Balancing Efficacy and Risks: A Systematic Review and Meta-Analysis of Concomitant Surgical Ablation for Atrial Fibrillation and Valve Surgery

Atrial fibrillation (AF) affects 30-50% of patients undergoing valve surgery. While concomitant surgical ablation effectively restores sinus rhythm, it has been associated with an increased incidence of permanent pacemakers (PPMs). No previous meta-analysis has quantified the integrated risk-benefit ratio to guide clinical decision-making. We aimed to calculate the number needed to treat (NNT) for AF freedom relative to the number needed to harm (NNH) for pacemaker implantation. Randomized controlled trials (RCTs) and observational studies comparing surgical ablation plus valve surgery versus valve surgery alone were included. Primary outcomes were freedom from AF at 12 months and PPM implantation. Freedom from AF at 12 months was selected as the primary efficacy endpoint to balance clinical relevance with methodological consistency, as longer-term outcomes were inconsistently reported across studies and could not be reliably pooled. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) using random-effects meta-analysis. Thirteen studies (61,088 patients; 6 RCTs, 4 propensity-matched, and 3 observational) were included. Surgical ablation significantly increased freedom from AF at 12 months (RR, 2.96; 95% CI, 2.29-3.83; P < 0.0001; I2 = 67.4%) with NNT of 2.1. Radiofrequency ablation demonstrated superior efficacy compared to cryoablation (RR 6.22 vs 2.56, P = 0.0044). PPM implantation increased 2.77-fold (95% CI, 1.65-4.65; P < 0.001) with NNH of 15.9, yielding a favorable risk-benefit ratio of 1:7.6. No significant increases in 30-day mortality or stroke were observed among RCTs. This favorable NNT:NNH ratio of 1:7.6 supports routine concomitant ablation in appropriately selected patients with AF undergoing valve surgery.