Variability in Adoption of Surgical Ablation of Atrial Fibrillation: An International Survey of Cardiac Surgeons

Background: Surgical ablation of atrial fibrillation (AF) during cardiac surgery is a guideline-recommended procedure with demonstrated effectiveness in restoring sinus rhythm. Nonetheless, rates of utilization are relatively low, a situation that needs to be better understood. Methods: This study used an electronically distributed survey to characterize the use, techniques, and clinical indications for concomitant AF ablation among cardiac surgeons. Results: Of the 362 surveys distributed internationally, 79 responses were received (22%). After excluding 3 incomplete responses, 76 surveys were included in the final analysis. A majority of respondents (67 of 76; 88%) reported performing concomitant surgical ablation of AF. Among surgeons who perform AF ablation, practice variation was observed. Pulmonary vein isolation was the most common lesion set (45%), and over half of surgeons (52%) tailored lesion selection to AF type, favouring more extensive ablation for persistent AF. Regarding patient selection, notable deterrents to concomitant ablation included the following: increased left atrial size, more persistent forms of AF, severe left ventricular dysfunction, reoperation, minimally invasive surgeries, and complex cases with long pump times. Among non-ablating surgeons (9 of 76; 12%), common factors reported to help increase future adoption of AF ablation included stronger clinical evidence and more affordable and accessible equipment. Conclusions: Our findings reveal that surgical ablation of AF is performed by the majority of research-active cardiac surgeons, yet meaningful variation persists in how and when it is applied. These findings underscore the need for a well designed, definitive trial to guide future care and address the gap between recommendations and practice.