Concomitant Atrial Fibrillation Ablation Research Articles

Surgical options for atrial fibrillation treatment during concomitant cardiac procedures.

Current guidelines recommend concomitant surgical ablation (SA) of atrial fibrillation (AF) in the context of mitral valve disease. A variety of energy sources have been tested for SA to perform effective transmural lesions reliably. To date, only radiofrequency and cryothermy energies are considered viable options. The gold standard for SA is the Cox-Maze ablation set, especially for non-paroxysmal AF (nPAF), with the aim of interrupting macro-reentrant drivers perpetuating AF, without hampering the sinus node activation of both atria, and to maintain the atrioventricular synchrony. Although the efficacy of SA in terms of early and late sinus rhythm restoration has been clearly demonstrated over the years, concomitant AF ablation is still underperformed in patients with AF undergoing cardiac surgery. From a surgical standpoint, concerns have been raised about whether a single (left) or double atriotomy would be justified in AF patients undergoing a "non-atriotomy" surgical procedure, such as aortic valve or revascularization surgery. Thus, an array of simplified lesion sets have been described in the last decade, which have unavoidably hampered procedural efficacy, somewhat jeopardizing the standardization process of ablation surgery. As a matter of fact, the term "Maze" has improperly become a generic term for SA. Surgical interventions that do not align with the principles of forming conduction-blocking lesions according to the Maze pattern, cannot be classified as Maze procedures. In this complex scenario, a tailored approach according to the different AF patterns has been proposed: for patients with concomitant nPAF, a biatrial Cox-Maze ablation is recommended. Conversely, it might be reasonable to limit lesions to the left atrium or the pulmonary veins in patients with paroxysmal AF (PAF) in some clinical scenarios. The aim of this review is to provide an overview of the current ablation strategies for patients with AF undergoing concomitant cardiac surgery.

The outcomes of concomitant catheter ablation in non-mitral valve cardiac surgery-a systematic review and meta-analysis of the literature.

Atrial fibrillation (AF) is the most common form of cardiac arrythmia, with a key importance in the perioperative setting of cardiac surgery. In recent years, the question as to whether pre-existent AF should be treated concomitantly when undergoing cardiac surgery has been heatedly debated. This systematic review and meta-analysis sought to delineate the outcomes of patients undergoing concomitant AF ablation procedures alongside cardiac surgery. The methods for this systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Four databases were searched, ultimately yielding 22 papers for inclusion, using appropriate search terminology. Meta-analysis using proportions or means, as appropriate, were applied. Kaplan-Meier curves were digitized and aggregated using previously reported and validated techniques. A total of 9,428 patients (67% male) were identified across the study period as having received non-mitral cardiac surgery and concomitant AF ablation procedures. On actuarial assessment, freedom from AF was found to be 93%, 88%, 85%, 82%, and 79% at 1 through to 5 years, respectively. Freedom from mortality was found to be 94%, 93%, 91%, 90%, and 87% at 1 through to 5 years, respectively. This review demonstrated excellent freedom from AF out to a long-term follow-up of 5 years. Freedom from mortality was also encouraging. Emerging data are increasingly illustrating that in this patient cohort, concurrent treatment of pre-existent AF with cardiac and/or valvular disease at the point of operation should be the standard of care. Robust data in the form of randomized control trials will hopefully solidify this assertion.

Surgical ablation of atrial fibrillation during mitral valve surgery: a systematic review and meta-analysis.

Atrial fibrillation (AF) is a common tachyarrhythmia, affecting approximately 33 million people worldwide, and is frequently associated with mitral valve disease. Surgical ablation during mitral valve surgery provides an opportune circumstance for arrhythmia correction. The results of recent randomized trial data are promising, demonstrating both safety and efficacy. The aim of this systematic review is to report the efficacy and morbidity of concomitant surgical ablation for AF during mitral valve surgery. Five electronic databases were searched from inception to March 2023. All studies reporting the primary outcome, freedom from AF (FFAF), for patients with a history of AF undergoing concomitant mitral valve surgery were identified. Studies with patient cohorts less than 100 were excluded. Relevant data were extracted and a meta-analysis of proportions was conducted using a random-effects model. Survival data were pooled from original Kaplan-Meier curves and reconstructed, reporting aggregate FFAF and survival. Thirty-six studies with a total of 8,340 patients were included in the systematic review. All 36 papers reported postoperative FFAF with a pooled result of 76.9% [95% confidence interval (CI): 73.8-79.9%] at a weighted mean follow-up of 40.2 months, however this result was associated with significant heterogeneity (I2=89%). A total of 31 studies reported postoperative short-term mortality, with a pooled result of 1.68% (95% CI: 1.15-2.29%). Aggregate survival at 1 to 5 years was 93.7%, 92.5%, 91.3%, 89.4%, and 87%, respectively, and aggregate FFAF for 1 to 5 years was 90.2%, 83.5%, 79.5%, 76.4% and 73.2%, respectively. Evaluation of the evidence suggests that concomitant ablation for AF during mitral valve surgery is both safe and efficacious. The results were associated with significant heterogeneity, reflective of variable institutional protocols, patient characteristics, and lesion sets. Randomized data with longer term follow-up would help validate these results.

Prognostic impact of preoperative atrial fibrillation in patients undergoing heart surgery in cardiogenic shock

Surgical intervention in the setting of cardiogenic shock (CS) is burdened with high mortality. Due to acute condition, detailed diagnoses and risk assessment is often precluded. Atrial fibrillation (AF) is a risk factor for perioperative complications and worse survival but little is known about AF patients operated in CS. Current analysis aimed to determine prognostic impact of preoperative AF in patients undergoing heart surgery in CS. We analyzed data from the Polish National Registry of Cardiac Surgery (KROK) Procedures. Between 2012 and 2021, 332,109 patients underwent cardiac surgery in 37 centers; 4852 (1.5%) patients presented with CS. Of those 624 (13%) patients had AF history. Cox proportional hazards models were used for computations. Propensity score (nearest neighbor) matching for the comparison of patients with and without AF was performed. Median follow-up was 4.6 years (max.10.0), mean age was 62 (± 15) years and 68% patients were men. Thirty-day mortality was 36% (1728 patients). The origin of CS included acute myocardial infarction (1751 patients, 36%), acute aortic dissection (1075 patients, 22%) and valvular dysfunction (610 patients, 13%). In an unadjusted analysis, patients with underlying AF had almost 20% higher mortality risk (HR 1.19, 95% CIs 1.06–1.34; P = 0.004). Propensity score matching returned 597 pairs with similar baseline characteristics; AF remained a significant prognostic factor for worse survival (HR 1.19, 95% CI 1.00–1.40; P = 0.045). Among patients with CS referred for cardiac surgery, history of AF was a significant risk factor for mortality. Role of concomitant AF ablation and/or left atrial appendage occlusion or more aggressive perioperative circulatory support should be addressed in the future.

Heart failure after left atrial appendage occlusion: insights from the LAAOS-III randomized trial

Abstract Background Left atrial appendage removal or occlusion (LAAO) might increase the risk for heart failure (HF) due to the loss of the LAA`s reservoir function, active contraction and neuroendocrine function. Purpose To investigate the incidence of HF hospitalizations and/or HF related death after LAAO in the Left Atrial Appendage Occlusion Study (LAAOS III). Methods In LAAOS III, 4811 patients with atrial fibrillation (AF) and a CHA2DS2-VASc score ≥2 were randomized to undergo or not undergo surgical LAAO during cardiac surgery for another indication. We compared the incidence of a composite endpoint of HF hospitalizations and HF related death between the two randomized groups (LAAO vs no-LAAO). We also pre-specified subgroups including: sex, age, BMI, surgery type, concomitant AF ablation, prior history of HF, history of hypertension, diabetes, prior myocardial infarction, left ventricular ejection fraction, sinus rhythm and occlusion method. Results We included 2379 patients in the LAAO and 2391 patients in the no-LAAO group. Overall, mean age was 71 years, 67% were male and 57% had prior HF. Baseline characteristics including drug treatment were balanced between the groups. Over a mean follow-up of 3.8 years, 395 (8.3%) patients met the primary HF endpoint: 209 (8.8%) in the LAAO group and 186 (7.8%) in the no-LAAO group. We did not find a significant difference for the primary endpoint between the randomized groups (Hazard ratio [95% confidence intervals] 1.13 [0.93-1.37], p=0.233) (Figure). The only significant subgroup interaction was for concomitant AF ablation (p for interaction = 0.004). Patients in the LAAO group without concomitant AF ablation had a higher risk for the primary endpoint (HR [95% CI] 1.37 [1.08-1.74], p=0.009) than patients with ablation (HR [95% CI] 0.74 [0.51-1.06], p=0.097). Conclusion LAAO did not increase the risk for a combined endpoint of HF hospitalizations and HF related death in patients with AF. Patients with concomitant AF ablation might have lower risk for the combined endpoint.Figure

Concomitant ablation of atrial fibrillation: New pacemakers and early rhythm recovery

ObjectiveNew permanent pacemaker (PPM) implantation after concomitant atrial fibrillation (AF) ablation has been associated with surgical ablation (SA). We sought to determine factors for PPM use as well as early rhythm recovery. MethodsFrom 2004 through 2019, 6135 patients underwent valve surgery and were grouped: No AF (n = 4584), AF no SA (n = 346), and AF with SA (n = 1205) to evaluate predischarge PPM and 3-month rhythm recovery (intrinsic heart rate >40 beats per minute). ResultsOverall, 282 (4.6%) patients required a predischarge PPM: atrioventricular node dysfunction in 75.3%, sick sinus syndrome in 19.1%, both (5%), and indeterminate (0.7%). Patients with AF had more PPMs: AF with SA (7.9%) versus AF no SA (6.9%) versus No AF (3.6%) (P < .001). For patients with AF, PPM rates were not significantly higher for ablation patients (7.6% SA vs 6.9% AF no SA; P = .56). There were differences in PPM by SA lesion set (biatrial 12.8%; left atrial only 6.1%; pulmonary vein isolation 3.0%; P < .001). Among patients with AF treated with 3-month PPM follow-up, rhythm recovery was common (35 out of 62 [56.5%]) and did not differ by lesion set. Rhythm recovery was seen in 63 out of 141 (44.7%) in the atrioventricular node dysfunction group versus 24 out of 35 (68.6%) in the sick sinus syndrome group (P = .011). In propensity score-matched groups, late survival was similar (P = .63) for new PPM patients. ConclusionsAvoiding conduction system trauma and delaying implantation reduces the need for postoperative PPM. Rhythm recovery within 3 months is frequent, especially for patients with sick sinus syndrome. A conservative approach to the implantation of a new PPMs is warranted.

Atrial Appendage Aneurysms: Natural History and Outcomes.

Left (LAAA) and right atrial appendage aneurysms (RAAA) are rare entities, and their natural history, management, and long-term outcomes are not well studied. This retrospective review includes all patients from 2000 to 2021 with atrial appendage aneurysms at our institution identified using an electronic search tool. LAAA and RAAA were confirmed using multimodality imaging and intraoperative findings. We identified 13 (87%) patients with LAAA and 2 (13%) with RAAA. At diagnosis, 11 (73%) were female, mean age was 51.4 ± 18.8 years, and ejection fraction 56.5 ± 13.1%. Three (20%) patients had congenital heart disease including 2 (13%) with atrioventricular septal defects and 1 (7%) with congenitally corrected transposition. LAAA/RAAA was diagnosed due to new-onset atrial fibrillation (AF) in 6 (40%) patients and embolic stroke in 2 (13%). Ten patients had preexisting AF diagnosed 2.9 ± 1.4 years earlier at a mean age of 50.2 ± 15.5 years. Thrombus within the aneurysm was identified in 2 (15%) LAAA patients. All patients were on anticoagulation and follow-up of the cohort from diagnosis was 7.1 ± 6.2 years. Eleven (73%) patients were surgically managed with 7 (64%) lesions excised, 1 (9%) stapled, and 3 (27%) ligated. Postoperative complications occurred in 2 (18%) patients with 1 (7%) developing tricuspid regurgitation and another with pericardial effusion and tamponade. Atrial appendage aneurysm is a rare disease and nearly half of patients present with AF. Surgical treatment with concomitant AF ablation is a reasonable and safe management option.

Functional Insufficiency of Mitral and Tricuspid Valves Associated With Atrial Fibrillation: Impact of Postoperative Atrial Fibrillation Recurrence on Surgical Outcomes.

To identify the factors associated with adverse outcomes following surgery for functional insufficiency of the mitral valve (MV) or tricuspid valve (TV) associated with atrial fibrillation (AF). We evaluated 100 patients (age, 66.5±10.0 years; 47 males) who consecutively underwent surgery for functional insufficiency of the MV or TV associated with AF between January 2000 and December 2020 at our center. The primary outcome was a composite endpoint of all-cause death, valve reoperation, congestive heart failure (CHF) requiring rehospitalization, and stroke. During follow-up (532 patients-years [PYs]), adverse events included death in 16 (3.0%/yr), MV reoperation in 1 (0.2%/yr), CHF in 14 (2.6%/yr), and stroke in 5 (0.9%/yr) patients, demonstrating a 5-year rate of freedom from the primary endpoint of 69.5%. The rate of postoperative AF was high even in those who underwent AF ablation (n=92), with cumulative rates of 48.1% at 1 year and 60.2% at 5 years. In multivariable analyses, the primary outcome was significantly associated with age (adjusted hazard ratio [aHR], 1.06; 95% confidence interval [CI], 1.02-1.10; p=0.005), chronic kidney disease (aHR, 7.76; 95% CI, 2.28-26.38; p=0.001), left atrial appendage exclusion (aHR, 0.35; 95% CI, 0.16-1.78; p=0.010), and postoperative AF as a time-varying covariate (aHR, 3.33; 95% CI, 1.50-7.40; p=0.003). Among patients undergoing surgery for functional atrioventricular insufficiency associated with AF, a significant proportion showed recurrence of AF over time after concomitant AF ablation, which was significantly associated with poor clinical outcomes.

Abstract 14511: A Single Center Experience With the Safety and Feasibility of Concomitant Atrial Fibrillation Ablation and Left Atrial Appendage Occlusion: Six-Month Outcomes

Introduction: Given the procedural similarities between atrial fibrillation (AF) catheter ablation and left atrial appendage (LAA) occlusion, interest has grown over recent years in combining them into a single concomitant procedure as a strategy for rhythm control and stroke prevention. We report on the short-term outcomes of the combined procedure in a single center case series. Methods and Results Data was gathered by retrospective chart review. Between June 2015 to August 2021, 242 patients (61% male, mean age 72 ± 8, CHA2DS2-VASc 3.8 ± 1.3, HAS-BLED 2.5 ± 1.1) underwent concomitant AF ablation and LAA occlusion with the Watchman device. Successful occlusion occurred in 224 patients (93%) with a mean procedural time of 182 ± 76 minutes, mean maximum compression of 25 ± 5.5%, and a median number of 1 device. Reasons for aborting included anatomic difficulties (83%), the presence of sludge or thrombus in the LAA (11%), and edema at the site of ablation in only 1 case (6%). Peri-procedural complications included 2 cases of left atrial appendage perforation requiring surgical device extraction, 1 stroke, 6 cases of pericarditis, and 4 vascular access site complications including 1 retroperitoneal bleed, 1 superficial hematoma, 1 persistent bleeding requiring admission, and 1 arteriovenous fistula. 205 patients (92%) had appropriate follow-up within 6 months. Anticoagulation was successfully discontinued in 90 patients (44%) at 3 months, and 178 patients (87%) at 6 months. Antiarrhythmics were discontinued in 25 patients at 3 months (12%) and 35 patients at 6 months (17%). Ninety-day complications included 12 cases of gastrointestinal bleeding, 4 cases of genitourinary bleeding, 3 cases of volume overload, 2 cases of epistaxis, and 1 intracerebral hemorrhage. All patients with repeat imaging (95%) over a mean follow-up duration of 93 days remained with adequate occlusion, with 5 cases of device thrombosis (2%). Conclusion In conclusion, the combined procedures of catheter ablation for AF and LAA occlusion with the Watchman device appears to be safe and feasible. Further data are needed on long-term outcomes of arrhythmia recurrence, bleeding, and thromboembolic events to determine which patients might benefit most from the hybrid approach.

The German Cardiosurgery Atrial Fibrillation Registry: 1-Year Follow-up Outcomes.

This study of German Cardiosurgery Atrial Fibrillation (CASE-AF) registry aims to describe the 1-year outcomes of patients undergoing ablative procedures for atrial fibrillation (AF) in a cardiosurgical setting. Between January 2017 and April 2020, 17 German cardiosurgical units enrolled 1,000 consecutive patients undergoing concomitant or stand-alone ablation for AF. In-hospital and 1-year follow-up data were collected on web-based electronic case report forms. The protocol mandated telephone-based follow-up contact after 1 year. At 1-year follow-up (median, 14.5 months [12.6-18.2 months]), significant improvement (p < 0.0001) in baseline modified European Heart Rhythm Association Class I was reported in both concomitant and stand-alone patients. Follow-up examinations were completed in 97.9% of cases, and a sinus rhythm was reported in 60.2 and 63.6% of stand-alone and concomitant patients, respectively. Statistically significant factors determining late recurrence were female gender (p = 0.013), preoperative persistent AF (p < 0.0001), and presence of cardiac implantable electronic device (p = 0.011). All-cause mortality at 1 year was 1% (n = 1) in stand-alone patients and 6.7% (n = 58) in concomitant patients. Surgical ablation of AF is safe and provides satisfactory results at short-term follow-up, with significant improvement in patient symptoms. Adequate cardiac rhythm monitoring should be prioritized for higher quality data acquisition.

Minimally invasive atrial fibrillation ablation and left anterior descending bypass grafting

Abstract Funding Acknowledgements Type of funding sources: None. Background Minimally invasive direct coronary artery bypass (MIDCAB) with robotic left internal mammary artery (LIMA) harvesting for a critical left anterior descending (LAD) stenosis and thoracoscopic ablation for atrial fibrillation (AF) may represent safe and effective alternatives to more invasive surgical approaches via sternotomy. Purpose To evaluate the feasibility, safety and efficacy of a MIDCAB procedure with concomitant thoracoscopic AF ablation. Methods We prospectively analysed all patients who underwent a minimally invasive, off-pump, MIDCAB through a left mini-thoracotomy with concomitant left-sided thoracoscopic AF ablation using a bipolar radio frequent clamp between 2017 and 2021. Results Twenty-three patients were included (age 69±8 years, BMI 29±4kg/m2, paroxysmal AF 61%, LAVI 42±11 ml/m2). All patients received an off-pump LIMA-LAD anastomosis. Ablation of the left (n=23) and right (n=22) pulmonary veins and box (n=21) was succeeded by epicardial validation of exit- and entrance block (n=22). No procedural complications were observed and complications during hospital admission and after discharge were: bleeding of the LIMA-LAD anastomosis n=1; myocardial infarction requiring percutaneous intervention of the LIMA-LAD n=1, respiratory insufficiency due to pleural effusion or atelectasis n=3, hospital readmission due to pleural- and pericardial effusion n=2. Duration of hospital stay was 6±2 days. After 12 months, 16/20 (80%) patients were in sinus rhythm when allowing anti-arrhythmic drugs and 18/20 (90%) patients were free from myocardial infarction. Conclusion Robot-assisted MIDCAB surgery for LIMA-LAD grafting concomitant with left-sided thoracoscopic AF ablation is a feasible, safe and efficacious minimally invasive treatment strategy for patients with a critical LAD stenosis and AF suitable for minimally invasive surgery.

Concomitant Atrial Fibrillation Procedures During Cardiac Surgery in a UK Center: Reflection of Worldwide Practice?

BackgroundGuidelines recommend concomitant atrial fibrillation (AF) ablation during cardiac surgery to restore normal sinus rhythm (NSR). The study determines, to what extent patients with AF undergoing cardiac surgery at our institution received a concomitant AF procedure, what these procedures entailed, and short-term outcomes.MethodsA retrospective study of 2,984 patients undergoing cardiac surgery over 18 months. Patients who were in preoperative AF were identified and those who underwent a concomitant AF procedure (Group 1) were compared with those who did not (Group 2).ResultsThree hundred and thirteen (10.5%) patients had pre-operative AF; paroxysmal (19.5%), persistent (11.8%), longstanding (63%), unknown (5.8%). 116/313 (37.1%) patients had a concomitant AF procedure: 7.7% patients had a concomitant AF ablation and 29.4% had only a Left Atrial Appendage Occlusion (LAAO). Fewer patients with paroxysmal and persistent AF underwent concomitant AF procedures compared with the ones who had no AF procedures (6.7 vs. 12.8% and 17.6 vs. 31%, respectively). Greater in-hospital survival (99.1 vs. 93.9%, p = 0.025) and survival at a mean follow up of 6 weeks (97.4 vs. 89.3%, p = 0.09) was probably determined by patient's preoperative comorbidities. There were no differences in readmission rates, permanent pacemaker insertion, cerebral events or NSR at discharge or follow-up, between groups.ConclusionsIn our center, concomitant AF ablation is performed only in 7.7% of cases, 29.4% had only an LAAO performed at the time of surgery. There was no difference in restoring NSR, cerebral events, or readmission rates compared with patients who had nothing done for their preoperative AF.

Safety and efficacy of concomitant ablation for atrial fibrillation in rheumatic mitral valve surgery: A meta-analysis.

This review aimed to evaluate the safety and efficacy of concomitant surgical ablation (SA) for patients with atrial fibrillation(AF) undergoing rheumatic mitral valve (MV) surgery. A systematic search of relevant studies focusing on SA for patients with AF undergoing rheumatic MV surgery was performed. The primary outcomes included mortality, efficacy, and complications. Four randomized controlled trials (RCTs) and four observational studies covering 1931 patients met the inclusion criteria. In RCTs, no significant differences in reoperation for bleeding, low cardiac output syndrome, thromboembolic events, and early (risk ratio [RR], 2.07; 95% confidence intervals [CI], 0.37-11.40; p = .41) and midterm all-cause death (RR, 1.07; 95% CI, 0.40-2.88; p = .89) were noted between the SA group and the nonablation group. These results were similar to those obtained from observational studies. However, ablation was associated with a higher incidence of permanent pacemaker implantation (RR, 2.44; 95% CI, 1.15-5.18; p = .02) in observational studies but not in RCTs (RR, 2.03; 95% CI, 0.19-21.26; p = .56). Furthermore, additional SA was significantly more effective in sinus rhythm (SR) restoration than MV surgery alone at discharge and at the 12-month and 3-year follow-ups. Concomitant SA during rheumatic MV surgery does not increase perioperative adverse events. In addition, SA promotes considerable restoration of SR. Although some evidence exists that permanent pacemaker implantation is more common after ablation, not all studies support this notion.

Decision-Making in Transcatheter Edge-to-Edge Repair: Insights into Atrial Functional Mitral Regurgitation.

The 2020 American College of Cardiology focused update on the mitral regurgitation (MR) pathway provides an excellent summary of the decision-making trees in the treatment of severe MR, in which 2 main branches of the flowchart are suggested depending on whether MR is primary or secondary. Surgery is suggested as preferable over transcatheter edge-to-edge repair (TEER) in primary MR that needs intervention. The decision-making for secondary MR generally prioritizes TEER over surgery according to the guidelines, but further stratification is necessary based on the pathophysiologic mechanisms of MR. TEER is probably the more suitable option in secondary MR caused by left ventricular dysfunction or dilatation, given the high perceived surgical risks, despite the lack of sufficient evidence in support of overt clinical benefits from surgical therapy in these patients. In atrial functional MR associated with atrial fibrillation (AF), however, concomitant ablation of AF seems to be a desirable option, as it has been demonstrated to be a key factor leading to improved survival, reduced stroke risk, and more durable mitral and tricuspid function in patients undergoing mitral surgery. Therefore, atrial functional MR requiring intervention may be best treated by surgical therapy that combines mitral repair and AF ablation in the majority of patients. This particular issue, however, needs further research to obtain scientific evidence to guide optimal management strategies.

B-PO04-214 ATRIAL TRANS-SEPTOPLASTY DURING CONCOMITANT ATRIAL FIBRILLATION ABLATION AND LEFT ATRIAL APPENDAGE CLOSURE: A CASE REPORT

Transseptal catheterization (TC) is routine in electrophysiology and structural heart procedures. TC can be technically challenging due to a thick or scarred septum. Intracardiac echo (ICE) and Radiofrequency (RF) has helped in the success of TC. We report the first case of concomitant Atrial Fibrillation (AF) ablation with Left Atrial Appendage Closure (LAAC) with atrial trans-septoplasty (ATS). N/A A 63-year-old male with drug-refractory paroxysmal AF, CHADS Vasc Score of 6, and recurrent epistaxis presented for concomitant AF ablation and LAAC implant. ICE demonstrated a very thick septum of 1.2 cm without sparing of the fossa ovalis. Following transseptal (TS) puncture using RF needle, the TS sheath could not be advanced to the Left atrium (LA) despite different approaches including the use of a stiff pigtail wire in the LA, extra stiff wire in the right and left superior pulmonary vein (LSPV), and sequential dilation with progressively larger diameter long dilators. Successful ATS was performed under ICE and fluoroscopy guidance using a non-compliant 8 x 20 mm balloon over a stiff wire in the LSPV as shown in the figure, allowing access of a 14 Fr cryosheath into the left atrium. Pulmonary veins were successfully isolated using the cryoballoon. After the exchange of a Watchman (WM) sheath, a WM FLX device was successfully implanted under ICE and fluoroscopy guidance. ATS can be safely performed in difficult TC due to a thick septum. The balloon used for ATS can be selected based on the diameter of the transeptal sheath required to complete the procedure. Additional studies are needed to evaluate the long-term effects of this technique.

Totally endoscopic mitral valve surgery: early experience in 188 patients

IntroductionTotally endoscopic technique has been widely used in cardiac surgery, and minimally invasive totally endoscopic mitral valve surgery has been developed as an alternative to median sternotomy for many patients with mitral valve disease. In this study, we describe our experience about a modified minimally invasive totally endoscopic mitral valve surgery and reported the preliminary results of totally endoscopic mitral valve surgery. The aim of this retrospective study is to evaluate the results of totally endoscopic technique in mitral valve surgery.Material and methodsWe retrospectively reviewed the profiles of 188 patients who were treated for mitral valve disease by modified totally endoscopic mitral valve surgery at our institution between January 2019 and December 2020. The procedure was performed under endoscopic right minithoracotomy and with femoro-femoral cannulation using the single two-stage venous cannula.ResultsA total of 188 patients underwent total endoscopic mitral valve surgery. Fifty-six patients had concomitant tricuspid valvuloplasty, 11 patients underwent concomitant ablation of atrial fibrillation and atrial septal defect repair was performed in three patients. Only one patient postoperatively died of multi-organ failure. Two patients were converted to median sternotomy. Except for one patient underwent operation to stop the bleeding from the incision site, no other serious complications nor reintervention occurred during the follow-up period.ConclusionsThe modified totally endoscopic mitral valve surgery performed at our institution is technically feasible and safe with the same efficacy as reported studies.

Barriers to atrial fibrillation ablation during mitral valve surgery

BackgroundNearly 40% of patients with atrial fibrillation (AF) undergoing mitral valve surgery do not receive concomitant ablation despite societal guidelines. We assessed barriers to implementation of this evidence-based practice through a survey of cardiac surgeons in 2 statewide quality collaboratives. MethodsAdult cardiac surgeons across 2 statewide collaboratives were surveyed on their knowledge and practice regarding AF ablation. Questions concerning experience, clinical practice, case scenarios, and barriers to implementation were included. ResultsAmong 66 respondents (66 of 135; 48.9%), the majority reported “very comfortable/frequently use” cryoablation (53 of 66; 80.3%) and radiofrequency (55 of 66; 83.3%). Only 12.1% (8/66) were not aware of the recommendations. Approximately one-half of the respondents reported learning AF ablation in fellowship (50.0%; 33 of 66) or attending courses (47.0%; 31 of 66). Responses to clinical scenarios demonstrated wide variability in practice patterns. One-half of the respondents reported no barriers; others cited increased cross-clamp time, excessive patient risk, and arrhythmia incidence as obstacles. Desired interventions included cardiology/electrophysiology support, protocols, pacemaker rate information, and education in the form of site visits, videos and proctors. ConclusionsKnowledge of evidence-based recommendations and practice patterns vary widely. These data identify several barriers to implementation of concomitant AF ablation and suggest specific interventions (mentorship/support, protocols, research, and education) to overcome these barriers.

Surgical Atrial Fibrillation Ablation With and Without Left Atrium Reduction for Patients Scheduled for Mitral Valve Surgery: A Prospective Randomised Study

The influence of left atrium (LA) enlargement on atrial arrhythmia recurrence (AAR) after surgical ablation in patients with mitral valve (MV) disease remains unresolved. Left atrial size is critical to the success of concomitant atrial fibrillation (AF) ablation in patients scheduled for MV surgery. However, a large LA should not be a limiting factor when evaluating surgical candidates with AF if they receive appropriate treatment during concomitant ablation. This randomised study assessed whether adding LA reduction (LAR) to the maze procedure for MV surgery patients can improve freedom from AAR. From September 2014 to September 2017, 140 patients were randomly assigned into two groups. The maze group underwent MV surgery with concomitant surgical AF ablation (n=70). The maze+ LA reduction group underwent MV surgery with concomitant AF ablation and LA reduction procedure (n=70). Rhythm outcomes were estimated by Holter monitoring, according to Heart Rhythm Society guidelines. The concomitant LA reduction procedure did not increase early mortality and complications rates. Significant differences in freedom from AAR were observed at 24 months (maze, 78.4%; maze+ LAR group, 92.3%; p=0.025). A significant difference in LA volume was detected at discharge (p<0.0001); however, it was not significantly different at 24 months (p=0.182). Adding LA reduction to the maze procedure led to improvements in freedom from AAR for patients with AF and LA enlargement scheduled for MV surgery. A concomitant LA reduction procedure did not increase mortality and perioperative risk.

Three-year outcomes of the postapproval study of the AtriCure Bipolar Radiofrequency Ablation of Permanent Atrial Fibrillation Trial.

The Cox Maze IV operation is commonly performed concomitant with other cardiac operations and effectively reduces the burden of atrial fibrillation. Prospective randomized trials have reported outcomes early and at 12months, but only single-center late durability results are available. As part of the postapproval process for a bipolar radiofrequency ablation system, we sought to determine early and midterm outcomes of patients undergoing the Cox Maze IV operation. A prospective, multicenter, single-arm study of 363 patients (mean age, 70years, 82% valve surgery) with nonparoxysmal atrial fibrillation (mean duration, 60months, 94% Congestive heart failure, Hypertension, Age≥75, Diabetes, Stroke, VAScular disease, Age 65-74, Sex category ≥2) undergoing concomitant Maze IV atrial fibrillation ablation at 40 sites with 70 surgeons was performed between June 2010 and October 2014. Compliance with the study lesion set was 94.5%, and 99% had left atrial appendage closure. Freedom from atrial fibrillation was determined by extended monitoring, with a 48-hour Holter monitor minimum. There were no device-related complications. Freedom from atrial fibrillation off antiarrhythmic medications at 1, 2, and 3years was 66%, 65%, and 64%, respectively, and including those using antiarrhythmics was 80%, 78%, and 76%, respectively. Warfarin was used in 49%, 44%, and 40%, respectively. In patients with nonparoxysmal atrial fibrillation, compliance with the protocol was high, and freedom from atrial fibrillation off antiarrhythmics was high and sustained to 3years. The safety and effectiveness of the system and Cox Maze IV procedure support the Class I guideline recommendation for concomitant atrial fibrillation ablation in patients undergoing cardiac surgery.

Surgical ablation of atrial fibrillation in hypertrophic obstructive cardiomyopathy: Outcomes of a tailored surgical approach.

To assess outcomes of concomitant ablation for atrial fibrillation (AF) in patients with preoperative AF undergoing septal myectomy for hypertrophic obstructive cardiomyopathy. From 2005 to 2016, 67 patients underwent concomitant ablation for AF and septal myectomy and had a follow-up beyond a 3-month blanking period. Ablation strategy (pulmonary vein isolation [PVI], modified Cox-maze III [CM-III], or Cox-maze IV [CM-IV]) was tailored to preoperative AF burden, with high AF burden defined as persistent AF or need for cardioversion. AF recurrence was analyzed as a time-related event and predictors of recurrence identified using a random forest methodology. A total of 38 patients (57%) had low AF burden and 29 (43%) high burden. Patients with low AF burden most frequently underwent PVI (68%). Patients with high AF burden more frequently underwent CM-III (62%) or CM-IV (35%). Besides the preoperative AF burden, baseline characteristics were similar between patients receiving CM-III, CM-IV, and PVI. After surgery, the maximum provoked left ventricular outflow tract (LVOT) gradient decreased from 99 ± 34 to 18 ± 11mm Hg (P < .001). Eight patients (12%) required a permanent pacemaker. Cumulative AF recurrence at 1, 2, and 5 years was 11%, 22%, and 48%, respectively. Age, low preoperative resting LVOT gradient, and large left atrial diameter were predictors of AF recurrence. Surgical outcomes of concomitant ablation for AF and septal myectomy are good, although recurrence of AF by 5 years is frequent.