The fate of patients after failed epicardial ablation of atrial fibrillation

Giuseppe Nasso,Angelo M Dell’Aquila,Arash Motekallemi,Pasquale Mastroroberto,Roberto Lorusso,Nicola Di Bari,Giuseppe F Serraino,Saverio Iacopino,Marco Moscarelli,Giuseppe Speziale,Giuseppe Santarpino,Ignazio Condello

doi:10.1186/s13019-021-01635-3

Abstract

BackgroundMuch debate is still going on about the best ablation strategy—via endocardial or epicardial approach—in patients with atrial fibrillation (AF), and evidence gaps exist in current guidelines in this area. More specifically, there are no clear long-term outcome data after failed surgical AF ablation.MethodsSince June 2008, 549 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency device was used (151 patients), whereas from 2011 to 2020 a bipolar radiofrequency device was used (398 patients). Patients were scheduled for surgery on the basis of the following criteria: recurrent episodes of paroxysmal or persistent lone AF refractory to maximally tolerated antiarrhythmic drug dosing and at least one failed cardioversion attempt. Besides the recommended follow-up by the local cardiologist, starting from 2021, surviving patients were asked to undergo assessment of left ventricular function and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF.ResultsAt a mean follow-up of 77 months, the rate of AF recurrence was 20.7% (n = 114). On multivariate analysis, impaired left ventricular ejection fraction (58 patients, 51%, p = 0.002), worsening of European Heart Rhythm Association (EHRA) symptom class (37 patients, 32%, p = 0.003) and cognitive decline or depression (23 patients, 20%, p = 0.023) during follow-up were found to be significantly associated with AF recurrence.ConclusionsSurgical AF ablation through a right minithoracotomy is safe, but a better outcome could be achieved using a hybrid approach. Patients after initial failed surgical AF ablation show worsening of cardiac function, clinical status and quality of life at follow-up compared to patients with successful AF ablation.

Highlights

Much debate is still going on about the best ablation strategy—via endocardial or epicardial approach—in patients with atrial fibrillation (AF), and evidence gaps exist in current guidelines in this area
By comparing guideline recommendations of 2016 vs 2020, catheter or surgical ablation should be considered in patients with symptomatic persistent or long-standing persistent AF (Class IIb in 2016), but only AF catheter ablation for Pulmonary vein (PV) isolation is recommended for rhythm control after one failed or intolerant drug therapy (Class I in 2020) [1]
It is necessary to look for alternative/integrative strategies to reduce the risk for AF recurrence, given that this event negatively correlates with cardiac function, clinical status and quality of life of patients experiencing failed ablation procedures

Summary

Introduction

Much debate is still going on about the best ablation strategy—via endocardial or epicardial approach—in patients with atrial fibrillation (AF), and evidence gaps exist in current guidelines in this area. There are no clear long-term outcome data after failed surgical AF ablation. By comparing guideline recommendations of 2016 vs 2020, catheter or surgical ablation should be considered in patients with symptomatic persistent or long-standing persistent AF (Class IIb in 2016), but only AF catheter ablation for PV isolation is recommended for rhythm control after one failed or intolerant drug therapy (Class I in 2020) [1]. It is well known that patients undergoing catheter ablation have an increased long-term risk for heart failure [2], regardless of left ventricular ejection fraction before the procedure [3]. No data are available regarding patients with lone AF undergoing isolated surgical ablation by PV isolation [4]

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Discussion

Conclusion