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• W3146218844 abstract "Central MessageStand-alone surgical ablation was associated with excellent long-term rates of mortality and stroke. Long-term freedom from atrial tachyarrhythmia rates should be carefully interpreted.See Article page 1515. Stand-alone surgical ablation was associated with excellent long-term rates of mortality and stroke. Long-term freedom from atrial tachyarrhythmia rates should be carefully interpreted. See Article page 1515. In this month's Journal, MacGregor and colleagues1MacGregor R. Bakir N. Pedamallu H. Sinn L. Maniar H. Melby S. et al.Late results after stand-alone surgical ablation for atrial fibrillation.J Thorac Cardiovasc Surg. 2022; 164: 1515-1528.e8Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar present a single-center, retrospective analysis of long-term follow-up of patients undergoing isolated surgical ablation via the Cox-Maze IV procedure (CMP-IV) for atrial fibrillation between 2001 and 2019. Perioperative outcomes were excellent, with 6% of patients requiring new pacemaker implantation, 0% 30-day mortality, and only 1% experiencing postoperative stroke—none of which was associated with permanent deficits. These clinical outcomes appear to be durable as well. No patients were observed to experience late stroke, and at 10 years, 67% of patients with paroxysmal atrial fibrillation and 88% of those with nonparoxysmal atrial fibrillation remained free from anticoagulation. Late mortality occurred in 5% of patients. Less obvious is how we should interpret the results of freedom from atrial tachyarrhythmia (ATA). Less than one-half of the cohort (n = 91 of 227) were available for follow-up at 5 years, and only 14% were available at 10 years. At 5 and 10 years, only 57% (52 of 92) and 52% (16 of 31) of patients available for follow-up had prolonged monitoring (ie, Holter monitoring, pacemaker interrogation, implantable loop recording); the remainder were assessed via intermittent monitoring (ie, electrocardiography). This snapshot of rhythm status might not accurately capture a patient's burden of ATA, especially given that patients who are status-post CMP-IV are overwhelmingly asymptomatic during recurrence of ATA. Further clouding potential inferences regarding freedom from ATA is the difficulty in analyzing this type of data. Recurrence of ATA is a recursive outcome (ie, the outcome can occur multiple times throughout the study) that ideally would be analyzed with longitudinal mixed modeling, which would capture the burden of ATA over the entire study period. However, due to concerns regarding nonrandom missingness (ie, those in sinus rhythm may be more likely to be lost to follow-up), the authors chose a Fine–Gray regression to assess freedom from first recurrence of ATA. However, the authors already demonstrated that the vast majority of patients who have ATA after CMP-IV remain asymptomatic, making informative censoring less of a concern. A potential solution for future studies would be to use a preplanned sensitivity analysis that addresses missing data via multiple imputation, evaluating the sensitivity of recursive freedom from ATA to the nonrandom missingness assumption of longitudinal modeling.2Detry M.A. Ma Y. Analyzing repeated measurements using mixed models.JAMA. 2016; 315: 407-408Crossref PubMed Scopus (182) Google Scholar,3Li P. Stuart E.A. Allison D.B. Multiple imputation: a flexible tool for handling missing data.JAMA. 2015; 314: 1966-1967Crossref PubMed Scopus (207) Google Scholar These limitations are by no means unique to this study, and long-term follow-up for arrhythmia surgery is notoriously difficult. The authors are in fact far ahead of most programs in their long-term tracking of patients, and these criticisms apply to our specialty as a whole. More complete follow-up from a greater number of programs may provide the evidence needed to help increase the adoption of this clearly successful operation. Questions of a statistical nature aside, the authors should be congratulated on this unprecedented, long-term series of patients undergoing isolated surgical ablation for atrial fibrillation. As oft is said in theatre also applies to analysis, namely “perfect is the enemy of good.” Late results after stand-alone surgical ablation for atrial fibrillationThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 5PreviewStand-alone surgical ablation of atrial fibrillation is indicated in patients with refractory atrial fibrillation who have failed medical or catheter-based ablation. Few reports of late outcomes after stand-alone surgical ablation exist using comprehensive follow-up with strict definitions of success. This study examined our late outcomes of the stand-alone Cox-Maze IV procedure. Full-Text PDF Implementation of the aortic no-touch technique to reduce stroke after off-pump coronary surgeryThe Journal of Thoracic and Cardiovascular SurgeryVol. 156Issue 2PreviewDespite substantial scientific effort, the relationship between stroke after coronary artery bypass grafting and the use of the aortic no-touch off-pump technique (anOPCAB) remains incompletely understood. The present study aimed to define the effect of anOPCAB on the occurrence and time point of stroke. Full-Text PDF Open Archive" @default.
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• W3146218844 date "2022-11-01" @default.
• W3146218844 modified "2023-09-25" @default.
• W3146218844 title "Commentary: The curse of missing long-term data in cardiac surgery" @default.
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• W3146218844 doi "https://doi.org/10.1016/j.jtcvs.2021.03.067" @default.
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