Biatrial Ablation Research Articles

Comparative characteristics of a pacemaker implantation after biatrial or left atrial ablation of atrial fibrillation in combination with coronary artery bypass grafting in patients with ischemic heart disease and long-standing persistent atrial fibrillation.

Aim To compare the incidence of a permanent pacemaker (PP) implantation based on the chosen treatment technology (biatrial ablation, BA, or left atrial ablation (LAA) for long-standing persistent atrial fibrillation (AF) with simultaneous coronary bypass (CB).Material and methods The study included 116 patients with long-standing persistent AF and indications for CB. Patients were randomized to two equal groups (58 patients in each). Group 1 underwent BA in combination with CB; group 2 patients underwent isolated LAA with simultaneous CB under the conditions of artificial circulation. Incidence of PP implantation was assessed during the early (to 30 days) and late (to 60 months) postoperative periods.Results For the observation period, a total of 9 PPs was implanted in both groups, 6 in the BA group and 3 in the LAA group (odds ratio, OR, 0.5; 95 % confidence interval, CI, 0.1-2.4; р=0.490). During the early postoperative period, 5 patients in the BA group and 2 patients in the LAA group were implanted with PP (OR, 0.4; 95 % CI. 0-2.5; р=0.438). During the late postoperative period, one (2%) patient of the BA group was implanted with a permanent PP at 30 months of follow-up due to the development of sick sinus syndrome (SSS); also, one (2%) patient of the LAA group required PP implantation at 54 months of follow-up due to the development of SSS. The causes for PP implantation in the BA group included the development of complete atrioventricular (AV) block in 9 % of cases (95 % CI, 4-19 %); sinus node dysfunction and junctional rhythm in 2 % of cases (95 % CI, 0-9 %). Compared to this group, the LAA group showed a statistically significant difference in the incidence of AV block (0 cases, р=0.047). The major cause for PP implantation in the LAA group was the development of sinus node dysfunction in 3 (5 %) patients (95 % CI, 2-14 %).Conclusion The use of BA in surgical treatment of long-standing persistent AF with simultaneous myocardial revascularization is associated with a high risk of AV block, which requires permanent PP implantation in the postoperative period. Total incidence of permanent PP implantation for dysfunction of the cardiac conduction system following the combination surgical treatment of long-standing persistent AF and IHD, either CB and LAA or BA, did not differ between the treatment groups both in early and late postoperative periods.

Quality of life in patients with long-standing persistent atrial fibrillation after surgical ablation and simultaneous coronary artery bypass grafting

Aim. To analyze quality of life (QOL) of patients with coronary artery disease (CAD) in combination with long-standing persistent atrial fibrillation (AF) in the long-term postoperative period, depending on chosen surgical strategy for concomitant pathology.Material and methods. The analysis of QOL changes in the long-term postoperative period (12 and 24 months) in 116 patients with CAD and concomitant long-term persistent AF who selectively underwent biatrial (BA) or isolated left atrial (LA) ablation with simultaneous on-pump coronary artery bypass grafting. To assess QOL, a non-specific Medical Outcomes Study 36-Item Form Health Status Survey (SF-36) questionnaire was used. Patients were questioned in preoperative and long-term postoperative periods (12 and 24 months).Results. All SF-36 parameters significantly improve after open surgical treatment in the long-term postoperative period (24 months) with both treatment strategies (BA and LA ablation) for AF. In the BA ablation group, 74% of patients did not have arrhythmia after 12 months, and only 38,5% of patients in the LA ablation group belonged to European Heart Rhythm Association (EHRA) score class 1 (p=0,001). After 24 months, a comparison revealed a significant diff erence between the two groups in arrhythmia symptoms (p=0,014), with maintaining the advantage of the BA ablation group. After 12 and 24 months, none of the patients in both compared groups had severe class IV angina.Conclusion. SF-36 parameters were improved 24 months after surgical treatment of CAD and long-standing persistent AF, regardless of the ablation strategy. Elimination of angina symptoms and long-term maintenance of sinus rhythm can improve the QOL of patients in the long-term postoperative period.

Predictors of atrial fibrillation recurrence after surgical ablation of long-standing persistent AF with concomitant coronary artery bypass grafting

Abstract Background A long-standing persistent form of atrial fibrillation (AF) in anamnesis, requiring surgical ablation together with coronary artery bypass surgery (CABG), significantly increases the risk of reccurence in the postoperative period. Before operation should consider the predictors of AF for long-term preservation of rhythm after surgery. Purpose To evaluate the predictors of AF recurrence on 3rd day and at discharge in patients after CABG with concomitant surgical ablation of long-standing persistent AF. Methods A prospective randomized single-center analysis was performed on patients with long-standing persistent AF, undergoing CABG with concomitant left atrial ablation (LAA) or biatrial ablation (BA) between 2016 and 2019. 116 patients were randomized into two groups: 58 in LAA+CABG, 58 in BA+CABG. The median age of the patients was 65 (IQR, 61 to 67.75) years in gr. BA and 62 (IQR, 58 to 66) in gr. LAA (Mann-Whitney U-test, p=0.050), 83% of men were in gr. BA (Fisher test, p>0.999). Predictors of AF development on day 3 were identified using multivariable logistic regression from the following baseline characteristics: myocardial infarction in anamnesis, time of artificial circulation, time of application of radiofrequency energy, the size of the left and right atrium, funcrional class of cardiac angina and heart failure, gender, age, acute cerebrovascular accident (CVA), additional intervention on the heart (operations for aortic aneurysm, mitral, aortic and tricuspid valves replacement), concomitant cardiovascular, respiratory, digestive and urogenital diseases. Results Using a multivariate model of logistic regression, the following significant predictors of arrhythmias on the 3rd day in gr. BA were included: additional intervention on the heart valves (OR 63.13, p=0.001); an increase in the functional class (FC) of chronic heart failure (CHF) NYHA by 1 (OR 40.06, p=0.018); a history of CVA (OR 9.13, p=0.026). The following significant predictors of AF reccurence on the 3rd day in gr.LAA were identified: an increase in the long axis of the right atrium by 1 cm (OR 3.05, p=0.006); an increase of the FC of cardiac angina by 1 (OR 7.11, p=0.011); in women (OR 7.14, p=0.017). In BA significant predictors of AF reccurence at discharge were: an increase in the long axis of the left atrium by 1 cm (OR4.86, p=0.015); reccurence of AF on the 3rd day (OR 17.45, p=0.005); 1 year increase in age (OR 1.24, p=0.023); the presence of diabetes (OR 47.67, p=0.002). In gr. LAA the predictors at discharge were: reccurence of AF on 3rd day (OR 38.35, p=0.001); a history of CVA increases the chances of arrhythmia (OR 210.83, p=0.032). Conclusion Number of clinical and functional characteristics of a patient may be predictors of AF. We examined the predictors of reccurence of AF after surgical ablation of long-standing persistent AF with concomitant CABG. Taking them into account when choosing the optimal strategy of treatment is important. Funding Acknowledgement Type of funding sources: None.

An off-pump biatrial mini-maze procedure for treatment of long-standing persistent atrial fibrillation

Abstract Background Surgical treatment has assumed a more prominent role in the therapy of atrial fibrillation (AF) with favorable efficiency and acceptable safety during the last decades. The traditional Cox-Maze procedure and Wolf Mini-Maze procedure focused on left atrial ablation. However, it is ubiquitous that patients with long-standing persistent atrial fibrillation (LSPAF) typically suffer from biatrial electrical and structural remodeling. The left atrial procedures are still not enough in patients with LSPAF. Purpose Herein, we aimed to introduce a modified biatrial off-pump ablation procedure based on the Wolf Mini-Maze procedure and to detect the safety and efficacy of the surgery for patients with LSPAF. Methods Between January 2016 and September 2020, 102 patients of LSPAF underwent our modified Mini-Maze procedure using bipolar radiofrequency ablation. Those patients firstly underwent a Mini-Maze procedure using Dallas lesion set, including video-assisted bilateral mini-thoracotomy, left atrial appendage excision, bilateral pulmonary vein isolation, ganglionic plexi evaluation and destruction, left atrial roof connecting lesion, and a linear lesion connecting this roofline to the root of the aorta at the junction of the left coronary and the non-coronary cusp. Secondly, a purse-string suture was performed on the right atrium, and then four ablation lesions were made to the superior vena cava, to the inferior vena cava, to the appendix of the right atrium, and to the tricuspid valve annulus from the purse-string suture point by the bipolar radiofrequency clamp. After the operation, the patients were followed up at an interval of 3, 6, 12 months, and every 1 year after that. Results No mortality No surgical re-exploration for bleeding. No permanent pacemaker implantation. 99 patients were free from LSPAF upon discharge. A follow-up at interval of 3, 6, 12, 24, 36, and 48 months showed a success rate free from LSPAF was 95.1% (97/102), 94.4% (85/90), 94.8% (73/77), 91.5% (54/59), 90.3% (28/31) and 100% (9/9), respectively Conclusions The modified biatrial Mini-Maze suggested a safe and feasible procedure. Early follow-up demonstrated an acceptable success rate free from AF. It might have the potential to become another option for clinical treatment of LSPAF. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): General Program of the National Natural Science Foundation of China Schematic of the procedure

Long-Term Outcomes of Surgical Ablation for Atrial Fibrillation: Impact of Ablation Lesion Sets.

The lesion sets for surgical ablation of atrial fibrillation (AF) that provide optimal outcomes have remained controversial. We evaluated the effects of left-atrial (LA) ablation of AF compared with bi-atrial (BA) ablation on the clinical and rhythm outcomes, and examined the predictors for AF recurrence and permanent pacing in consideration of ablation lesion sets. Between 2001 and 2018, 1,965 patients underwent surgical ablation during cardiac surgery at our institution. Among these, 796 and 1,169 patients underwent LA and BA ablation, respectively. The clinical outcomes were evaluated after propensity score adjustment, with death accounting for a competing event. The probability of AF recurrence was estimated with the generalized estimating equations model. The patients with BA ablation had morbidities greater than those with LA ablation. The probability of AF recurrence at 1 and 5 years was 13.9% and 37.1% in patients with LA ablation, and 11.2% and 30.1% in those with BA ablation (hazard ratio [HR]: 1.24; 95% confidence interval [CI]: 0.96-1.61; P=0.100). After adjustment, LA ablation was associated with a decreased risk of early death (<30days) (odds ratio [OR]: 0.56; 95%CI: 0.31-0.96; P=0.041) and new-onset dialysis (OR 0.47; 95%CI: 0.27-0.78; P=0.003). However, the risk of overall mortality (HR: 1.03; 95%CI: 0.75-1.41; P=0.878) and permanent pacing (HR: 0.68; 95%CI: 0.43-1.06; P=0.091) was comparable between the 2groups. The risk of AF recurrence and adverse events was comparable between the 2 ablation lesion sets. BA ablation was not related to an increased risk of permanent pacing.

Comparative efficacy and safety of biatrial versus left atrial ablation in the surgical treatment of long-standing persistent atrial fibrillation with concomitant coronary artery bypass grafting in patients with ischemic heart disease

Purpose. To compare the results of biatrial (BA) and left atrial ablation (LAA) performed in patients with long-standing persistent atrial fibrillation (AF) with concomitant coronary artery disease (CAD) with indication for coronary artery bypass grafting (CABG).Material and Methods. A prospective, randomized, single-center, blinded study was conducted on the basis Meshalkin National Medical Research Center in the period from 2016 to 2019. A total of 116 patients with long-standing persistent AF and CAD were randomized into two groups: BA + CABG group (n = 58) and LAA + CABG group (n = 58). Patients of both groups underwent CABG surgery with the chosen atrial ablation technique (LAA or BA).Results: BA technique proved to be more effective in maintaining sinus rhythm (58%) compared with isolated LAA (31%) at 24 months (p = 0.019) after surgical treatment of long-standing persistent AF with concomitant CABG.Conclusion: BA technique was more effective than isolated LAA in the late postoperative period of 24 months.

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.

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

Abstract Purpose To compare the efficacy and safety of left atrial ablation (LAA) with those of biatrial ablation (BA) in patients with long-standing persistent atrial fibrillation (AF) in common with CABG. Background AF is the most common heart rhythm disorder, while CAD is the most common cardiovascular disease. Chronic coronary syndrome and atrial fibrillation coexist in many patients. Long-standing persistent atrial fibrillation (AF) is frequent pathology in patients undergoing CABG. Surgical ablation in such patients is currently an effective treatment of AF. Pulmonary vein isolation (PVI) may reduce AF recurrences in 70% of patients with paroxysmal form of AF. However, the efficacy of ablation in patients with long-standing persistent AF is rather low. Clinical studies have shown that the right atrium can also be involved in the AF initiation and maintenance. Areas localized in both atrias are characterized by rapid electrical activity, which is critical in the AF persistence. Therefore, we have hypothesized that in long-standing persistent AF BA could be more effective than isolated LAA. Methods Between 2016 and 2019, 116 patients with long-standing persistent AF and CAD who underwent open-heart surgery were included in this single blind prospective randomized study and divided into two groups: 58 patients in group 1 underwent isolated LAA + CABG, and group II (58 patients) - BA + CABG. All the patients had Reveal LINQ ICM System (Medtronic, USA) implanted during the index procedure. The mean age was 65 [61; 67.75] years versus 62 [58; 66] years (p=0.050) and 83% versus 84% (p&amp;gt;0.999) were men in BA and LAA groups, respectively. The follow-up time was 22±3 months for two groups. The primary endpoint was freedom from AF during 24-month follow-up based on 24-hour Holter monitoring ECG registration and Reveal device data. Results This study has demonstrated that in CAD patients with long-standing persistent AF, PVI in combination with multiple linear lesions in the right atrium while GABG produce a significantly higher success rate than PVI alone. After 24 months, AF recurred in 38% of patients in the BA group and in 64% – in the LAA group (p=0.010). Univariate logistic regression analysis showed indicators as long axis of left atria in mm (OR 3.45, 95%; CI 1.77 to 7.64, p=0.001) in LAA group and (OR 2.02, 95%; CI 1.03 to 4.26, p=0.049) in-group BA increases the risk of AF. Chronic kidney disease (OR 2.95, 95% CI 1.05 to 9.22, p=0,048), and mitral regurgitation (OR 1.18, 95% CI 1.01 to 1.41, p=0.047) have been found the independent predictors of AF recurrence in the LAA group. Arrhythmia on the third day after procedure increases the risk of AF (OR 3.79, 95% CI 1.45 to 10. 58, p=0.008) in the LAA group in a long-term follow-up. Conclusion The study has demonstrated that BA is more effective for treatment of long-standing persistent AF in CAD patients undergoing CABG. Funding Acknowledgement Type of funding source: None

Risk scoring by CHADS2 and CHA2DS2-VASc as predictors for long-term outcomes after surgical ablation for atrial fibrillation

Abstract Background Following catheter ablation for atrial fibrillation (AF), CHADS2 and CHA2DS2-VASc have utility in predicting long-term outcomes. However, it is currently unknown if the same holds for patients undergoing surgical ablation. Purpose To determine whether CHADS2 and CHA2DS2-VASc predict long-term outcomes after surgical ablation in concomitance with other cardiac surgery. Methods In this prospective, follow-up study, we included patients who underwent biatrial ablation - or pulmonary vein isolation procedure concomitantly with other cardiac surgery between 2004 and 2018. CHADS2 and CHA2DS2-VASc scores were assessed prior to surgery and categorized in groups as 0–1, 2–4 or ≥5. Outcomes were death, AF, and AF-related death. Follow-up was ended in April 2019. Results A total of 587 patients with a mean age of 68.7±0.4 years were included. Both CHADS2 and CHA2DS2-VASc scores were predictors of survival p=0.005 and p&amp;lt;0.001, respectively (Figure). For CHADS2, mean survival times were 5.9±3.7 years for scores 0–1, 5.0±3.0 years for scores 2–4 and 4.3±2.6 years for scores ≥5. For CHA2DS2-VASc mean survival times were 7.3±4.0 years for scores 0–1, 5.6±2.9 years for scores 2–4 and 4.8±2.1 years for scores ≥5. The incidence of death was 20.1% for CHADS2 0–1, 24.8% for CHADS2 2–4, and 35.3% for CHADS2 ≥5, p=0.186. The incidence of AF was 50.2% for CHADS2 0–1, 47.9% for CHADS2 2–4, and 76.5% for CHADS2 ≥5, p=0.073. The incidence of AF related death was 13.0% for CHADS2 0–1, 16.8% for CHADS2 2–4, and 35.3% for CHADS2 ≥5, p=0.031. The incidence of death was 16.8% for CHA2DS2-VASc 0–1, 26.2% for CHA2DS2-VASc 2–4, and 45.0% for CHA2DS2-VASc ≥5, p=0.001. The incidence of AF was 49.6% for CHA2DS2-VASc 0–1, 52.5% for CHA2DS2-VASc 2–4, and 72.5% for CHA2DS2-VASc ≥5, p=0.035. The incidence of AF related death was 12.2% for CHA2DS2-VASc 0–1, 16.0% for CHA2DS2-VASc 2–4, and 42.5% for CHA2DS2-VASc ≥5, p&amp;lt;0.001. Conclusion Both CHADS2 and CHA2DS2-VASc scores predict long-term outcomes after surgical ablation for AF. However, CHA2DS2-VASc was superior in predicting death, AF, and AF-related death. Survival curves Funding Acknowledgement Type of funding source: None

Medium-term results of cardioneuroablation for clinical bradyarrhythmias and vasovagal syncope: effects on QT interval and heart rate.

Although parasympathetic effects of cardioneuroablation (CNA) in vagally mediated bradyarrhythmias (VMB) were studied, sympathetic effects have not been elucidated, yet. We aimed to investigate the acute and medium-term outcomes of CNA as well as the impact of CNA on ventricular repolarization by using corrected QT interval (QTc) measurements. Sixty-five patients (58.5% men; age 39.4 ± 14years) undergoing CNA were included in the study. Patients who underwent CNA due to VMB were divided into two groups: (1) bi-atrial CNA and (2) right-sided CNA. QTc was calculated at 3 time points: before the procedure (time point 1); 24h post-ablation (time point 2); and at the last follow-up visit (time point 3). The mean follow-up time was 20.0 ± 20months. Acute success was achieved in 64 (98.4%) of cases. In the whole cohort, from time point 1 to 2, a significant shortening in QTcFredericia, QTcFramingham, and QTcHodges was observed which remained lower than baseline in time point 3. Although the difference between measurements in time point 1 and 2 was not statistically significant for QTcBazett, a significant shortening was detected between time point 1 and 3. There was significant difference between groups for shortening in QTcFredericia and QTcFramingham (p = 0.01). Event-free survival was detected in 90.7% (59/65) of cases. Our results demonstrate a significant shortening of QTc in addition to high acute and medium-term success rates after CNA. The most likely mechanism is the effect of CNA on the sympathetic system as well as on the parasympathetic system. Bi-atrial ablation was found related to higher QTc shortening effect.

Сравнительная характеристика биатриальной и левопредесердной аблации в хирургическом лечении длительно персистирующей формы фибрилляции предсердий у пациентов с сочетанной патологией сердца

Сравнительная характеристика биатриальной и левопредесердной аблации в хирургическом лечении длительно персистирующей формы фибрилляции предсердий у пациентов с сочетанной патологией сердца

Contemporary use of surgical radiofrequency ablation and coronary artery bypass in patients with long-standing, persistent atrial fibrillation and coronary heart disease

Atrial fibrillation is one of the main types of arrhythmia; it leads to deterioration in haemodynamics, a decrease in patient’s quality of life, the development of complications such as stroke, a decrease in tolerance to physical stress and ultimately death. The reported prevalence of atrial fibrillation among the general population is 0.4%–1%. The incidence of atrial fibrillation has been found to increase with age such that every 10-year increase in age doubles the incidence of this disease. The incidence of coronary heart disease also increases with age. Current studies have shown an increase in concomitant diseases such as coronary heart disease and atrial fibrillation; these pose a serious health threat and increase the risk of patient death. The present review discusses surgical methods for treating long-standing, persistent atrial fibrillation in patients with coronary heart disease based on radiofrequency and cryoablation with simultaneous coronary artery bypass grafting. The present review revealed that biatrial ablation allows achieving high levels of markers that indicate atrial fibrillation recurrence-free survival following simultaneous surgical correction of coronary heart disease in the long-term postoperative period; however, patients undergoing this procedure require permanent pacemaker implantation due to the high incidence of irreversible sinus node dysfunction caused by the exposure to additional ablation lines in the right atrium. Published articles were searched from January to July 2019 using PubMed, eLIBRARY, Elsevier and MEDLINE. Received 9 July 2019. Revised 22 November 2019. Accepted 26 November 2019. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributions Conception and study design: A.T. KalybekovaDrafting the article: A.T. Kalybekova, A.A. AlmazovCritical revision of the article: A.T. Kalybekova, S.S. RahmonovFinal approval of the version to be published: A.T. Kalybekova, S.S. Rahmonov, A.M. Chernyavskiy, A.A. Almazov, G.P. Narcissova, S.P. Mironenko

The Same is Not the Same: Device Effect during Bipolar Radiofrequency Ablation of Atrial Fibrillation

Different ablation devices deliver the same type of energy but use individual control mechanisms to estimate efficacy. We compared patient outcome after the application of radiofrequency ablation systems, using temperature- or resistance-control in paroxysmal and persistent atrial fibrillation (AF). This is an unselected all-comers study. Patients underwent standardized left atrial (paroxysmal atrial fibrillation, [PAF] n = 31) or biatrial ablation (persistent atrial fibrillation [persAF] n = 61) with bipolar RF from October 2010 to June 2013. Patients with left atrial dilatation (up to 57 mm), reduced left ventricular (LV) function, and elderly were included. We used resistance-controlled (RC) or temperature-controlled (TC) devices. We amputated atrial appendices and checked intraoperatively for completeness of pulmonary vein exit block. All patients received implantable loop recorders. Follow-up interval was every 6 months. Antiarrhythmic medical treatment endured up to month 6. We reached 100% freedom from atrial fibrillation (FAF) in PAF. In perAF 19% of the RC but 82% of the TC patients reached FAF (12 months; p < 0.05). TC patients exhibited higher creatine kinase-muscle/brain (CK-MB) peak values. In persAF, CK-MB-levels correlated to FAF. No and no mortality (30 days) was evident. Twelve-month mortality did not correlate to AF type, AF duration, LV dimension, or function and age. Prolonged need of oral anticoagulants was 90.1% (RC) and 4.5% (TC). In patients with persAF undergoing RF ablation, TC reached higher FAF than RC. Medical devices are not "the same" regarding effectiveness even if used according to manufacturer's instructions. Thus, putative application of "the same" energy is not always "the same" efficacy.

P3778Long-term outcome of non-pharmacologial treatment of atrial fibrillation in hypertrophic cardiomyopathy: a large single-centre experience

Abstract Introduction Atrial fibrillation (AF) is common in hypertrophic cardiomyopathy (HCM) and is generally associated with a significant deterioration of clinical status. Non-pharmacological treatment such as surgical and catheter ablation has become an established therapy for symptomatic AF but in patients with HCM often having a chronically increased left atrial pressure and extensive atrial cardiomyopathy the long-term outcome is uncertain. Purpose The present study aimed to analyse the long-term outcome of AF ablation in HCM and the mechanism of recurrent atrial arrhythmias using high-density mapping systems. Methods A total of 65 patients (age 64.5±9.9 years, 42 (64.6%) male) with HCM undergoing AF ablation for symptomatic AF were included in our study. The ablation strategy for catheter ablation included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines if appropriate. In patients with suspected atrial tachycardia (AT) high-density activation and substrate mapping were performed. A surgical ablation at the time of an operative myectomy for left ventricular outflow tract obstruction was performed in 8 (12.3%) patients. The outcome was analysed using clinical assessment, Holter ECG and continuous rhythm monitoring of cardiac implantable electric devices. Results Paroxysmal AF was present in 27 (41.6%), persistent AF in 37 (56.9%) and primary AT in 1 (1.5%) patients. The mean left atrial diameter was 54.1±12.5 ml. In 11 (16.9%) patients with AT high-density mapping was used to characterize the mechanism of the ongoing tachycardia. After 1.9±1.2 ablation procedures and a follow-up of 48.5±37.2 months, ablation success was demonstrated in 58.9% of patients. The success rate for paroxysmal and persistent AF was 70.0% and 55.8%, respectively (p=0.023). Of those patients with AT high-density mapping guided ablation was successful in 44.4% of patients. The LA diameter of patients with a successful ablation was smaller (52.2 vs. 58.1 mm; p=0.003). Conclusion Non-pharmacological treatment of AF in HCM is effective during long-term follow-up. Paroxysmal AF and a smaller LA diameter are favourable for successful ablation. In patients with complex AT the use of high-density mapping can guide ablation resulting in further ablation success in a reasonable number of patients.

Long-term efficacy and safety of radiofrequency catheter ablation of atrial fibrillation in patients with cardiac implantable electronic devices and transvenous leads.

Long-term efficacy and safety are uncertain in patients with cardiac implantable electronic devices (CIED) and transvenous leads (TVL) undergoing radiofrequency catheter ablation of atrial fibrillation (AF). Thus, we assessed the outcome of AF ablation in those patients during long-term follow-up using continuous atrial rhythm monitoring (CARM). A total of 190 patients (71.3 ± 10.7 years; 108 (56.8% men) were included in this study. At index procedure 81 (42.6%) patients presented with paroxysmal AF and 109 (57.4%) with persistent AF. The ablation strategy included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines, if appropriate. AF recurrences were assessed by CARM- and CIED-related complications by device follow-up. After a mean follow-up of 55.4 ± 38.1 months, freedom of AF was found in 86 (61.4%) and clinical success defined as an AF burden less than or equal to 1% in 101 (72.1%) patients. Freedom of AF was reported in 74.6% and 51.9% (P = 0.006) and clinical success in 89.8% and 59.3% (P < 0.001) of patients with paroxysmal and persistent AF, respectively. In 3 of 408 (0.7%) ablation procedures, a TVL malfunction occurred within 90 days after catheter ablation. During long-term follow-up 9 (4.7%) patients showed lead dislodgement, 2 (1.1%) lead fracture, and 2 (1.1%) lead insulation defect not related tothe ablation procedure. Our findings using CARM demonstrate long-term efficacy and safety of radiofrequency catheter ablation of AF in patients with CIED and TVL.

Robotic-Assisted Surgical Ablation of Atrial Fibrillation Combined With Mitral Valve Surgery

Data on robotic-assisted surgical atrial fibrillation (AF) ablation in patients undergoing mitral valve (MV) operations are lacking. This study aimed to evaluate early and late outcomes after robotic-assisted ablation of AF combined with MV surgery. Between 2007 and 2017, this study enrolled 94 patients (age: 53.9 ± 12.7 years; 67 men) undergoing AF ablation by using an argon-based flexible cryoablation system during robotic-assisted MV surgical procedures. Persistent (n= 34, 36.2%) or long-standing persistent (n= 38, 40.4%) AF was present in most patients. Primary valve procedures included isolated mitral repair in 58 patients, isolate mitral replacement in 2 patients, and combined mitral and tricuspid repair in 34 patients. Sixty patients (63.8%) received left-side-only AF ablation, whereas the others (n= 34, 36.2%) received biatrial ablation. The operation times for cardiopulmonary bypass and aortic cross-clamping were 222.7 ± 57.8 minutes and 134.1 ± 30.4 minutes, respectively. No early death was seen. Major early complications included neurologic injury in 2 patients (2.1%) and low cardiac output syndrome in 2 patients (2.1%). No patients required permanent pacemaker implantation. Early AF occurred in 14 patients (14.9%) during a postablation blanking period (90 days). During a median follow-up of 49.6 months (quartiles 1 to 3: 17.2 to 79.4 months, 95.7% complete), there were two late deaths (0.49% per patient-year) and one stroke (0.25% per patient-year). Five-year survival was greater than 96%, and results from largely electrocardiograms showed a low recurrence of AF (2.2% at 1 year, 6.7% at 5 years). Surgical AF ablation with the use of robotic-assistance in the setting of mitral valve surgery showed excellent safety and favorable long-term clinical outcomes.

Perspective and practice of surgical atrial fibrillation ablation: an international survey of cardiac surgeons.

Despite recommendations stating that surgical atrial fibrillation (AF) ablation is reasonable for patients with AF undergoing cardiac surgery for other indications, the clinical impact of this procedure remains unclear. We aimed to describe surgeons' practices and perceptions of this procedure. We built a self-administered survey in collaboration with content and methodology experts. We surveyed 268 cardiac surgeons from 80 centres in 18 countries. The response rate was 76% (n = 204/276), 49% from North America, 39% Europe, and 12% other regions. Respondents performed a median 10 [interquartile range (IQR) 4-30] AF ablation procedures/year, with marked variation in proportions of patients with AF considered for ablation (median 25%, IQR 10-61). 94% and 80% of surgeons respectively, thought symptomatic and asymptomatic patients benefit from ablation. Surgeons estimated the added major complication rate of concomitant AF ablation at 16% [median (IQR) 7-25]. Of participating surgeons, 61% believed that evidence supported surgical AF ablation reducing the incidence of thrombo-embolic complications, and 46% modified anticoagulation decision-making based on whether they performed AF ablation. During coronary artery bypass grafting, isolated pulmonary vein isolation was the most commonly performed lesion set (70%), whereas complete left atrial ablation (46%) and biatrial ablation (44%) were favoured with valve surgery. In a multinational group of academic surgeons, surgical AF ablation utilization appears variable, and average case volumes are low. Despite no evidence to that effect, the majority believe that ablation reduces AF-related thrombo-embolic risk of patients. Reported practice patterns suggest clinical equipoise; a definitive trial appears feasible based on respondent willingness to participate.

Impact of a modified Maze procedure on the atrial hormonal function and level of myocardial damage markers

Surgical treatment of atrial fibrillation (AF) in patients with valvular heart disease remains one of the most pressing problems in cardiac surgery. The purpose of the study was to determine the dynamics of proANP and myocardial damage markers depending on a modification of the radiofrequency (RF) Maze procedure used. The study involved 86 patients operated over a period from November 2007 to December 2010. A concomitant RF Maze procedure during mitral valve (MV) surgery was performed in two groups of the cohort; in group 1 it was the standard Maze IV scheme, in group 2 it was the modified one. In both groups we assessed the levels of proANP and myocardial damage markers. In group 1 a more significant decrease in proANP (by 4 times) was seen as compared to group 2 (by half). In group 1, the pleural effusion rate was 46.2%, and thoracocentesis rate reached 25.6%. In group 2, the corresponding rates were lower,14.9% and 27.7%. During the first postoperative day there was an increase in creatine phosphokinase MB fraction and Troponin T in both groups, and the rise was significantly higher in group 1. It should be noted that modified Maze IV RF ablation results in 80% freedom from AF, which is consistent with that of the standard Maze IV scheme. In patients with left atrial ablation the proANP secretion is less prominent early after surgery, and myocardial damage is lower in comparison with biatrial ablation.

Сравнительный анализ потребности в имплантации кардиостимулятора при левопредсердной и биатриальной конкомитантной аблации у пациентов с клапанными пороками сердца

Сравнительный анализ потребности в имплантации кардиостимулятора при левопредсердной и биатриальной конкомитантной аблации у пациентов с клапанными пороками сердца

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.