Persistent Lone Atrial Fibrillation Research Articles

The fate of patients after failed epicardial ablation of atrial fibrillation

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

P2658Can we successfully cure long-standing persistent lone atrial fibrillation? long-term results of thoracoscopic epicardial ablation: a perspective multicenter study

P2658Can we successfully cure long-standing persistent lone atrial fibrillation? long-term results of thoracoscopic epicardial ablation: a perspective multicenter study

Relationship between serum level of CD40 ligand and persistent lone atrial fibrillation

Inflammation is thought to play a role in the pathogenesis of atrial fibrillation. The relationship between CD40 ligand (CD40L), a prothrombotic and proinflammatory molecule, and lone atrial fibrillation was presently investigated for the first time. Levels of serum CD40L were also tested, regarding potential to distinguish patients with lone atrial fibrillation from healthy individuals. Presently included were 35 patients with lone persistent atrial fibrillation and a control group of 30 healthy individuals. Serum levels of CD40L and high-sensitive C-reactive protein (hs-CRP) were measured, and transthoracic echocardiography was performed. Mean serum CD40L, hs-CRP, left ventricular end-diastolic diameter, and left atrial diameter values were significantly higher in the group with lone persistent atrial fibrillation than in the control group (7.4±3.5 ng/mL vs 4.3±1.2 ng/mL, p<0.0001; 3.7±1.6 mg/L vs 1.7±0.8 mg/L, p<0.0001; 53.0±4.2 mm vs 46.0±3.8, p<0.0001; 43.5±3.5 mm vs 33.7±3.5, p<0.0001, respectively). Serum CD40L levels were positively correlated with left atrial diameter (r=0.81, p<0.0001) and hs-CRP (r=0.72, p<0.0001). Receiver operating characteristic curve analysis revealed that serum CD40L at the optimal cut-off level of >4.5 ng/mL successfully discriminated patients with lone atrial fibrillation from controls (area under the curve: 0.847; 95% confidence interval: 0.759-0.934; p<0.0001). The present findings suggest that CD40L levels play a crucial role in the development of lone atrial fibrillation. In addition, results support that regular clinical follow-up of these patients is necessary, due to increased cardiovascular disease risk, determined by elevated CD40L levels.

Abstract 11513: Eplerenone Treatment Mitigates Atrial Structural Remodeling but Does Not Modify the Transition From Paroxysmal to Persistent Atrial Fibrillation in an Ovine Model

Introduction: Recently we demonstrated that inhibition of the pro-fibrotic protein Galectin-3 reduces atrial dilatation, fibrosis and electrical remodeling as well as atrial fibrillation (AF) burden in a clinically relevant sheep model of lone persistent AF (Takemoto Y, et al. Heart Rhythm 12:S4; 2015). The mineralocorticoid blocker eplerenone (EPL) has been shown to reduce fibrosis and the incidence of AF in patients with systolic heart failure and mild symptoms, but the mechanism is poorly understood. We tested the hypothesis that by reducing atrial dilatation and fibrosis alone in the absence of heart failure EPL treatment also reduces atrial fibrosis and prevents AF perpetuation. Methods: We conducted a placebo-controlled drug study in 17 atrially tachypaced sheep for 14±2 weeks (maximum 23 weeks). We compared effects of EPL treatment (100 mg/day, N=10) with sugar pill (SP, N=7) orally administered daily from the start of tachypacing. The terminal point of the study was a continuous 7-day stretch of persistent AF (N=14) or the completion of 23-weeks tachypacing (N=3). Results: In vivo, EPL significantly reduced the rate of left atrial (LA) dilatation, mitral regurgitation, cellular hypertrophy, interstitial fibrosis (picrosirius red staining), and serum procollagen III N-terminal peptide (P3NP) levels during AF progression. However EPL did not affect the rate of dominant frequency (DF) increase or the maximum DF (DFmax). Ex-vivo optical mapping of the explanted hearts showed that EPL did not affect action potential duration or conduction velocity during pacing, or the DFmax during AF compared with hearts from SP-treated animals. However, EPL treatment significantly reduced the number of rotors and the trajectory areas of wavebreaks in LA during AF. Most important, unlike Gal-3 inhibition, EPL treatment did not change AF inducibility or AF burden at any time of weekly evaluation during AF progression. Conclusions: Mineralocorticoid inhibition during AF progression mitigates fibrosis and structural remodeling, which reduces complexity of AF and possibly contributes to delay the AF substrate somewhat. However, while reduction of fibrosis might be necessary, it is not sufficient to prevent AF perpetuation when electrical remodeling endures.

Electrophysiologic Results After Thoracoscopic Ablation for Chronic Atrial Fibrillation

Thoracoscopic ablation for lone atrial fibrillation (AF) has evolved rapidly in the past decade. We investigated the electrophysiologic results and midterm durability of totally thoracoscopic ablation in patients with lone persistent AF. Seventy-nine consecutive patients with paroxysmal AF (8 patients, 10.1%), persistent AF (17 patients, 21.5%), and long-standing persistent AF (54 patients, 68.3%) were prospectively enrolled. Thoracoscopic ablation consisted of a bilateral closed-chest approach to performing pulmonary isolation (a box lesion), ganglionated plexus ablation, division of the Marshall ligament, and left atrial auricle resection. An electrophysiologic study was performed 5 days after the surgical procedure in 61 patients (77%). Freedom from AF was assessed with electrocardiograms or Holter monitoring every 3 months, with a mean follow-up of 12.1 (maximum, 28) months. No deaths or conversion to cardiopulmonary bypass occurred. During electrophysiologic study, 28 residual pulmonary vein potentials were observed in 15 patients (19%). Out of a total of 28 gaps, 20 (71%) were located in the superior and inferior ridges of pulmonary veins. Six gaps (21%) were detected in the carina of pulmonary veins. The mitral isthmus was ablated in 2 patients (7%). Freedom from AF at 2 years was 92.6 ± 3.3%. Freedom from cardiac-related events at 2 years was 74.7 ± 6.0%. Cox regression analysis demonstrated that the predictors of atrial arrhythmias were old age, hypertension, and left atrial volume index. Thoracoscopic ablation followed by electrophysiologic confirmation was safe and provided excellent midterm durability in patients with AF. However, the incidence of residual potentials around the pulmonary veins was not negligible.

Electrophysiological and Electroanatomical Mapping of the Right Atrium in Persistent Atrial Fibrillation: Relation to Collagen Turnover.

Atrial fibrillation (AF) is associated with abnormal atrial substrate. We investigated whether patients with persistent lone AF and patients with persistent AF and nonischemic dilated cardiomyopathy (NIDCM) exhibit any differences in electrophysiological and electroanatomical properties of right atrium (RA) and collagen turnover. We also investigated the relationship between mean RA bipolar voltage and collagen turnover. Ten patients with a history of persistent lone AF and eight patients with a history of persistent AF and NIDCM were studied. Sinus node recovery times (SNRTs) and effective refractory periods (ERPs) at 600 ms, 500 ms, and 400 ms from the high (HLRA) and low (LLRA) lateral RA, proximal coronary sinus (pCS), and right atrial appendage (RAA) were evaluated, and RA electroanatomic mapping was created. Serum N-terminal propeptide of collagen type I (PINP), cross-linked C-terminal telopeptide of collagen type I (CTx), matrix metalloproteinase-1 (MMP-1), and tissue inhibitor of matrix metalloproteinases (TIMP-1) were measured as markers of collagen synthesis and degradation. No differences were found in SNRTs, ERPs from the HLRA, LLRA at 600 ms, pCS and RAA, mean RA bipolar voltage, serum PINP, CTx, MMP-1, and TIMP-1 between the two groups. In persistent lone AF, serum levels of TIMP-1 were related with mean HLRA and HPRA bipolar voltage. Persistent AF patients with or without NIDCM, demonstrate similar changes in electrophysiological and electroanatomical properties of the RA, as well as similar structural changes. Moreover, serum markers of collagen synthesis are correlated with bipolar voltage in specific regions of RA in persistent lone AF.

Plasma mid-regional pro-atrial natriuretic peptide and N-terminal pro-brain natriuretic peptide improve discrimination of lone atrial fibrillation

Atrial fibrillation (AF) is the most common sustained arrhythmia in the general population and is associated with substantial morbidity and mortality. Lone AF is a subtype of AF that occurs in young patients <60 years of age without known established risk factors for AF such as hypertension, diabetes and structural heart disease [ 1 Potpara T.S. Lip G.Y. Lone atrial fibrillation — an overview. Int. J. Clin. Pract. 2014; 68: 418-433 Crossref PubMed Scopus (23) Google Scholar , 2 Fuster V. Ryden L.E. Cannom D.S. et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J. Am. Coll. Cardiol. 2006; 48: 854-906 Abstract Full Text Full Text PDF PubMed Scopus (958) Google Scholar ]. The pathophysiology underlying lone AF is not well understood. Atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) are cardiac natriuretic circulating hormones with bioactivity promoting pressure and volume homeostasis. Having been derived from common precursors of BNP and ANP, respectively, N-terminal pro-BNP (NTproBNP) and N-terminal pro-ANP (NTproANP) are co-secreted with longer half-lives [ 3 Daniels L.B. Maisel A.S. Natriuretic peptides. J. Am. Coll. Cardiol. 2007; 50: 2357-2368 Abstract Full Text Full Text PDF PubMed Scopus (824) Google Scholar , 4 Morgenthaler N.G. Struck J. Thomas B. Bergmann A. Immunoluminometric assay for the midregion of pro-atrial natriuretic peptide in human plasma. Clin. Chem. 2004; 50: 234-236 Crossref PubMed Scopus (284) Google Scholar ]. An immunoassay has been developed to the mid-regional sequence of NTproANP (MRproANP) and plasma levels are reported to perform similarly to BNP and NTproBNP as a heart failure biomarker [ [4] Morgenthaler N.G. Struck J. Thomas B. Bergmann A. Immunoluminometric assay for the midregion of pro-atrial natriuretic peptide in human plasma. Clin. Chem. 2004; 50: 234-236 Crossref PubMed Scopus (284) Google Scholar ]. Both NTproBNP and MRproANP have been found to be elevated in common AF (AF associated with aging and risk factors such as hypertension) [ 5 Patton K.K. Heckbert S.R. Alonso A. et al. N-terminal pro-B-type natriuretic peptide as a predictor of incident atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis: the effects of age, sex and ethnicity. Heart. 2013; 99: 1832-1836 Crossref PubMed Scopus (92) Google Scholar , 6 Meune C. Vermillet A. Wahbi K. et al. Mid-regional pro atrial natriuretic peptide allows the accurate identification of patients with atrial fibrillation of short time of onset: a pilot study. Clin. Biochem. 2011; 44: 1315-1319 Crossref PubMed Scopus (8) Google Scholar ], but thus far, there has been no study describing MRproANP levels in patients with lone AF. In this well-characterized retrospective case–control study of patients with lone AF, we hypothesized that [ [1] Potpara T.S. Lip G.Y. Lone atrial fibrillation — an overview. Int. J. Clin. Pract. 2014; 68: 418-433 Crossref PubMed Scopus (23) Google Scholar ] similar to common AF, MRproANP is also associated with lone AF, and [ [2] Fuster V. Ryden L.E. Cannom D.S. et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J. Am. Coll. Cardiol. 2006; 48: 854-906 Abstract Full Text Full Text PDF PubMed Scopus (958) Google Scholar ] MRproANP and NTproBNP will improve our ability to discriminate between the presence and absence of lone AF, and between paroxysmal and persistent lone AF.

Abstract 11710: Plasma Mid-Regional Pro-Atrial Natriuretic Peptide and N-terminal Pro-Brain Natriuretic Peptide Can Discriminate Between Paroxysmal and Persistent Lone Atrial Fibrillation

Purpose: The progression from paroxysmal to persistent atrial fibrillation (AF) is associated with an increased prevalence of cardiovascular comorbidities. Plasma atrial and B-type natriuretic peptides are increased in atrial fibrillation. We sought to determine whether mid-regional pro-ANP (MRproANP) and N-terminal pro-brain natriuretic peptide (NTproBNP) can discriminate between paroxysmal vs. persistent lone AF. Methods: We enrolled patients with lone AF (patients aged &lt;60 years without hypertension, diabetes, or structural heart disease). Biomarkers were measured in normal sinus rhythm. We compared the ability of MRproANP versus NTproBNP in discriminating between paroxysmal and persistent lone AF by estimating the area under the ROC curve (AUC). Results: We enrolled 68 paroxysmal and 13 persistent lone AF patients (median age, 48 and 50 years; 88% and 92% male, respectively). Median MRproANP (121.5 v. 56.6 pmol/L, P&lt;0.001) and NTproBNP (292.0 v. 48.0 pmol/L, P=0.004) were higher in persistent than paroxysmal lone AF. MRproANP (AUC [95% CI] 0.82 [0.72-0.92]) was marginally better than NTproBNP (0.76 [0.65-0.88]) in discriminating between paroxysmal and persistent lone AF, P=0.06 (Figure). The AUC of using both markers (0.85 [0.75-0.94]) was not significantly different from MRproANP alone (P=0.08), but was slightly better than NTproBNP alone (P=0.03). Conclusions: MRproANP and NTproBNP may be helpful in discriminating between paroxysmal and persistent lone AF. Further prospective studies are needed to assess whether these biomarkers can predict progression of paroxysmal to persistent lone AF.

Work-up and management of lone atrial fibrillation: results of the European Heart Rhythm Association Survey.

The purpose of this European Heart Rhythm Association (EHRA) survey was to explore the work-up and management of lone atrial fibrillation (AF) among the European centres. Thirty-two European centres, all members of the EHRA electrophysiology (EP) research network, responded to this survey and completed the list of questions. The prevalence of lone AF has been reported to be ≤10% by 19 (60%) of the participating centres. The presence of isolated left atrial enlargement and left ventricular diastolic dysfunction represent heart disease according to 50 and 84% of the centres, respectively, and exclude the diagnosis of lone AF. Fifty-nine per cent of responders do not routinely consider genetic testing in lone AF patients. The initial therapeutic approach in symptomatic paroxysmal lone AF is antiarrhythmic drug therapy as reported by 31 (97%) of the centres. Pulmonary vein isolation only is the first ablation strategy for patients with symptomatic persistent lone AF at 27 (84%) of the responding centres. Assessment for sleep apnoea, obesity, and intensive sports activity in lone AF is performed at 27 (84%) centres. In conclusion, this EP Wire survey confirms that the term 'lone AF' is still used in daily practice. The work-up typically includes screening for known risk factors but not genetic testing. The preferred management of paroxysmal lone AF is rhythm control with antiarrhythmic drugs, whereas pulmonary vein isolation is the first ablation strategy for the majority of patients with symptomatic persistent lone AF.

The inconvenient truth of elevated left atrial pressure and AF recurrence despite catheter ablation

Complex and progressive electrical and structural remodeling of the left atrium (LA) is critical to the formation of substrate for the maintenance and progression of atrial fibrillation (AF).1 Several well-known clinical conditions such as aging, hypertension, and heart failure create atrial substrate for AF.1 Lone AF is also associated with widespread and progressive atrial structural abnormalities,2 a process that is accentuated in persistent lone AF, suggesting a progressive remodeling process in the absence of structural heart disease.

Maze surgery normalizes left ventricular function in patients with persistent lone atrial fibrillation†

The aim of this study is to evaluate the mid-term clinical and functional outcomes of maze surgery in symptomatic refractory lone atrial fibrillation (AF) patients. Between March 2008 and January 2013, 39 highly symptomatic patients [mean age 51 ± 10 (mean ± standard deviation); 95% CI, European Heart Rhythm Association class III-IV] underwent maze surgery for lone AF. Biatrial ablations were performed with bipolar radiofrequency and cryoenergy, according to a maze III lesion set (modified by omitting the intercaval line in 5 of 39 patients). Mean ejection fraction was 51 ± 9% (range 17-60), <45% in 10 patients (26%). Seventeen of 39 patients (44%) had persistent, 22 of 39 patients (56%) long-standing persistent AF, and 35 of 39 patients (90%) had previous transvenous ablations (median = 2; range 0-8). No patient had concomitant structural heart disease. A minimally invasive approach was adopted in 22 patients (56%). Major complications were 1 mediastinitis, 1 re-exploration for bleeding and 2 pacemaker (5%) implantation. At a mean follow-up of 29.4 ± 14.2 months, freedom from arrhythmias was 92 and 93% at 24 and 36 months, respectively. Freedom without antiarrhythmic drugs was 75 and 85% at 24 and 36 months, respectively. Ejection fraction normalized in all cases, from 51.3 ± 9% to 61.1 ± 3% (P < 0.001) overall, and from 37.0 ± 10% to 60.3 ± 3% (P < 0.001) when ≤ 45% preoperatively. AF-related symptoms score decreased to class I in 36 patients (93%). No early or late stroke occurred. Within a dedicated AF centre, maze surgery grants excellent outcomes, with symptoms relief and negligible risk. It provides a complete reversal of arrhythmia-related myocardial dysfunction and is therefore a convenient alternative to His bundle ablation and lifelong pacemaker dependency in symptomatic refractory patients.

Persistent lone atrial fibrillation: Clinicopathologic study of 19 cases

The extent to which atrial myocardium is remodeled in patients with persistent lone atrial fibrillation (LAF) is largely unknown. The purpose of this study was to perform a clinicopathologic investigation in patients with persistent LAF. We characterized structural and molecular remodeling in atrial biopsies from 19 patients (17 males, mean age 49 years) with persistent (>7 days; n = 8) or long-lasting persistent (>1 year; n = 11) LAF who underwent surgical ablation. Atrial tissue from 15 autopsy samples without clinicopathologic evidence of heart disease served as controls. Morphometric analysis showed cardiomyocyte hypertrophy and greater amounts of myolytic damage and interstitial fibrosis in persistent LAF patients compared to controls (P <.0001). Atrial tissue levels of heme oxygenase-1 and 3-nitrotyrosine were increased in persistent LAF patients (P <.001), consistent with oxidative stress. Levels of superoxide dismutase-2, interleukin-8, interleukin-10, tumor necrosis factor-α, and thiobarbituric acid reactive substance were greater in controls than in persistent LAF patients. Immunoreactive signal for connexin43 was reduced more frequently in persistent LAF patients than controls. There was no correlation between features of structural or molecular remodeling and clinical parameters, including persistent LAF duration. In persistent LAF patients, the atria are modified by structural remodeling and molecular changes of oxidative stress. Tissue changes in persistent LAF appear to occur early after its onset and are qualitatively no different than those observed in patients with atrial fibrillation related to conventional risk factors. These findings suggest that different types of atrial fibrillation are associated with the same spectrum of tissue lesions. Early intervention to restore sinus rhythm in persistent LAF patients may prevent irreversible tissue change, especially interstitial fibrosis.

Effect of sinus rhythm restoration on platelet function in patients with lone atrial fibrillation

Atrial fibrillation (AF) is associated with increased risk of thrombo- embolic complications. The aim of thestudywasto assessif arrhythmia, independent of other risk factors leads to increased platelet activation. The study involved 34 (mean age 50 +/� 9.03, range 21-59) male patients with lone persistent atrial fibrillation. The exclusion criteria were: age N60, coronary artery disease, left ventricular dysfunction (ejection fraction EF b 40%), congenital and acquired heart defects, artificial heart valve, diabetes, thyroid disease, inflammatory diseases, cancer, renal disease, and active smoking. The exclusion criteria precluded more than 95.4% of patients with AF hospitalized in our Department within the last 6 years. The AF patients underwent cardioversion to restore sinus rhythm and remained subsequently under observation for 1 month. Echocardi- ography, ECG and blood collection was performed before cardioversion (T0) and 4 weeks after successful cardioversion (T1). During the study period, patients were contacted and examined weekly along with 24-hour ECG monitoring. In all patients sinus rhythm was maintained at the end of the study period, however in 12 patients recurrence of AF was observed, confirmed by 24-hour ECG monitoring (atrial fibrillation recurrence group — AFR). In 10 patients the episodes of arrhythmia were asymp- tomatic, while only 2 patients complained of arrhythmia symptoms. In 22 patients no recurrence of AF in 24-hour ECG monitoring was observed (sinus rhythm group — SR). Parameters of resting platelets collected from peripheral blood activation was measured using flow cytometry. Platelet activation was assessed by expression of p-selectin (CD62) on platelets (CD61 positive cells). The platelet aggregate number was presented as a percentage of CD61+ blood elements bigger than platelets. The platelet derived microparticles (PDMPs) were assessed based on FSC histogram profile as CD61+ particles smaller than platelets. The leukocyte-platelet aggregates were detected based on coexpression of CD11b and CD62

A novel KCND3 gain-of-function mutation associated with early-onset of persistent lone atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia, and early-onset lone AF has been linked to mutations in genes encoding ion channels. Mutations in the pore forming subunit KV4.3 leading to an increase in the transient outward potassium current (Ito) have previously been associated with the Brugada Syndrome. Here we aim to determine if mutations in KV4.3 or in the auxiliary subunit K(+) Channel-Interacting Protein (KChIP) 2 are associated with early-onset lone AF. Two hundred and nine unrelated early-onset lone AF patients (<40 years) were recruited. The entire coding sequence of KCND3 and KCNIP2 was bidirectionally sequenced. One novel non-synonymous mutation A545P was found in KCND3 and was neither present in the control group (n = 432 alleles) nor in any publicly available database. The proband had onset of persistent AF at the age of 22, and no mutations in genes previously associated with AF were found. Electrophysiological analysis of KV4.3-A545P expressed in CHO-K1 cells, revealed that peak-current density was increased and the onset of inactivation was slower compared with WT, resulting in a significant gain-of-function both in the absence and the presence of KChIP2. Gain-of-function mutations in KV4.3 have previously been described in Brugada Syndrome, however, this is the first report of a KV4.3 gain-of-function mutation in early-onset lone AF. This association of KV4.3 gain-of-function and early-onset lone AF further supports the hypothesis that increased potassium current enhances AF susceptibility.

Cardiac surgery Left atrial appendage stapling during totally thoracoscopic ablation of long-standing lone persistent atrial fibrillation – lessons learnt

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Witkowska A, Smoczyński R, Drobiński D, et al. Cardiac surgeryLeft atrial appendage stapling during totally thoracoscopic ablation of long-standing lone persistent atrial fibrillation – lessons learnt. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2013;10(4):330-333. doi:10.5114/kitp.2013.39732. APA Witkowska, A., Smoczyński, R., Drobiński, D., Kosior, D., Sypuła, S., & Niewińska, M. et al. (2013). Cardiac surgeryLeft atrial appendage stapling during totally thoracoscopic ablation of long-standing lone persistent atrial fibrillation – lessons learnt. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 10(4), 330-333. https://doi.org/10.5114/kitp.2013.39732 Chicago Witkowska, Anna, Radosław Hugon Smoczyński, Dominik Drobiński, Dariusz Kosior, Sławomir Sypuła, Monika Niewińska, and Zygmunt Kaliciński et al. 2013. "Cardiac surgeryLeft atrial appendage stapling during totally thoracoscopic ablation of long-standing lone persistent atrial fibrillation – lessons learnt". Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery 10 (4): 330-333. doi:10.5114/kitp.2013.39732. Harvard Witkowska, A., Smoczyński, R., Drobiński, D., Kosior, D., Sypuła, S., Niewińska, M., Kaliciński, Z., Szafron, B., Świstowski, J., and Suwalski, P. (2013). Cardiac surgeryLeft atrial appendage stapling during totally thoracoscopic ablation of long-standing lone persistent atrial fibrillation – lessons learnt. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, 10(4), pp.330-333. https://doi.org/10.5114/kitp.2013.39732 MLA Witkowska, Anna et al. "Cardiac surgeryLeft atrial appendage stapling during totally thoracoscopic ablation of long-standing lone persistent atrial fibrillation – lessons learnt." Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery, vol. 10, no. 4, 2013, pp. 330-333. doi:10.5114/kitp.2013.39732. Vancouver Witkowska A, Smoczyński R, Drobiński D, Kosior D, Sypuła S, Niewińska M et al. Cardiac surgeryLeft atrial appendage stapling during totally thoracoscopic ablation of long-standing lone persistent atrial fibrillation – lessons learnt. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2013;10(4):330-333. doi:10.5114/kitp.2013.39732.

Morphologies of the Atria and Pulmonary Veins in Relation to Lone Atrial Fibrillation Progression: A Dual‐Source Computed Tomography Scan Study

Atrial Remodeling and Lone Atrial Fibrillation. We sought to investigate the role of anatomic remodeling of the atria and pulmonary veins (PVs) in the progression of lone atrial fibrillation (AF) using dual-source computed tomography (DSCT). From 1,308 consecutive patients referred for an index ablation procedure for AF, we prospectively enrolled 29 consecutive patients with recently developed (<3 months) lone persistent AF (PsAF) and 23 consecutive patients with short-lasting (6-12 months) lone PsAF, all of whom had a history of paroxysmal AF (PAF). The control group consisted of 33 patients with lone PAF. On DSCT, the recently developed PsAF group showed more extensive atrial anatomic remodeling than the PAF group as shown by ∼40% higher spot biatrial volume, even though the mean duration of continuous AF was only 6 weeks. In contrast, the DSCT variables in the recently developed PsAF group and the short-lasting PsAF group were comparable, despite the fact that the mean duration of continuous AF in the latter group was 8 months. Series of cross-sectional areas of the ostial 1.5 cm of PV trunks were comparable in the PAF and PsAF groups in all but 3 ostial planes. A higher spot left atrial volume was the only independent factor associated with the progression of lone PAF to PsAF (OR: 1.06, 95% CI: 1.03-1.09, P<0.0001) on logistic regression. Prominent anatomic remodeling of the atria, rather than the PVs, underlies the mechanism of recent progression of lone paroxysmal AF to the persistent variety.

Successful Treatment of Lone Persistent Atrial Fibrillation by Means of a Hybrid Thoracoscopic-Transcatheter Approach

Ablation strategies for the treatment of lone persistent atrial fibrillation (AF) have rapidly evolved during the past decade both with electrophysiological (EP) and surgical approaches. We investigated the safety and efficacy of a novel staged hybrid approach combining surgical thoracoscopic and EP ablation in patients with lone persistent AF. Twenty-four consecutive patients with either persistent (three patients, 12.5%) or long-standing persistent (21 patients, 87.5%) isolated AF were prospectively enrolled: the mean age was 63.2 ± 9.3 years, the mean left atrial dimension was 50.5 ± 8 mm, and the mean AF duration was 82.7 months (range, 7-240 months). The surgical procedure consisted of a monolateral, right-sided, thoracoscopic closed-chest approach to perform a "box" lesion set with a temperature-controlled, internally cooled, radiofrequency monopolar device with suction adherence (Cobra Adhere XL; Estech, San Ramon, CA USA). A continuous monitoring rhythm device (Reveal XT; Medtronic, Minneapolis, MN USA) was implanted at the time of surgery in all patients for continuous long-term monitoring of the heart rhythm. Successful completion of the procedure was achieved in all cases, with a mean ablation time of 29 ± 9 minutes and an overall procedural time of 84 ± 16 minutes. After surgical ablation, the exit block was documented in all cases, whereas the entrance block was achieved in 87.5% (21 of 24 patients). No intensive care unit stay was required, and no complications occurred postoperatively; hospital mortality was 0%. At a mean interval of 33 ± 2 days after surgery, an EP study was performed: bidirectional block was confirmed in 79.1% (19 of 24 patients), whereas gaps at the level of the box lesion were observed in 20.8% of the patients (5 of 24 patients). Additional transcatheter endocardial right- and left-sided lesions were performed in 62.5% of cases (15 of 24 patients). At a mean follow-up of 28 months (range, 1-55 months), 87.5% of the patients (21 of 24 patients) are in sinus rhythm, and the incidence of left atrial flutter was 0%. The combination of thoracoscopic box lesion and transcatheter ablation in a staged hybrid approach proved to be safe, providing excellent mid-term clinical outcomes in patients with long-standing, isolated, persistent AF. Moreover, the implantable loop recorders documented such incremental benefits in sinus rhythm restoration for up to 28 months.

Successful Treatment of Lone Persistent Atrial Fibrillation by Means of a Hybrid Thoracoscopic-Transcatheter Approach

Successful Treatment of Lone Persistent Atrial Fibrillation by Means of a Hybrid Thoracoscopic-Transcatheter Approach

Treatment of lone atrial fibrillation: a look at the past, a view of the present and a glance at the future

Despite its proven efficacy, the Cox-Maze III procedure did not gain widespread acceptance for the treatment of lone atrial fibrillation (LAF) because of its complexity and technical difficulty. Surgical ablation for LAF can now be successfully performed utilizing minimally invasive techniques. This article provides an overview of the current state of the art in the surgical treatment of LAF. A brief review of pathophysiology, pharmacological treatment as well as catheter ablation is also provided. The most widely employed minimally invasive approach to LAF has been the video-assisted bilateral mini-thoracotomy or thoracoscopic pulmonary vein island creation and left atrial appendage removal or exclusion, usually with ganglionic plexi evaluation and destruction. Recently, a hybrid approach has been introduced, which combines a mono or bilateral epicardial approach with a percutaneous endocardial ablation in a single-step procedure to limit the shortcomings of both techniques. Suboptimal results of both catheter ablation and surgery suggest that success in the treatment of LAF will probably rely on a close collaboration between the surgeon and the electrophysiologist. Further studies are warranted to determine whether the hybrid approach is effective, especially in patients with long-standing persistent and persistent LAF.

Minimally invasive thoracoscopic hybrid treatment of lone atrial fibrillation: early results of monopolar versus bipolar radiofrequency source

We compare results of a hybrid monopolar vs. a hybrid bipolar thoracoscopic approach employing radiofrequency (RF) sources for the surgical treatment of lone atrial fibrillation (LAF). From January 2008 to June 2010, 19 patients (35.1%) underwent RF monopolar/monolateral RF ablation, whereas 35 (64.9%) had RF bipolar/bilateral thoracoscopic ablation. One-year time-related prevalence of postoperative AF was 13.3 (11.0-17.4) and 5.2% (4.2-6.7), in monopolar and bipolar groups, respectively (P < 0.001). It was 21.1 (17.6-24.9) vs. 8.2% (5.1-11.6) in long standing persistent (P < 0.001), 13.2 (10.6-17.8) vs. 3.8% (1.4-6.9) in persistent (P < 0.001) and 5.6 (2.8-8.3) vs. 3.2% (1.0-6.5) in paroxysmal AF (P = 0.64). At 12 months, estimated prevalence of anti-arrhythmic drugs was 26 (22.4-30.1) and 18.0% (15.5-21.7, P = 0.04), whereas prevalence of warfarin use was 48.2 (44.2-52.2) and 29.0% (26.2-33.1, P < 0.001) in the monopolar and bipolar groups, respectively. Left atrial (LA) reverse remodelling occurred in 47.3% of monopolar patients (n = 9) and in 77.1% of bipolar patients (P = 0.03). The hybrid bilateral approach with a bipolar device for the treatment of LAF showed a good 1-year success rate independently of the AF type and seems to be the better choice for longstanding persistent and persistent LAF.