Concomitant AF Procedures During Non-Mitral Surgery Less Likely in Women

The gap in care shown by statewide data substantiate certain biases among cardiothoracic surgeons, says Armin Kiankhooy.

Concomitant AF Procedures During Non-Mitral Surgery Less Likely in Women

Women undergoing non-mitral cardiac surgeries—specifically CABG or aortic valve replacement—are less likely than their male counterparts to receive guideline-recommended concomitant procedures to treat existing atrial fibrillation (AF), according to registry data from Michigan.

The findings highlight yet another sex-based discrepancy existing in cardiovascular care that deserves thoughtful consideration by surgeons when planning these operations, the authors say.

“The reason that females are less likely to get concomitant A-fib procedures is really complex and multifactorial,” said Catherine Wagner, MD (University of Michigan, Ann Arbor), who presented the findings at the American Association for Thoracic Surgery (AATS) 2024 meeting.

“Number one, women are higher risk for cardiac surgery, and I think that we all want to provide the safest and best operation for patients and that may mean that some surgeons don't want to add on an extra procedure if the patients are already higher risk,” she told TCTMD. “But these procedures have been shown to provide long-standing benefit to patients while not really increasing the operative risks. We may need to help adjust that risk-benefit calculation that surgeons may have when deciding whether or not to do these A-fib procedures.”

Armin Kiankhooy, MD (Cedars-Sinai Medical Center, Los Angeles, CA), who commented on the study for TCTMD, said the results are “unfortunately” not surprising. “It substantiates this idea that A-fib is undertreated across the board, and this is basically a statewide study that reinforces the data that's present nationally,” he said, adding that the results are especially notable given the number of quality improvement efforts in place in the state of Michigan.

“It's really disappointing actually,” he continued. “There is this kind of unconscious, subconscious, inherent bias that if someone doesn't look like us in gender or someone doesn't look like us in race, maybe we don't feel that same sort of connection [or] obligation that we would to somebody who does.”

Fewer Procedures for Females

For the study, which was simultaneously published in the Journal of Thoracic and Cardiovascular Surgery, Wagner and colleagues included 5,460 patients (mean age 71 years; 24% female) from the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative with preoperative AF undergoing non-mitral cardiac surgery—CABG or aortic valve replacement—at 33 hospitals between 2014 and 2022. Compared with males, females were more likely to have paroxysmal AF (80% vs 72%) and had a greater mean STS PROM score (5% vs 3%; P < 0.001 for all).

Unadjusted analyses showed a greater rate of concomitant AF procedures—left atrial appendage (LAA) management and/or ablation—in males than in females (67% vs 59%; P < 0.001). The overall rate of these concomitant procedures increased over the study period, but it was consistently lower for women compared with men each year. The type of procedure did not differ by sex within the group of patients who received them with about 41% receiving LAA occlusion only, 1% receiving ablation only, and 57% receiving both.

After adjustment for baseline differences, female patients remained 26% less likely to receive a concomitant AF procedure compared with male patients (58% vs 64%; OR 0.74; 95% CI 0.64-0.86). In fact, female sex was the strongest predictor of not receiving a concomitant AF procedure. Black patients were also less likely than white patients to receive additional treatment, but this trend was not statistically significant (OR 0.75; 95% CI 0.54-1.04).

Operative mortality was greater for women compared with men (5% vs 4%; P = 0.03), as was major morbidity (20% vs 15%; P < 0.001), driven by the individual components of stroke (3% vs 1%; P = 0.007) and prolonged ventilation (14% vs 11%; P < 0.001).

“It's really important to note that we did successfully increase the use of A-fib procedures for everybody,” Wagner said. “If you look at the rates when we started this study in 2014 to compare to 2022, it went from about 50% of patients were getting A-fib procedures to almost 80%. . . . But despite that, there is a persistent gap in A-fib procedures for females with preoperative A-fib. And I think that it's really important.”

Wagner plans to share these data with the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, she said, and “partner with our surgeons and our quality improvement experts to identify barriers to A-fib procedures in women and partner with the collaborative to really narrow that gap and increase the use of A-fib procedures not only for women, but for all patients undergoing cardiac surgery.”

Senior author Robert Hawkins, MD (University of Michigan), told TCTMD that at a minimum, surgeons should be at least performing LAA occlusion. “It has good benefits about reducing the risk of stroke and it's definitely faster,” he said. “And then you layer on an ablation if you think it's appropriate. Now, that's not as effective and takes longer and may or may not increase the risk, some studies show, of kidney injury. It's mostly just related to how much longer you are on the heart/lung machine. So, if you can get away with a smaller ablation that is done quickly, that's one option versus an extensive ablation.”

In totality, Hawkins added, it’s important to recognize how much benefit these procedures can provide to all patients with A-fib. “We pushed to increase adoption and have been quite successful in that, and we're also recognizing the importance of measuring all possible disparities so that we can identify any differences and really ensure equitable care for all of our patients,” he said.

A Quality Indicator?

Gilbert Tang, MD (Mount Sinai Hospital, New York, NY), who was not involved in the study, told TCTMD his take-home messages from the study are that all patients “should be screened more proactively” for concomitant AF procedures and that experienced centers, at a minimum, should perform them more routinely. “Perhaps there needs to be some consensus document changes to kind of push the field,” he said, adding that a randomized controlled trial in this space would be difficult.

In general, Tang said, there needs to be increased awareness that the AF burden in all patients, “not just minorities and women, is not benign.” Doing so can empower patients to ask about receiving these concomitant procedures when planning their cardiac surgeries.

Kiankhooy agreed about the need for these procedures to become more routine and even potentially for their use to become a quality indicator. “There need to be substantial reasons to not treat patients, so this can't just be a kind of an accolade,” he said. “It can't be: ‘Hey, you did it, high five, good job.’ It should be: ‘You didn't do it. Why didn't you do it?’ And you should be penalized for it if you didn't do it.”

There is “no legitimate reason” why female, and possibly Black patients as well, are being undertreated, Kiankhooy added. “That's just unacceptable. That's not what we should be striving for as a society.”

Now that the problem has been identified, Wagner stressed that the focus should turn to how to fix it. “Within cardiac surgery we have a huge opportunity to provide these procedures that can substantially increase survival,” she concluded. “It's important that we're able to do all of the procedures that we can to really improve patient survival and give them the best chance for long-term outcomes.”

  • Wagner, Hawkins, and Tang report no relevant conflicts of interest.
  • Kiankhooy reports serving as a consultant for Atricure.