Patient-reported quality of life after stand-alone and concomitant arrhythmia surgery: a systematic review and meta-analysis

Abstract

Objectives: Patient-reported quality of life (QOL) has become an important endpoint for arrhythmia surgery for atrial fibrillation (AF). While studies specifically evaluating the effect of arrhythmia surgery on QOL are scarce, we aimed to summarize current evidence of QOL following concomitant and stand-alone arrhythmia surgery for AF.

Methods: All studies reporting on QOL using questionnaires from patients undergoing arrhythmia surgery for AF, both stand-alone and concomitant, were included in this systematic review. A meta-analysis was performed on inter-study heterogeneity of changes in QOL on 9 of 12 included studies that used the Short-Form 36 tool and meta-regression based on rhythm outcome after 1 year was executed. Finally, differences in QOL following stand-alone arrhythmia surgery and concomitant procedures were evaluated.

Results: Overall, QOL scores improved 1 year after surgical ablation for AF evaluated by several questionnaires. In stand-alone arrhythmia procedures, meta-regression showed significant improvements in those who were in sinus rhythm compared to those in AF after 1 year. This association between an improved QOL and the procedural effectiveness was also suggested in concomitant procedures. However, when comparing QOL of patients undergoing cardiac surgery with and without add-on surgical ablation for AF, only the variable 'physical role' demonstrated a significant improvement.

Conclusions: In patients with AF, QOL improves after both stand-alone and concomitant arrhythmia surgery. In the concomitant group, this improvement can be attributed to both the cardiac procedure itself as well as the add-on arrhythmia surgery. However, both in stand-alone and concomitant procedures, the improvement in QOL seems to be related to the effectiveness of the procedure to maintain sinus rhythm after 12 months.

Keywords: Atrial fibrillation; Quality of life; Surgical arrhythmia ablation; Systematic review and meta-analysis.

Figure 1:

Forest plots showing the changes per Short-Form 36 quality of life variable after 12 months of follow-up, expressed by the standardized mean difference. The weight given to each study is illustrated by the size of the square box, the point effect estimate by its mid-point and the degree of variance per study by the horizontal line through the box. A greater horizontal line indicates a greater 95% confidence interval for the effect estimates. Red boxes are studies where all patients were still in atrial fibrillation after 12 months. The overall effect estimate is represented by the diamante shape. (A) Physical functioning. Heterogeneity: τ2 = 0.503, Q(df = 10) = 106.286, P < 0.001, I² = 90.6%. (B) Role physical. Heterogeneity: τ2 = 0.354, Q(df = 10) = 78.169, P < 0.001, I² = 87.2%. (C) Bodily pain. Heterogeneity: τ2 = 0.482, Q(df = 10) = 111.276, P < 0.001, I² = 91.0%. (D) General health. Heterogeneity: τ2 = 0.577, Q(df = 10) = 125.791, P < 0.001, I² = 92.0%. (E) Role emotional. Heterogeneity: τ2 = 0.265, Q(df = 10) = 65.670, P < 0.001, I² = 84.7%. (F) Vitality. Heterogeneity: τ2 = 0.215, Q(df = 10) = 52.832, P < 0.001, I² = 81.1%. (G) Social functioning. Heterogeneity: τ2 = 0.327, Q(df = 10) = 75.008, P < 0.001, I² = 86.7%. (H) Mental health. Heterogeneity: τ2 = 0.253, Q(df = 10) = 62.246, P < 0.001, I² = 83.9%. AF: atrial fibrillation; SR: sinus rhythm.

Figure 2:

Forest plots showing the changes per Short-Form 36 quality of life variable after 12 months of follow-up, expressed by the standardized mean difference, comparing studies with 100% sinus rhythm (black box) with 100% atrial fibrillation (red box) after 12 months of follow-up. The weight given to each study is illustrated by the size of the square box, the point effect estimate by its mid-point and the degree of variance per study by the horizontal line through the box. A greater horizontal line indicates a greater 95% confidence interval for the effect estimates. Red boxes are studies where all patients had AF after 12 months. The overall effect estimate is represented by the diamante shape. (A) Physical functioning. Heterogeneity: τ2 = 0.069, Q(df = 3) = 7.888, P = 0.048, I² = 62.0%. (B) Role physical. Heterogeneity: τ2 = 0.069, Q(df = 3) = 7.887, P = 0.048, I² = 62.0%. (C) Bodily pain. τ2 = 0.000, Q(df = 3) = 1.345, P = 0.718, I² = 0%. (D) General health. Heterogeneity: τ2 = 0.095, χ(df = 3) = 9.990, P = 0.019, I² = 70.0%. (E) Role emotional. Heterogeneity: τ2 = 0.000, Q(df = 3) = 2.155, P = 0.541, I² = 0%. (F) Vitality. τ2 = 0.040, Q(df = 3) = 5.842, P = 0.120, I² = 48.7%. (G) Social functioning. Heterogeneity: τ2 = 0.035, Q(df = 3) = 5.476, P = 0.140, I² = 45.2%. (H) Mental health. Heterogeneity: τ2 = 0.004, Q(df = 3) = 3.306, P = 0.347, I² = 9.3%. AF: atrial fibrillation; SR: sinus rhythm.