Biatrial Group Research Articles

Sinus nodal denervation by targeting the superior paraseptal ganglionated plexus: randomized comparison of right-atrial and bi-atrial cardioneuroablation guided by ablation index

Abstract Background Radiofrequency (RF) catheter ablation of superior paraseptal ganglionic plexus (SPSGP) that significantly suppresses the vagal modulation of the sinus node is used for the treatment of functional bradyarrhythmias. A reasonable effect can be achieved by targeting this plexus from the endocardial aspect of both the right and left atria. Purpose The study aimed to compare the acute efficacy of unifocal right-atrial (RA) and comparably extensive bi-atrial (BA) ablation of SPSGP for sinus nodal denervation as assessed by intraprocedural extracardiac vagus nerve stimulation (ECVS). Methods A population of 22 patients (age: 43±9 years, 55% males) undergoing cardioneuroablation (CAN) for functional bradyarrhythmias were randomized 1:1 to two ablation strategies that included: [1] single RF lesion at the very posterior site of the junction between right atrium and superior vena cava with ablation index (AI) = 800 (RA group) and [2] the same but twice smaller RF lesion (AI = 400) complemented with strictly contralateral left-atrial lesion (AI = 400) at the anterior vestibulum of right superior pulmonary vein (BA group). The effect of ablation was investigated by the post-ablation change in sinus rate and the attenuation of the response of the sinus node to ECVS (frequency: 50 Hz, pulse width: 0.05 ms, output: 1 V/kg [<70V], duration: 5 s) via the right internal jugular vein. Results Per-protocol ablation resulted in sinus acceleration by 9±15 bpm vs. 15±16 bpm (P=0.40) in RA vs. BA groups, respectively. Inducible sinus arrests were shortened by 4.7±4.2 s vs. 6.2±1.5 s (P=0.27) and reached the post-ablation level of 3.0±3.7 s vs. 1.0±0.3 s (P=0.08) in RA vs. BA groups, respectively. The results are also displayed in the Figure as medians, interquartile range (boxes) and total range (whiskers). Complete sinus nodal denervation was achieved in 8/11=73% vs. 11/11=100% patients (Fisher exact test P=0.21) in RA vs. BA groups, respectively. Practically 100% denervation efficacy in the BA group contrasted with 3 patients in the RA group in whom ablation had virtually no effect on ECVS-based indices (duration of post-ablation sinus arrests: 11.2, 8.7, and 5.2 s). Acute effects did not change substantially during the waiting period of 20±5 min. Conclusions In this small study with acute procedural endpoints, unifocal RA ablation of SPSGP appeared numerically less effective for sinus nodal denervation than comparably extensive BA ablation although the difference was formally non-significant. The ECVS-based outcome measure was valuable in detecting the differences between study groups. Change in sinus rate was not a reliable marker of sinus nodal denervation.

Impact of the operative technique on mid- and long-term results following paediatric heart transplantation.

The aim of this study is to evaluate and compare the impact of the bicaval technique versus the biatrial technique (by Lower and Shumway) in paediatric heart transplant patients. Only a few studies investigate this matter regarding the long-term outcome after paediatric heart transplantation. We compared the two surgical methods regarding survival, the necessity of pacemaker implantation. All 134 patients (aged <18years) - (group-1) biatrial (n=84), versus (group-2) bicaval (n=50), who underwent heart transplantation between October 1988 and December 2021, were analysed. Freedom from events were estimated using the Kaplan-Meier method. Potential differences were analysed using the log rank test and Cox proportional hazard models. Mean±standard deviation: Bypass time (per minutes) was higher in the group 1 as compared with group 2 (P=0.050). Survival was not significantly different (P=0.604) in either groups. Eighteen patients required permanent pacemaker implantation in the group 1 and only one patient required it in the group 2 (P=0.001). Paediatric heart transplantation using bicaval technique results similar long-term survival compared with the biatrial technique. The incidence of atrial rhythm disorders was significantly higher in the biatrial group, requiring a higher frequency of pacemaker implantation in this group. As a results, the bicaval technique has replaced the biatrial technique in our centre.

Analysis of the endocardial stage of treatment of tachyarhythmias after open interventions for atrial fibrillation. Experience of one center

AIM: To study EFI parameters and features of recurrent atrial tachyarrhythmias in patients who underwent surgical correction of AF.&#x0D; MATERIALS AND METHODS: from January 2013 to December 2021, 447 combined interventions were performed to eliminate AF using the labyrinth-3 and left atrial labyrinth techniques with correction of CHD (congenital heart disease) and/or coronary artery disease.&#x0D; Rhythm disturbances were detected in 57 (12.7%) patients at various follow-up periods. Endovascular interventions were performed in 39 patients. The average follow-up period after the endocardial stage was 34.37 (standard deviation 24.32) months. The median age of patients was 64 (58–67) years, 21 (54%) were men. The patients were divided into 2 groups: group 1 — after the classic biatrial (BA) labyrinth-3 — 23 (59%) patients, group 2 — after the left-atrial variant (LA) labyrinth-3 — 16 (41%) patients.&#x0D; At the endocardial stage, electrophysiological studies (EFI) were performed to clarify the mechanism of arrhythmia, and ablation eliminated tachyarrhythmia. EFI protocol: revision of the pulmonary veins, determination of the isolation of the posterior wall of the LA assessment of atrial arrhythmia, elimination of arrhythmia, control induction of arrhythmia after ablation. After repeated intervention, patients were observed in the operating clinic every 3 months.&#x0D; RESULTS: After the endocardial stage, a regular rhythm was determined in 19 (82.6%) patients of the BA group, 13 (92.9%) patients of the LA group (p = 0.914). Relapses in the form of AF were noted in 5 patients (4 — group 1 and 1 — group 2) group (p = 0.306) All relapses of tachyarrhythmia with an irregular cycle (AF) were detected in patients with AF before the endovascular stage In both groups, there were cases of restoration of conduction in the pulmonary veins — 10 (43.5%) patients after BA ablation and 1 (5.3%) patient after LA ablation. There are no recurrences of atrial arrhythmia after ablation of atrial flutter (arrhythmia with a stable cycle).&#x0D; CONCLUSION: The endocardial stage is highly effective and demonstrates subsequent freedom from atrial arrhythmia in patients who have tachycardia with a regular cycle after both methods of surgical ablation of AF. Recurrent tachyarrhythmia in the form of AF (irregular cycle) is associated with a low probability of maintaining a regular atrial rhythm after a repeated endocardial procedure, due to the presence of structural and electrophysiological changes in the atrial myocardium.

Impaired left atrial function in clinically well heart transplant patients.

Left atrial (LA) enlargement is present in the majority of adult heart transplant (HT) recipients. We used speckle-tracking echocardiography to investigate whether LA phasic function in HT patients is altered and explored its relationship to HT-related clinical variables. This study evaluated LA function in 112 clinically well HT patients and 40 healthy controls. Clinical data included recipient age at HT, donor age, ischemia time, left ventricular function, and biochemical indicators. Atrial deformation and volume indices were measured with two-dimensional and three-dimensional speckle-tracking echocardiography, respectively. Components of phasic atrial function were calculated and correlations to clinical variables were explored. Compared with controls, HT patients had worse LA reservoir, conduit, and pump function. LA reservoir function of the bicaval group was better than the biatrial group, but differences did not persist after adjustment for potential confounders. Among patients with HT, those with lower LAS-peak had an older recipient age, larger LA volume, as well as worse left ventricular systolic function than those patients with higher LAS-peak. However, E/e', biochemical indicators and donor-related information were similar across the quartiles of LA function. In HT cohort, we observed impairment in all phases of LA function, and LA reservoir function was decreased independent of surgical technique. LAS-peak was associated with worse left ventricular systolic function, which suggested that LA function may play an important role in HT patients.

Biatrial ablation vs. Pulmonary vein isolation in atrial fibrillation patients undergoing cardiac surgery: a retrospective study

Objectives Surgical ablation is an established treatment for patients with atrial fibrillation undergoing cardiac surgery. This study aimed to compare postoperative rhythm outcomes and pacemaker implantation rates after biatrial ablation or pulmonary vein isolation (PVI) concomitantly with other cardiac surgery. Design: In a retrospective study, we included patients who underwent biatrial ablation or PVI. Postoperative rhythm status was assessed by Holter monitoring. All data on outcomes and patient characteristics were collected retrospectively. Results: In total 109 patients had a biatrial procedure whereas 337 had PVI performed. In patients with persistent/long-standing persistent atrial fibrillation, freedom from atrial fibrillation was more common after biatrial ablation than after PVI (63% and 45%, respectively; p = .039). Postoperative permanent pacemaker implantation was more common after biatrial ablation (12% and 6%, respectively; p = .039), compared to PVI. Age < 65 years (OR:2.0, 95% CI:1.1–3.6) was a predictor of freedom from atrial fibrillation in the biatrial group, whereas absence of left atrial dilatation (OR:1.8, 95% CI:1.1–3.2) and HAS-BLED score < 2 (OR:1.9, 95% CI:1.0–3.8) were significant predictors of freedom from atrial fibrillation in the PVI group. Conclusions: In patients with persistent/long-standing persistent atrial fibrillation, biatrial ablation is more effective than PVI in terms of obtaining freedom from postoperative atrial fibrillation. Although our groups were heterogenic in terms of concomitant surgery, our study also indicates that the risk of needing a permanent pacemaker is higher after biatrial ablation, compared to PVI. Therefore, our study highlights that the decision between biatrial ablation or PVI should be performed on an individual basis.

RF74 SAFETY AND EFFICACY OF BIATRIAL VS LEFT ATRIAL APPROACHES IN PATIENTS UNDERGOING CONCOMITANT ATRIAL FIBRILLATION ABLATION DURING CARDIAC SURGERY: A META-ANALYSIS

Background: the latest STS guidelines recommend concomitant AF ablation not only during mitral surgery (Class I, Level A) but also during other cardiac surgery procedures (Class I, Level B) for patients with atrial fibrillation (AF). Nevertheless, it is still unclear if limiting the lesion set to the left atrium (LA) yields similar safety and efficacy compared to a biatrial (BA) approach. Methods: Pubmed, Scopus and WOS were searched from their inception to April 2018: 23 studies comparing BA vs. LA approaches for concomitant AF ablation (3, randomized, 5 propensity-adjusted, and 15 observational) including 6216 patients, were identified. Of these, 9 studies (1236 patients) focused on mitral surgery as main procedure. Results: Freedom from AF was significantly higher in the BA group at 6 months (OR 1.38, CI 1.08-1.76, p = 0.01) and one year (OR 1.53, CI 1.05-2.23, p = 0.03), but also permanent pacemaker (PPM) implants (OR 1.62, CI 1.17 – 2.24, p = 0.004) and reopening for bleeding (OR 1.83, CI 1.01 – 3.31, p = 0.05) were higher in the BA group. In the mitral surgery subgroup, BA approach was superior in terms of one year freedom from AF but no significant differences were found regarding PPM implants and postoperative bleeding. Conclusions: BA AF ablation seems more effective than LA approach achieving sinus rhythm at one year; on the other hand a LA approach may be preferable in patients with higher risk of bleeding (i.e. dual antiplatelet, complex surgery) and in procedures with a substantial risk of AV block.

A left atrial versus a biatrial lesion set for persistent atrial fibrillation ablation during open heart surgery.

To compare the outcomes of left atrial ablation and biatrial (BA) ablation in patients with persistent and long-standing persistent atrial fibrillation undergoing open heart surgery. Between January 2007 and December 2016, 588 consecutive patients with either persistent (20.9%) or long-standing persistent atrial fibrillation (79.1%) were enrolled in this study. To reduce between-group differences, propensity score-matched groups (156 patients/group) were obtained, with similar preoperative and perioperative characteristics. The propensity score-matched left atrial and BA groups did not differ regarding 30-day mortality (1.9% vs 0.6%; P = 0.617), 5-year overall survival (93.5 ± 2.2% vs 92.8 ± 2.9%, P = 0.998) or survival free from thromboembolic events (97.1 ± 2.8% vs 96.2 ± 2.7%, P = 0.309). The BA lesion set was more beneficial in terms of freedom from atrial arrhythmia recurrence (85.3 ± 4.5% vs 91.9 ± 3.1%, P = 0.049; hazard ratio 3.26; 95% confidence interval 1.33-7.99), but it was associated with higher pacemaker implantation rate (3.8% vs 17.3%; P < 0.001) due to sinus node dysfunction. There was no significant between-group difference regarding the incidence of atrioventricular conduction disturbances (3.2% vs 7.0%, respectively; P = 0.211). The 2 lesion sets (left atrial and BA) are associated with similar 30-day mortality, survival rates, incidences of embolic events and atrioventricular conduction disturbances. In patients with persistent atrial fibrillation, concomitant surgical ablation with BA lesion set provided better freedom from atrial arrhythmia recurrence, but BA ablation was associated with a higher incidence of sinus node dysfunction and a higher rate of pacemaker implantation.

Application of cryoablation for the treatment of atrial fibrillation in patients undergoing cardiac surgery: Our mid-term results.

In this study, we aimed to present mid-term results of concomitant argon-based cryoablation in patients undergoing cardiac surgery. Between August 2014 and May 2016, 33 patients (17 males, 16 females; mean age 63.9 years; range 45 to 82 years) underwent the Maze procedure using cryoablation for the treatment of atrial fibrillation during a concomitant open cardiac operation. Robot-assisted procedures were used in 12 patients. Biatrial or isolated left atrial ablation was performed according to the underlying pathology. The rhythm assessment with 12-lead electrocardiography and 24-hour Holter, and recordings of atrial fibrillation-related medications, stroke or other thromboembolic events were evaluated by the cardiologist at 3 and 12 months postoperatively. Thirty patients (90.9%) were in sinus rhythm and three (9.1%) were in atrial fibrillation at the time of discharge. Cryoablation failed in three patients (n=2, 8.3% in isolated left atrial and n=1, 11.1% in biatrial group) following the operation in the mid-term. Among the patients, there was no in-hospital mortality and no major postoperative complications such as stroke, sepsis, renal failure requiring dialysis, and prolonged respiratory failure. Concomitant surgical cryoablation is an effective method for the treatment of atrial fibrillation, when performed concomitantly with other cardiac surgical procedures and results in very low atrial fibrillation recurrence, even in robotic surgery.

Biatrial or Left Atrial Lesion Set for Ablation During Mitral Surgery: Risks and Benefits

Controversy exists when performing surgical atrial fibrillation ablation whether there is an increase in postoperative complications using biatrial (BA) lesions compared with only left atrial (LA) lesions, and some studies indicate similar efficacy. This study compares the clinical outcomes of BA and LA ablation lesions in mitral valve surgery patients. From 2004 through 2014, 2,137 patients had mitral valve surgery with or without other surgeries in a single center. Of those, 836 (39%) had preoperative atrial fibrillation, and of those, 724 (86%) underwent atrial fibrillation ablation surgery; 257 patients had BA lesion sets and 359 had LA lesion sets. Propensity score matching of BA and LA patients was performed. Baseline differences included more postoperative complications in the BA group, specifically, permanent pacemaker placement (13% versus 7%; p= 0.006). Freedom from atrial fibrillation off antiarrhythmic drugs (72% BA versus 75% LA; p= 0.50), postoperative ablation (7% BA versus 5% LA; p= 0.20), stroke (0.11 versus 0.11 per 10 person-years; p= 0.91), and survival were similar between the groups. After matching, patients in the LA group had a higher freedom from postoperative ablation (p= 0.015), but no difference in freedom from atrial fibrillation off antiarrhythmic drugs (79% BA versus 69% LA; p= 0.09), and no difference inpermanent pacemaker placement (10% versus 12%; p= 0.57). Patients undergoing mitral surgery with LA or BA ablation had similar outcomes, survival, and complications. Limiting lesions to the LA is an effective alternative to BA ablation for patients undergoing ablation with concomitant mitral valve surgery.

Left Atrial Versus Biatrial Maze Procedures in Atrial Fibrillation: Initial Institutional Randomized Trial with Literature Overview

Objectives: The objective of study is to compare in a randomized fashion biatrial and left atrial Maze by continuous event recorder at one year follow-up. Methods: From January 2011 to December 2012, 19 patients were prospectively enrolled. Patients were allocated in 3 groups regarding their rythm, 7 continuous atrial fibrillation, 8 paroxysmal atrial fibrillation and 4 sinus rhythm with atrial size above 45 mm. Patients were randomized to receive left atrial or biatrial or not receive a Maze. Patients were followed prospectively for 1 year. The interrogation of the recorder was done at 6 and 12 months. Results: Ten patients showed recurrence of atrial fibrillation at 1 year with a mean atrial fibrillation burden of 30.76%. The recurrence rate was higher in the biatrial lesion group (5 of 6 patients versus 5 of 8 patients; p=0.383) with a mean of atrial fibrillation burden slightly lower than in left lesion group (34.83% versus 38.32%). 50% of patients of biatrial lesion group showed sinus node dysfunction. Only 1 patient of the continuous atrial fibrillation group didn’t show a recurrence while 5 patients of the paroxysmal atrial fibrillation group were free of recurrence at 1 year (p=0.049). The mean of atrial fibrillation burden was 68.85% and 3.12% respectively. Conclusion: Biatrial lesion seems to be not superior to left atrial lesion in term of atrial fibrillation recurrence. Maze ablation is significantly more efficient in patients with paroxysmal atrial fibrillation. Continuous rhythm monitoring is safe, feasible and allows better evaluation of atrial fibrillation recurrence and sinus node dysfunction.

Modified radial v/s biatrial maze for atrial fibrillation in rheumatic valvular heart surgery

BackgroundAtrial fibrillation (AF) is commonest sustained atrial arrhythmia producing high morbidity. Although Cox's Maze III procedure cures AF in majority, reduced atrial transport function (ATF) is a concern. Radial approach with ablation lines radial from sinus node towards atrioventricular annulii and parallel to atrial coronary arteries, has shown better ATF. MethodsSingle blind open randomized prospective study of 80 patients was undertaken in two groups (40 each) of modified Cox's maze III and modified radial approach, to evaluate conversion to normal sinus rhythm (NSR) and ATF. Patients undergoing surgery for rheumatic valvular heart disease with continuous AF were prospectively randomized. Ablation lines were created with radiofrequency (RF) bipolar coagulation with cryoablation for the isthmal lesions and coronary sinus. Results were compared at 6 months and ATF was evaluated by atrial filling fraction (AFF) and A/E ratio on echocardiography. ResultsThe rate of conversion to NSR in both groups was statistically insignificant by Fisher's exact test (p > 0.05). ATF was better in modified radial approach compared to modified Cox's Maze III (A/E compared by unpaired t test:0.52 ± 0.08 v/s 0.36 ± 0.10; p < 0.05. AFF compared using Mann Whitney U test: median AFF for radial group was 23 v/s 20 for biatrial group; p < 0.05). DiscussionIn patients with AF undergoing rheumatic valvular surgery, radiofrequency radial approach is as effective as modified Cox's maze III for conversion to NSR with better atrial transport function.

Efficiency of radiofrequency ablation for surgical treatment of chronic atrial fibrillation in rheumatic valvular disease

BackgroundIt remains unclear whether concomitant radiofrequency ablation procedure in valvular surgery could offer additional benefits to patients with rheumatic valvular disease. We designed a prospective and randomized control study to evaluate the efficacy of surgical radiofrequency ablation in patients with rheumatic heart disease. MethodsFrom June 2008 to July 2011, 210 patients with chronic atrial fibrillation and rheumatic heart disease were randomized: (1) control group, patients underwent only valve replacement followed by amiodarone for rhythm control, (2) left atrial group (LA group), patients underwent valve replacement and left atrial mono-polar radiofrequency ablation, (3) bi-atrial group (BA group), patients underwent valve replacement and bi-atrial mono-polar radiofrequency ablation. The primary endpoints included: cardiac death, stroke, and recurrent AF after discharge. ResultsThere was no perioperative death. One patient died 4months after MVR in BA group. In univariate Cox analysis, the two ablation groups were associated with less AF (BA group vs control group: P<0.001; LA group vs control group: P<0.001) as well as atrial tachycardia arrhythmia (AF/AT/AFL) recurrent (BA group vs control group: P<0.001; LA group vs control group: P=0.02). The comparison between BA and LA groups revealed no differences in terms of AF (P=0.06) or AF/AT/AFL (P=0.09). Atrial transport function restoration rate 12months after operation was 31.4% in LA group, 32.9% in BA group, and 8.6% in control group respectively (P<0.01). ConclusionsRadiofrequency ablation concurring with valvular surgery can bring a higher sinus rhythm restoration rate when compared with medical anti-arrhythmic drug therapy in low-medium risk rheumatic heart disease.The trial was registered on Clinicaltrials.gov (registry number NCT01013688).

Event recorder monitoring to compare the efficacy of a left versus biatrial lesion set in patients undergoing concomitant surgical ablation for atrial fibrillation

Various lesion sets and subsequent success rates have been reported in patients receiving concomitant surgical ablation for atrial fibrillation. However, most of these results have been obtained by discontinuous monitoring. We report results using continuous event recorder rhythm monitoring to compare more accurately the efficacy of a left versus biatrial lesion set to treat patients with persistent atrial fibrillation. Between July 2008 and December 2011, 66 patients with persistent or long-standing persistent atrial fibrillation underwent concomitant surgical atrial fibrillation ablation with a biatrial lesion set and subcutaneous event recorder implantation. The results and outcomes were compared with a propensity score-matched cohort of 66 patients with a left atrial lesion set and event recorder implantation. Event recorder interrogation was performed at 3, 6, and 12 months follow-up. The mean patient age was 70.2±7.4 years, and 70.3% were male. No major ablation-related complications occurred. One-year survival was 94.8% with no statistically significant differences between the 2 groups. The overall rate of freedom from atrial fibrillation was 57.3% and 64.4% after 3 and 12 months follow-up, respectively. Three months postoperatively, patients in the biatrial group had a slightly higher rate of freedom from atrial fibrillation (63.6% vs 52.3% P=.22), but it did not reach statistical significance. At 12 months follow-up, a statistically significant higher rate of freedom from atrial fibrillation was observed in patients with a biatrial lesion set (74.4% vs 55.8%; P=.026). The mean atrial fibrillation burden in all patients was 15.1%±12.5% in the biatrial group and 21.2%±14.4% in the left atrial group 12 months postoperatively (P=.03). Continuous rhythm monitoring by subcutaneous event recorder implantation was safe and feasible. In patients undergoing biatrial ablation, a statistically significant higher rate of freedom from atrial fibrillation was observed at 12 months follow-up.

A comparison of the results of the bicaval and biatrial surgical technique in orthotopic heart transplantation: A review and meta-analysis

Background: This study aims to evaluate the outcomes of bicaval and biatrial techniques in orthotopic heart transplantation. Methods: Between May 1966 and May 2011, a literature survey was conducted using electronic search engines including PubMed, Medline and Google and manually surveying the magazines on heart and vascular surgery. A total of 36 prospective and retrospective controlled studies which met the inclusion criteria were included in the metaanalysis. The outcomes of both techniques were evaluated using random and fixed-effect method, based on their significant heterogeneous nature. Statistical analysis was performed using Comprehensive Meta Analysis version 2 software. Results: It was found that the results of eight meta-analyses obtained (tricuspid and mitral insufficiency, the need for permanent or temporary pacemaker, sinus rhythm, survival at 1 and 10 year, the right atrial pressure) were significantly improved in bicaval group, compared to the biatrial group. Conclusion: Our study results showed that the outcomes of the bicaval technique were better, compared to biatrial technique. We believe that the bicaval anastomosis technique may have a positive effect on morbidity, due to its clinical and hemodynamical benefits.

Does the surgical technique used in the orthotopic heart transplant affect the results regarding the rhythm

The aim of this study was to compare the requirement for temporary and permanent pacemaker insertion and the incidence of the problems regarding the rhythm following heart transplantation with the bicaval or biatrial technique in the early postoperative period. Sixty-one patients underwent orthotopic heart transplantation between the dates of September 1989 and December 2008 in our clinics were included to the study. The study was designed as retrospective analysis, and all data were collected from hospital records. The transplantation was performed by using standard biatrial method in 28 of the patients, by using bicaval anastomosis method in 33 of the patients. Statistical analyses were performed using Chi-square, Fischer's exact and Mann-Whitney U tests. Predictors of temporary and permanent pacemaker insertion were analyzed using logistic regression analysis. In the biatrial group, the temporary pacemaker requirement (p<0.05), left bundle branch block (LBBB) (p<0.01) and atrioventricular block (AV block) (p<0.05) were observed statistically significantly more than in bicaval anastomosis group. In addition, in the biatrial group, one patient needed implantation of permanent pacemaker and one patient-implantable cardioverter defibrillator. On the postoperative echocardiographic evaluation, in the patients operated with the bicaval technique, the tricuspid (p<0.01) and mitral insufficiency (p<0.01) were observed significantly less. In the logistic regression analysis, hypertension (OR: 1.053, 95% CI: 1.019-1.176, p<0.05), donor age (OR: 1.016, 95% CI: 1.023-1.038, p<0.05) and application of the operation with the biatrial technique (OR: 10.287, 95% CI: 1.298-91.278, p<0.01) were determined as the risk factors requiring the temporary pacemaker usage. In the bicaval group, arrhythmia (ventricular and atrial premature beats) and atrioventricular valve insufficiency were observed less, the rhythm returned to normal in an earlier period. Biatrial surgical technique, donor age and hypertension were determined as significant predictors of temporary pacemaker insertion in the orthotopic heart transplantation. Atrioventricular block, left bundle branch block, and arrhythmia frequency was significantly less in the bicaval group. In terms of factors affecting morbidity, the bicaval technical results were found superior than biatrial technique.

Exercise Performance Comparison of Bicaval and Biatrial Orthotopic Heart Transplant Recipients

Background The standard biatrial technique for orthotopic heart transplantation uses a large atrial anastomosis to connect the donor and recipient atria. A modified technique involves bicaval and pulmonary venous anastomoses and is believed to preserve the anatomic configuration and physiological function of the atria. Bicaval heart transplantation reduces postoperative valvular regurgitation and is associated with a lower incidence of pacemaker insertion. Objective The aim of this study was to compare postoperative functional capacity and exercise performance in patients with bicaval and biatrial orthotopic heart transplantation. Methods Patients were selected for the study if they did not have any of the following: obstructive coronary artery disease (>50% stenosis), severe mitral or tricuspid regurgitation, signs of rejection (grade ≥1B-1R) on endomyocardial biopsy during the prior year, respiratory impairment, a permanent pacemaker, orthopedic or muscular impediments, or lived more than 150 miles from the medical center. A total of 27 patients qualified. In 15 patients who received a biatrial heart transplant and 12 patients with a bicaval heart transplant, a stationary bicycle exercise test was performed. Ventilatory gas exchange and maximum oxygen consumption measurements were measured. Results Recipient and donor characteristics, including body surface area, donor/recipient weight mismatch, immunosuppressive regimen, and self-reported weekly exercise activity, did not differ between the biatrial and bicaval groups ( P = not significant [NS]). At peak exercise, similar heart rate, workload, oxygen consumption, carbon dioxide production, ventilation, functional capacity, and exercise duration were found between the 2 groups ( P = NS). Patients in the biatrial group were studied later than patients in the bicaval group (6.54 ± 0.71 vs 4.68 ± 0.28 years; P < .001). Conclusion There were no significant differences in the exercise capacity between patients with biatrial versus bicaval techniques for orthotopic heart transplantation. Factors other than the atrial connection (such as cardiac denervation, immunosuppressive drug effect, or physical deconditioning) may be more important determinants of subnormal exercise capacity after heart transplantation. Nevertheless, the reduction in morbidity and postoperative complications and the simplicity in the bicaval technique suggest that bicaval heart transplantation offers advantages when compared with the standard biatrial technique.

Comparison of Uniatrial and Biatrial Radiofrequency Ablation Procedures in Atrial Fibrillation: Initial Results

Atrial fibrillation (AF) is the most commonly sustained cardiac rhythm disturbance. Surgical ablation techniques were developed involving the left atrium only and modifications of the maze procedure in ablating both atria. The aim of this study was to compare, in patients with permanent AF, the efficacy of uniatrial versus biatrial radiofrequency ablation procedure in the treatment of chronic atrial fibrillation in patients with associated cardiac disease. Between September 2003 and May 2009, 30 patients were submitted to the radiofrequency ablation procedure for AF associated with concomitant cardiac surgery; 15 patients underwent a uniatrial procedure, and 15 patients underwent biatrial ablation. The mean age was 47.73 ± 9.85 years, and 53.4% were men. The average followup time was 12.16 ± 10.89 months for the uniatrial group and 7.0 ± 4.0 months for the biatrial group. Neither hospital mortality nor complications related to radiofrequency ablation were was registered. At the time of hospital discharge, 9 patients (60%) were in a state of sinus rhythm in both groups. However, patients undergoing biatrial ablation (range 73.3% versus 46.7%) demonstrated complete freedom from atrial fibrillation at all times. Biatrial ablation surgical procedures were more effective in controlling atrial fibrillation than procedures limited to the left atrium.

Left Atrial Ablation Versus Biatrial Ablation in the Surgical Treatment of Atrial Fibrillation

The purpose of this study was to compare the clinical and rhythm outcomes between left atrial ablation and biatrial ablation in patients with atrial fibrillation-associated mitral valve diseases. Data were collected on 284 patients who underwent left atrial ablation (n = 85) or biatrial ablation (n = 199) of atrial fibrillation using a cryoablation system combined with mitral operation from 2006 through 2009. Outcomes were compared using a propensity score study design based on 20 baseline patient characteristics. In baseline characteristics, patients in the biatrial group were more likely to have higher risk clinical and echocardiographic profiles than patients in the left atrial group. There were 2 early deaths (0.7%), 1 in each group, and 5 cases of permanent pacemaker implantation (1.8%) only in the biatrial group. Follow-up was complete in 95.1% (n = 270). During a mean follow-up duration of 26.0 ± 13.3 months, there were 12 late deaths (1 in the left atrial group, 11 in the biatrial group). Cumulative incidence of atrial fibrillation in the absence of antiarrhythmic medications at 2 years was 25.9% ± 5.8% in the left atrial group and 14.3% ± 2.8% in the biatrial group (adjusted hazard ratio 3.06, 95% confidence interval: 1.41 to 6.66, p = 0.005). Major adverse events included stroke in 1, cardiac reoperation in 3, and anticoagulation-related hemorrhages in 16, infective endocarditis in 1, and mechanical valve thrombosis in 1, with no significant intergroup differences in major event-free survival rate (p = 0.73). Compared with left atrial ablation, biatrial ablation was more effective in restoration and maintenance of sinus rhythm without increasing the risk of postoperative complications.

Long-Term Pulmonary Vascular Reactivity After Orthotopic Heart Transplantation by the Biatrial Versus the Bicaval Technique

Introduction Advantages of the bicaval versus the biatrial technique have been reported, emphasizing atrial electrical stability and less tricuspid regurgitation. Objective To analyze the impact of the surgical technique on long-term pulmonary pressures, contractility, and graft valvular behavior after heart transplantation. Methods Among 400 orthotopic heart transplantation recipients from 1985 to 2010, we selected 30 consecutive patients who had survived beyond 3 years. The biatrial versus bicaval surgical technique groups included 15 patients each. Their preoperative clinical characteristics were similar. None of the patients displayed a pulmonary vascular resistance or pulmonary artery pressure over 6U Wood or 60 mm Hg, respectively. We evaluated invasive hemodynamic parameters during routine endomyocardial biopsies. Two-dimensional echocardiographic parameters were obtained from routine examinations. Results There were no significant differences regarding right atrial pressure, systolic pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, cardiac index, systolic blood pressure, left ventricular ejection fraction, and mitral regurgitation ( P > .05). Tricuspid regurgitation increased significantly over the 3 years of observation only among the biatrial group ( P = .0212). In both groups, the right atrial pressure, pulmonary wedge capillary pressure, transpulmonary gradient, and pulmonary vascular resistance decreased significantly ( P < .05) from the pre- to the postoperative examination. In both groups cardiac index and systemic blood pressure increased significantly after transplantation ( P < .05). Comparative analysis of the groups only showed significant differences regarding right atrial pressure and degree of tricuspid regurgitation; the bicaval group showing the best performance. Conclusions Both surgical techniques ensure adequate left ventricular function in the long term; however, the bicaval technique provided better trends in hemodynamic performance, as well as a lower incidence and severity of tricuspid valve dysfunction.

Right Atrial Continuous Fractionated Electrograms in Patients with Long-Standing Persistent Atrial Fibrillation

Hypothesis: Continuous fractionated electrograms of the right atrium (RA-CFE) before ablation can predict clinical outcome of biatrial ablation. Methods: Consecutive 122 patients (56±9 years, 84% male) with long-standing persistent atrial fibrillation (AF) were enrolled. Catheter ablation at left atrium (LA) including electrical isolation of 4 pulmonary vein was performed in 70 patients (LA ablation), and electrograms-guided ablation at RA was performed in whom AF was not terminated after LA ablation (n=52, bi-atrial ablation). RA-CFE (+) was defined by >90 fractionation without isoelectric period for 30 seconds at crista terminalis and RA septum. Results: RA-CFE (+) at baseline was observed in 41.4% of LA ablation and in 67.3% of bi-atrial ablation group (p=0.006). Conversion rate to sinus rhythm by LA ablation was significantly lower in RA-CFE (+) than in RA-CFE (−) (69.0% vs 82.9%, p<0.001). During the mean 6-month, in patients with RA-CFE (+), freedom from recurrence was significantly higher in bi-atrial ablation than in LA ablation (71.4% vs 69.0%, p=0.009). RA-CFE (+) was associated with the recurrence after bi-atrial ablation (HR 3.646, 95% CI 1.288–10.324, p=0.015). Conclusions: RA ablation provides an increment in efficacy among patients with long-standing persistent AF who shows continuous fractionated electrograms in RA. RA-CFE is a good predictor in identifying whom RA ablation for long-standing persistent AF is beneficial.