Concomitant Treatment of Atrial Fibrillation With Surgical Aortic Valve Replacement: Effective, Evolving, and Underutilized

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EP LAB DIGEST. 2025;25(11):12-17.

Panos N Vardas, MD¹; Omar Mahmud²; Ioannis Liapis, MD³; and Marvi Tariq, MD^1
1Division of Cardiothoracic Surgery, Department of Surgery, the University of Alabama at Birmingham, Birmingham, Alabama; ²Medical Student, Medical College, The Aga Khan University, Karachi, Sindh, Pakistan; ³Department of Surgery, the University of Alabama at Birmingham, Birmingham, Alabama

Overview 
Atrial fibrillation (AF) is a common arrhythmia, affecting an estimated 30% to 50% of patients undergoing aortic valve replacement (AVR).^1-3 AF is a treatable driver of reduced survival and quality of life (QoL) due to palpitations, heart failure, and stroke.^1,4-6 Standard management relies on rate control and anticoagulation, but patients undergoing cardiac surgery present a unique opportunity to definitively treat AF with concomitant surgical ablation (SA) and left atrial appendage occlusion (LAAO). Strong evidence indicates that this combined approach is the most effective and durable treatment for AF, yet only a minority of surgeons routinely perform concomitant AF surgery.^7-10 To reflect this, the Society of Thoracic Surgeons (STS) issued a class I recommendation in its 2023 guidelines to add SA and LAAO during all index, elective cardiac operations (mitral and nonmitral). The guidelines also include a class IIa recommendation favoring surgical aortic valve replacement (SAVR) with concomitant AF treatment over transcatheter AVR (TAVR) in patients with AF (Table 1).³ In this article, we highlight how SA and LAAO can be safely and efficiently incorporated into SAVR to optimize patient outcomes. 

Mechanistic and Technical Considerations
Surgeons classify AF as paroxysmal (PAF) and nonparoxysmal (NP-AF) based on its pathophysiology and responsiveness to treatment. PAF is usually triggered by foci in the pulmonary veins (PVs) or posterior left atrium (LA), and it can often be controlled by electrically isolating that region (a “box lesion”). However, NP-AF is sustained by broader atrial substrates or “drivers” and usually requires a more extensive Cox-Maze IV lesion set to disrupt. Understanding these mechanisms guides the ablation strategy during SAVR.

Effective treatment of AF during SAVR rests on the following key principles: 

1. Prioritizing the valve surgery. Safe AVR should remain the primary goal, and the heart should be carefully assessed (tissue integrity, aortic root anatomy, etc). The surgeon should be willing to modify the SA if needed to ensure a successful and safe AVR. 
2. Strategically placing lesions. Place transmural ablations where they start and end on nonconductive structures (eg, existing atriotomy suture lines or the LAAO clip), in the event a Cox-Maze procedure is performed. This leverages surgical incisions and clips to minimize the number and duration of ablations required.¹¹ 
3. Using cryoablation for efficiency and safety. Flexible cryoprobes reliably create transmural lesions with 2-3 minutes of application (thin versus thick tissue, respectively), typically adding less than 15 minutes of cardiopulmonary bypass time.¹¹ The probe can be shaped to complete multiple lines at once (for example, simultaneously finishing the box lesion and mitral isthmus line) and can be safely reapplied to ensure lesion completeness without risking tissue injury or perforation.¹¹ 
4. Tailoring the lesion set to the patient. Each lesion in the SA procedure should have a clear purpose (Table 2) and its benefit must outweigh the cost of added bypass time or permanent pacemaker (PPM) risk.^8,12 In practice, lesion sets can be adjusted based on patient factors to balance efficacy and safety.

Underutilization of Concomitant Surgery With AVR
Given the prevalence and consequences of AF in AVR patients, effectively treating the rhythm disturbance, and not just the diseased valve, is critical for optimal outcomes.¹ Nevertheless, concomitant AF surgery remains underutilized and only about 30% of eligible patients receive AF treatment during SAVR.^3,13 Surveys of cardiac surgeons suggest that many overestimate the risk of adding SA, fearing complications such as cardiac perforation, or PPM at rates far higher than those actually observed.^14,15 This gap between perceived and real risk has led to a hesitancy to surgically ablate AF and underscores the need to reiterate the excellent safety and efficacy profile of concomitant SA and LAAO.

Safety of Concomitant Surgery for AF 
Multiple studies, including risk-adjusted and propensity-matched analyses, have found that adding SA and LAAO to ‘closed’ atrium operations (such as SAVR or CABG) does not increase operative morbidity or mortality; in fact, some studies suggest it can even improve outcomes.^1,2,5,16-18 Although LAAO alone is widely accepted to be safe, surgeons often cite the risks of SA, chiefly renal complications and PPM, as deterrents.^3,19,20 However, the observed renal issues in the literature have been mostly transient acute kidney injuries rather than permanent or severe renal failure, and do not negate the long-term benefits of treating AF.²¹ 

The incidence of new PPMs after concomitant SA is also lower than what many assume. In the CTSN randomized trial, about 10% of patients who underwent SA needed a PPM at 1 month, but other studies have reported lower rates.^20,22 Importantly, when PPMs are required after AF surgery, it is often for pre-existing conduction system disease, such as heart block or sick sinus syndrome (SSS), rather than due to direct injury from ablation. Surgical lesions avoid the atrioventricular node, making ablation-induced heart block unlikely, and SSS may simply be unmasked by restoring sinus rhythm in patients with long-standing AF.⁸ Yet, PPM placement is a significant event associated with worse long-term survival, and minimizing its occurrence is crucial.²³ Fortunately, techniques to reduce PPM risk have been described and validated.^11,12 These approaches emphasize balancing the completeness of lesion sets against the potential for complications. One proposed risk-benefit hierarchy for tailoring lesion sets during AF surgery is as follows:¹² 

1. LAAO for all. Performance of LAAO in every patient as it carries almost no risk, prevents stroke, and counts as an ablation line (the clipped appendage serves as an electrical barrier). 
2. LA ablation lines or completion of “box lesion set” as needed. Complete the LA lesion set (beyond the appendage) in most cases, as these are necessary to eliminate AF triggers and circuits in the majority of patients. However, extensive LA ablation adds cross-clamp time and can be challenging in friable tissue. Commercially available clamps can provide radiofrequency-mediated epicardial transmural ablation for the “box lesion set” without the need to perform an intracardiac procedure.
3. Right atrial (RA) lines in select cases. Use RA lesions only for patients with substantial RA enlargement or very long-standing AF, where biatrial involvement is likely. 

This tailored strategy remains under investigation, as some experts advocate for biatrial lesion sets in all cases to maximize efficacy.⁸ Overall, the risk of needing a pacemaker after concomitant AF surgery is not high and can be managed with careful technique. Additionally, concerns about atrial perforation or excessive tissue trauma are not borne out in clinical series and flexible cryoprobes allow lesions to be created without structural damage. In appropriate candidates, surgeons should not withhold SA during SAVR out of an unfounded fear of complications.

Efficacy of Concomitant Surgery for AF
With safety established, substantial evidence supports the efficacy of treating AF during SAVR. First, randomized trials in patients undergoing mitral valve surgery have demonstrated that adding surgical ablation yields high rates of durable sinus rhythm, and long-term follow-up from the PRAGUE-12 study even showed a reduction in stroke.^2,13,24-30 

Second, trials in other clinical scenarios have found that actively managing AF (with catheter ablation or aggressive rhythm control) improves major outcomes, including survival, especially in patients with heart failure or significant AF symptoms.^31-33 These contexts are not directly comparable to surgery, but reinforce the concept that sinus rhythm restoration benefits patients. Consistently, studies have shown that SA appears to be equally effective whether performed as a standalone procedure or alongside SAVR, with outcomes comparable or even superior to those seen in the mitral valve population.^2,13 Many patients undergoing SAVR have impaired ventricular function or complex pathology, so they stand to gain significantly from eliminating AF. Finally, LAAO works synergistically with ablation by removing the primary source of thromboembolism and reducing stroke in cardiac surgery patients, as confirmed by the LAAOS III trial.²⁰ Thus, SA and LAAO directly target the 2 main contributors to AF-related mortality (arrhythmia burden and stroke risk), making it plausible that their inclusion with SAVR improves long-term outcomes.^34,35 

Observational data align with this hypothesis. Multiple robust studies have reported that treating AF during cardiac surgery, including SAVR, is associated with higher freedom from AF, reduced need for anticoagulation, increased use of bioprosthetic valves, better QoL, and improved survival.^{1,2,5,17,19,36,37} The authors of the current STS guidelines performed a pooled analysis of long-term survival after SA versus no SA with cardiac surgery, and found a 23% decrease in risk of death.³ Similarly, a recent matched and adjusted analysis of over 10,000 Taiwanese patients who underwent SAVR found that those who received concomitant ablation had an 18% lower risk of death compared to those who had not.⁵ Taken together, SA and LAAO are thus very likely to enhance clinical outcomes for patients undergoing SAVR.

The Case for SAVR Over TAVR in Patients With AF
In recent years, TAVR has become increasingly common, often supplanting SAVR even in lower-risk patients. However, pre-existing AF is a well-known predictor of worse outcomes after TAVR, and only open surgery allows concomitant SA and LAAO.^39-41 Recognizing this, a matched cohort study by Patrick et al (2022) compared over 2000 patients with persistent AF who underwent AVR and found that those who underwent SAVR with concomitant AF treatment (SAVR-AF) had 22% lower mortality at 5 years versus those who underwent TAVR. 

Surgical patients also had fewer PPM implants, less bleeding, and fewer heart failure readmissions.⁴² Stroke rates were similar between groups. Likewise, Mehaffey et al (2024) reported an analysis of SAVR-AF versus TAVR in Medicare patients and found a 21% reduction in long-term mortality and a 32% reduction in stroke-related hospitalizations favoring the surgical group, along with a dramatically lower rate of new pacemakers (odds ratio ~0.3) and no increase in renal complications.⁴³ Given this evidence (Table 3), recent STS guidelines for the surgical treatment of AF classify as a IIa recommendation the combined approach of SAVR with SA and LAAO over isolated TAVR to restore sinus rhythm and improve long-term outcomes.³

Conclusions and Future Considerations
The greatest challenge in surgical AF management today is simply getting surgeons to use it. Uptake remains low, but the strengthened recommendations in recent guidelines (such as the STS 2023 class I endorsement of SA during concomitant cardiac surgery) and accumulating evidence of improved long-term outcomes should spur wider adoption of SA and LAAO during SAVR. This aligns with a modern vision of open heart surgery as a comprehensive intervention that can simultaneously address coronary artery disease, valve pathology, and arrhythmias in complex patients for whom medical or transcatheter options are suboptimal. In appropriately selected patients, adding SA and LAAO to SAVR is safe and necessary for the complete treatment of their cardiovascular disease. 

Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest, and have no disclosures to report. Dr Vardas reports honoraria from Medtronic for lectures, educational events, and support from Artivion for attending meetings and/or travel. 

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