacemaker placement. Among patients with symptomatic, persistent AF, a hybrid procedure combining epicardial and endocardial ablation has been shown to reduce the burden of atrial arrhythmia. Recommendation-Specific Supportive Text 1.	 The original atrial maze procedure consisted of a

biatrial lesion set derived from a “cut-and-sew” technical approach.8 Similar lesion sets delivered by cryoenergy or radiofrequency were subsequently developed. Surgical ablation concomitant with cardiac surgery currently takes place in approximately 1 in 5 patients with previous AF, most commonly at the time of a mitral valve procedure but also during aortic and tricuspid procedures or CABG.9 In a Cochrane review of 22 clinical trials conducted between 1998 and 2013, there was evidence that surgical ablation is associated with increased freedom from AF, AFL, or AT (RR, 2.04 [95% CI, 1.63-2.55]). However, risk of pacemaker placement was increased (RR, 1.69 [95% CI, 1.12-2.54]).1,2 A subsequent trial of patients undergoing mitral valve surgery with AF similarly found that ablation leads to increased freedom from AF at 1 year (63.2% versus 29.4%; P<0.001) but with increased risk of pacemaker placement (21.5 versus 8.1 per 100 patientyears; P=0.01).3 Observational data suggest surgical ablation is associated with increased survival as well as risk of pacemaker placement and renal dysfunction.10–14

2 Two components of Virchow’s triad—endothelial

injury and stasis of blood flow—can lead to a prothrombogenic milieu in the context of surgical ablation. The former is a consequence of suture lines or ablation lesions, whether they result from radiofrequency or cryoenergy. The latter can occur with postcardioversion atrial stunning and/or atrial manipulation and consequent loss of mechanical function. Accordingly, trial protocols for several key studies of surgical ablation include the use of oral anticoagulation for at least 3 months after intervention.2,3 Nonrandomized data suggest that stroke or systemic embolism in the first 3 months after catheter ablation is uncommon, but the risk increases with discontinuation of oral anticoagulation, especially in high-risk patients.4 Patients who undergo surgical ablation may be at similar risk, and thus oral anticoagulation, whether it be with warfarin or a DOAC15 because appropriate accounting for concomitant indications such as a mechanical heart valve or mitral stenosis, should be initiated regardless of stroke risk when adequate surgical hemostasis has been achieved. 3.	 In a randomized trial of 149 patients with symptom-

atic and refractory AF, compared with catheter ablation, a hybrid procedure consisting of closedchest, epicardial ablation combined with and followed by endocardial ablation led to increased freedom atrial arrhythmias, including AF, AFL, and AT at 12 months (67.7% versus 50.0%; P=0.036) at the expense of an increased risk of major adverse events such as stroke, bleeding, or pericardial effusion (0.0% versus 7.8%; P=0.0525).16 The ablation set of the hybrid procedure focused on surgical ablation of the LA posterior wall and PVI, while endocardial ablation completed PVI and addressed remaining gaps. Other observational studies of hybrid procedures with limited sizes show comparable rates of AF-free survival and safety.5–7

9 MANAGEMENT OF PATIENTS WITH HF

9.1 General Considerations for AF and HF

AF and HF frequently coexist, and either can predispose to the development of the other. Shared risk factors (eg, age, obesity, sedentary lifestyle, and hypertension) may contribute, as may atrial remodeling and diastolic dysfunction.1–3 The prevalence of AF is higher in patients with heart failure with preserved ejection fraction compared with HFrEF.4 In a recent study of the Framingham cohort, among individuals with new AF, more than one-third (37%) had HF.5 Conversely, among individuals with new HF, more than half (57%) had AF. A meta-analysis, including 53 969 patients from 9 observational and 7 randomized trials, concluded that after adjusting for confounding factors, AF was associated with an increased total mortality, irrespective of LV systolic dysfunction, with an OR of 1.40 (95% CI, 1.32- 1.48) in randomized trials and an OR of 1.14 (95% CI, 1.03-1.26) in observational studies.6 The risk of mortality is higher when AF is incident after a diagnosis of HF as compared with prevalent AF, and in patients with HFrEF compared with heart failure with preserved ejection fraction.4,7–9 Special considerations for the management of patients with HF and AF are discussed in the next section on management of AF in HF, as well as in Section 7.2 (“Specific Pharmacological Agents for Rate Control”) and Section 8.2 (“Electrical and Pharmacological Cardioversion”).

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