Efficacy of Left Atrial Radiofrequency Surgical Ablation in Patients with Atrial Fibrillation and Concomitant Cardiac Surgical Pathology

Surgical ablation procedure can restore sinus rhythm (SR) in patients with atrial fibrillation (AF) undergoing cardiac surgery. However, it is not known whether it has any impact on clinical outcomes. There is a need for a randomized trial with long‐term follow‐up to study the outcome of surgical ablation in patients with coronary and/or valve disease and AF. Patients are prospectively enrolled and randomized either to group A (cardiac surgery with left atrial ablation) or group B (cardiac surgery alone). The primary efficacy outcome is the SR presence (without any AF episode) during a 24‐hour electrocardiogram after 1 year. The primary safety outcome is the combined end point of death, myocardial infarction, stroke, and renal failure at 30 days. Long‐term outcomes are a composite of total mortality, stroke, bleeding, and heart failure at 1 and 5 years. We finished the enrollment with a total of 224 patients from 3 centers in 2 countries in December 2011. Currently, the incomplete 1‐year data are available, and the patients who enrolled first will have their 5‐year visits shortly. PRAGUE‐12 is the largest study to be conducted so far comparing cardiac surgery with surgical ablation of AF to cardiac surgery without ablation in an unselected population of patients who are operated on for coronary and/or valve disease. Its long‐term results will lead to a better recognition of ablation's potential clinical benefits.The PRAGUE‐12 trial is partially funded by the Charles University Research Projects MSM0021620817 and UNCE 204010/2012.The authors have no other funding, financial relationships, or conflicts of interest to disclose.

ObjectiveStudies investigating the efficacy of concomitant surgical atrial fibrillation (AF) ablation in hypertrophic obstructive cardiomyopathy (HOCM) patients undergoing myectomy are scarce and limited in terms of sample size. We aim to summarize current outcomes of concomitant surgical AF ablation in HOCM patients undergoing surgical myectomy. MethodsThis systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included all studies reporting any of the following outcomes of concomitant surgical AF ablation in HOCM patients: freedom from recurrence of AF, overall survival and complications. Outcomes were evaluated using traditional meta-analysis at given time-points and using pooled Kaplan-Meier curves. ResultsA total of 13 studies were included, resulting in a total of 616 individual patients available for analysis. AF was paroxysmal in 68.1% of the patients (95% CI 56.0–78.2%; I2 = 87.1%; 8 studies, 583 participants). The majority of patients (86.2%) underwent either conventional Cox Maze III or IV (95% CI 39.7–98.3%; I2 = 92.4%; 8 studies, 616 patients) procedure. The incidence of early post-operative pacemaker implantation was 6.1% (95% CI 3.1–11.8%). Overall survival at 3, 5 and 7 years was 95.6% (95% CI 93.4–97.9%), 93.6% (95% CI 90.8–96.5%) and 90.5% (95% CI 86.5–94.6%), respectively. Freedom from recurrent AF at 3, 5 and 7 years was 77.6% (95% CI 73.7–81.7%), 70.6% (95% CI 65.8–75.7) and 63.2% (95% CI 56.2–73.8%), respectively. ConclusionThis meta-analysis supports concomitant surgical AF ablation at the time of surgical myectomy in HOCM patients, as it seems to be safe and effective in terminating AF.

Surgical ablation in patients with atrial fibrillation and left ventricular dysfunction: A systematic review and meta-analysis.

Atrial fibrillation (AF) is the most common cardiac arrhythmia with a high stroke and mortality rate. The video-assisted thoracoscopic radiofrequency pulmonary vein ablation is a treatment option for patients who fail catheter ablation. Randomized data comparing surgical versus catheter ablation are limited. We performed a meta-analysis of randomized control trials to explore the outcome efficacy between surgical and catheter radiofrequency pulmonary vein ablation in patients with AF. We comprehensively searched the databases of MEDLINE and EMBASE from inception to December 2020. Included studies were published randomized control trials that compared video-assisted thoracoscopic and catheter radiofrequency pulmonary vein ablation. Data from each study were combined using the fixed-effects, generic inverse variance method of DerSimonian, and Laird to calculate odds ratios and 95% confidence intervals. Six studies from November 2013 to 2020 were included in this meta-analysis involving 511 AF patients (79% paroxysmal) with 263 catheter ablation (mean age 56 ± 3 years) and 248 surgical ablations (mean age 52 ± 4 years). Catheter ablation was associated with increased atrial arrhythmias recurrence when compared to surgical ablation (pooled relative risk = 1.85, 95% confidence interval: 1.44-2.39, p < .001, I2 = 0.0%) but associated with less total major adverse events (pooled relative risk = 0.29, 95% confidence interval: 0.16-0.53, p < .001, I2 = 0.0%). In subgroup analysis, catheter ablation was associated with increased AF recurrence in refractory paroxysmal AF when compared to surgical ablation (pooled relative risk = 2.47, 95% confidence interval: 1.31-4.65, p = .005, I2 = 0.0%) but not in persistent AF (relative risk = 1.09, 95% confidence interval: 0.60-2.0, p = .773). Catheter ablation was associated with higher atrial arrhythmia recurrence when compared with surgical ablation. However, our study suggests that the benefit of surgical ablation in patients with persistent AF is unclear. More studies and alternative ablation strategies investigation in persistent AF are warranted.

Untreated atrial fibrillation is associated with an increased risk of all-cause mortality and morbidity. Despite the current guidelines recommending surgical ablation of atrial fibrillation at the time of coronary artery bypass surgery, most patients with concomitant atrial fibrillation and coronary artery disease do not receive surgical ablation for their atrial fibrillation. This review reports the efficacy of different surgical ablation techniques used for the treatment of atrial fibrillation during coronary artery bypass. PubMed was systematically searched for studies reporting outcomes of concomitant surgical ablation in coronary artery bypass patients between January 2002 and March 2018. Data were independently extracted and analyzed by two investigators. Twenty-four studies were included. Twelve studies exclusively reported outcomes of surgical ablation in patients undergoing coronary artery bypass, whereas the remaining 12 reported outcomes of concomitant cardiac surgery with subgroup analysis. Only four studies performed the concomitant Cox-Maze procedure. Freedom from atrial tachyarrhythmia was reported as high as 98% at 1 year and 76% at 5 years with Cox-Maze procedure, whereas lesser lesion sets had more variable outcomes, ranging from 35% to 93%. In most studies, the addition of surgical ablation was not associated with increased morbidity and mortality. Although the Cox-Maze procedure had the greatest short- and long-term success rates, most studies comprising the evidence documenting the safety and efficacy of adding surgical ablation were of low or moderate quality. There was a great deal of heterogeneity among study populations, follow-up times, methods, and definition of failure. To establish a consensus regarding a surgical ablation technique for atrial fibrillation in coronary artery bypass population, larger multicenter randomized controlled studies need to be designed.

A prospective randomized trial comparing biatrial and isolated left atrial ablation in patients with long-standing persistent atrial fibrillation undergoing CABG

A wider scope on the treatment of atrial fibrillation.

Acute stroke remains one of the main causes of death and disability. The incidence of acute stroke is similar to the incidence of acute coronary syndrome, but the prognosis for the patient who suffered stroke is significantly worse. More and more scientific evidence confirms that at least 30-50 % (possibly more depending on the diagnostic approach) of ischemic strokes are caused by cardiac pathology (atrial fibrillation, of valvular heart diseaseor congenital heart disease, infective endocarditis, etc.). An even greater number of patients have concomitant cardiac pathology, which, if not the cause, worsens the course and prognosis of a patient with acute stroke. Therefore, it is important and relevant to determine the characteristics of these patients, taking into account the characteristics of comorbid pathology. It is important to cooperate with doctors of different specialties. In the acute period of stroke there are specific tacticsand treatment patients with concomitant hypertension, atrial fibrillation and other cardiac pathologies. The tactics of a cardiologist depends on the type of stroke – ischemic or hemorrhagic. In patients with a stroke, it is important to determine the etiologic factor. In the presence of cardiac pathology, which is the cause of embolism, using of anticoagulants is the prevention of repeated strokes. Therefore, effective diagnosis and treatment of heart disease can significantly contribute to both stroke prevention and its prognosis. The article reviews the literature on the problem of treatment cardiopathology in patients who suffered a stroke or a transient ischemic attack. The peculiarities of the treatment of hypertension in the acute period of stroke and the post-stroke period are considered; questions of statinotherapy. The principles of the using (start, initiation) of oral anticoagulants in atrial fibrillation in patients with acute stroke are discussed. Principles of prevention of stroke in atrial fibrillation and «triple» therapy (double antiplatelet plus oral anticoagulant) are described.

Background Although left atrial additional ablation other than pulmonary vein (PV) isolation is often performed in order to modify arrhythmogenic substrate, rhythm outcome in patients with long-standing persistent atrial fibrillation (LS-PerAF) is still challenging. Left atrial low-voltage areas (LVAs) is correlated with degeneration of atrial myocardium, and atrial fibrillation (AF) recurrence following catheter ablation. However, in patients with LS-PerAF, the association between the prevalence of LVAs and rhythm outcome has not been clarified. We hypothesized that AF recurrence after AF ablation more frequently occurred in patients with LVAs than in those without, and that the prevalence of LVAs was associated with the efficacy of left atrial additional ablation. Purpose The purpose of this study was to investigate the association between the prevalence of LVAs and rhythm outcome or efficacy of left atrial additional ablation in patients with LS-PerAF ablation. Methods In total, 123 (age, 66 ± 9 years; female, 28 [23%]) consecutive patients who underwent initial ablation for LS-PerAF were included. Left atrial additional ablation was defined as an ablation for left atrium other than PV isolation and ablation for non-PV foci. The definition of LVAs was sites with a bipolar voltage of &amp;lt;0.5 mV covering ≥5 cm² of left atrium. Rhythm outcome after the catheter ablation was followed for 24 months. Results LVAs was found in 31 (25%) patients, and left atrial additional ablation was performed for 31 (25%) patients. Freedom from AF recurrence was significantly lower in patients with LVAs than in those without (Figure 1A). In contrast, freedom from AF recurrence was similar between patients with left atrial additional ablation and those without (Figure 1B). In patients without LVAs, freedom from AF recurrence was significantly higher in patients with left atrial additional ablation than in those without (Figure 2A). On the contrary, in patients with LVAs, freedom from AF recurrence during was similar between patients with left atrial additional ablation and those without (Figure 2B). Conclusions In patients undergoing LS-PerAF ablation, AF recurrence more frequently occurred in patients with LVAs than in those without. Only in patients without LVAs, freedom from AF recurrence was significantly higher in patients with left atrial additional ablation than in those without.Figure 1Figure 2

Feasibility and clinical efficacy of left atrial ablation for the treatment of atrial tachyarrhythmias in patients with left atrial appendage closure devices.

ObjectivesTo identify independent predictors of late recurrence of atrial fibrillation (AF) after surgical ablation in patients undergoing rheumatic valve surgery.MethodsA total of 258 patients who underwent surgical ablation for AF with rheumatic heart disease at our hospital between January 2019 and June 2022 were retrospectively included. The patients were followed up for 12 months. Late recurrence was defined as any AF recurrence longer than 30 s between 3 and 12 months. Patients with or without late recurrence were divided into non-recurrence and recurrence groups. Univariate and multivariate analyses were performed to identify the predictors of late recurrence.ResultsThe in-hospital mortality rate was 0.8% (2/258), and the late recurrence rate of AF was 38.4%, including 152 and 95 cases in the non-recurrent and recurrent groups respectively, with a follow-up completion rate of 96.5% (247/256). There were no deaths during follow-up, two patients (0.8%) experienced a stroke, and one patient (0.4%) experienced gastrointestinal hemorrhage. The results of the univariate and multivariate analyses of the preoperative risk factors for late recurrence showed a left atrial (LA) anteroposterior diameter ≥ 52.9 mm (odds ratio [OR] = 2.366, 95% confidence interval [CI] = 1.089–5.138, P = 0.030], ratio of the superoinferior to the anteroposterior diameters of LA (S-AR) < 1.19 (OR = 4.639, 95% CI = 2.181–9.865, P < 0.001), and AF duration ≥ 39 months (OR = 6.152, 95% CI = 2.897–13.061, P < 0.001), and cardiothoracic ratio ≥ 0.63 (OR = 2.716, 95% CI = 1.314–5.612, P = 0.007) were the most significant independent risk factors.ConclusionsLA anteroposterior diameter ≥ 52.9 mm, S-AR < 1.19, and AF duration ≥ 36 months and cardiothoracic ratio ≥ 0.63 are independent predictors for late recurrence of AF after surgical ablation in patients undergoing rheumatic valve surgery.

HAEMOSTASIS CHANGES AND ENDOTHELIUM ACTIVATION DURING PERCUTANEOUS TRANSCATHETER ISOLATION OF THE PULMONARY VEINS IN PATIENTS WITH ATRIAL FIBRILLATION

Late Survival Benefits of Concomitant Surgical Ablation for Atrial Fibrillation During Cardiac Surgery: A Systematic Review and Meta-Analysis

Acutely, when left atrial ablation is performed during atrial fibrillation (AF), the AF may persist and require cardioversion, or it may convert to sinus rhythm or to atrial tachycardia/flutter. The prevalence of these acute outcomes has not been described. Left atrial ablation, usually including encirclement of the pulmonary veins, was performed during AF in 144 patients with drug-refractory AF. Conversion to sinus rhythm occurred in 19 patients (13%), to left atrial tachycardia in 6 (4%), and to atrial flutter in 6 (4%). In the 6 patients with a focal atrial tachycardia, the mean cycle length was 294 +/- 45 ms. The tachycardia arose in the left atrial roof in 3 patients, the left atrial appendage in 2, and the anterior left atrium in 1. In 3 of 6 patients, the focal atrial tachycardia originated in an area that displayed a relatively short cycle length during AF. In 6 patients, AF converted to macroreentrant atrial flutter with a mean cycle length of 253 +/- 47 ms, involving the mitral isthmus in 5 patients and the septum in 1 patient. All atrial tachycardias and flutters were successfully ablated with 1 to 15 applications of radiofrequency energy. When left atrial ablation is performed during AF, the AF may convert to atrial tachycardia or flutter in approximately 10% of patients. Focal atrial tachycardias that occur during ablation of AF may be attributable to driving mechanisms that persist after AF has been eliminated, whereas atrial flutter results from incomplete ablation lines.

▪ Abstract Atrial fibrillation is frequently disabling and resistant to antiarrhythmic drugs. Curative treatment by catheter-based ablation has been shown to be feasible either by achieving long linear lesions, mainly in the left atrium, or by targeting the initiating focus, most frequently in the pulmonary veins. This paper reviews the different ablation approaches, their results, potential complications, and relative merits.