Surgical Ablation Of Atrial Fibrillation Research Articles

Atrial Tachycardias After Surgical AtrialFibrillation Ablation: Clinical Characteristics, Electrophysiological Mechanisms, and Ablation Outcomes From a Large, Multicenter Study.

The clinical characteristics, electrophysiological mechanisms, and ablation outcomes of post-surgical atrial fibrillation ablation (SAFA) atrial tachycardias (ATs) have not been studied in a large, multicenter cohort. ATs are often seen following SAFA. Analysis was performed on 137 patients (age, 62 ± 10 years; 74% male) who underwent catheter ablation for symptomatic post-SAFA AT from 2004 to 2013 at 3 high-volume institutions in the United States. A total of 137 patients had 149 ATs that were mapped; 103 (69%) had a left atrial (LA) origin and 46(31%) had a right atrial origin. Of the 149, a total of 44 (30%) had a focal mechanism, with 29 (66%) having an LA origin, with53% localized to LA posterior wall. Of the 105 re-entrant ATs, 74 (71%) were of LA origin. Thepredominant circuits were cavotricuspid isthmus (n= 25), perimitral (n= 19), LA roof (n= 17), left pulmonary veins(n= 13), right pulmonary vein/LA septum (n= 12), and LA appendage (n= 7). A total of 93% of patients had≥1 pulmonary vein reconnection requiring reisolation. Catheter ablation resulted in termination and noninducibility of 97% of right atrial and 93% of LAATs. Over a 12-month follow-up, 80% of patients were free ofany AT or AF. In this large multicenter cohort of post-SAFA ATs, most were of LA origin, with macro-re-entry being the most common arrhythmia mechanism. Wide variability in location of AT circuits was seen in both right atrialand LA andlikely reflects underlying arrhythmogenic substrate and differences in modified SAFA techniques. Catheterablation was highly successful in eliminating the culprit AT with favorable long-term outcomes.

Electrophysiological findings after surgical ablation of atrial fibrillation using AtriCure system

IntroductionLong-term results of catheter ablation (CA) of persistent and long-standing persistent atrial fibrillation (AF) have been disappointing. The hybrid approach is one method of overcoming the limitations of CA. AimTo present electrophysiological (EP) findings in patients undergoing hybrid surgical ablation to treat atrial fibrillation. MethodsPatients with persistent and long-standing persistent AF underwent thoracoscopic epicardial radiofrequency (RF) isolation of the pulmonary veins (PV) using AtriCure clamps followed by linear ablations in the left atrium (LA) using a linear pen and complemented by Marshall ligament disruption and left atrial appendage exclusion using an AtriClip device. As part of the study protocol, all patients underwent an EP study and RF ablation to eliminate any and all residual epicardial conduction gaps. ResultsSeventy patients (49 male, median 63.5 years) were recruited for the study. The EP-phase of the study was performed 87 days (median) after the thoracoscopic ablation. At the time of the EP study, 76% of patients presented with sinus rhythm (SR), 7% with typical atrial flutter, 11% with atrial tachycardia, and 6% with AF. Left sided PVs were found to be isolated less often than right PVs (75.7% vs. 91.4%, p<0.001). Complete isolation of all PVs was seen in 68.6% of patients. Complete isolation of the LA posterior wall was found in 22.9% of patients only. Conduction gaps in the left PVs were mostly found on the superior portion and on the ridge between the superior vein and LA appendage. In the right PVs, gaps were most often on the superior and posterior walls of the vessels. It was impossible to find typical gap locations on the LA roof connecting line since most patients required re-ablation of the whole line. The most common re-conduction site on the inferior line was found on the third of the line adjacent to the right inferior PV. ConclusionSurgical epicardial ablation of the right sided PVs is significantly more successful compared to ablation of left-sided PVs. Linear epicardial ablations, completed under direct visual control are often unsuccessful. Our results may help cardiac surgeons focus on the typical sites of re-conduction and improve their results through additional RF applications.

Surgical and Hybrid Ablation of Atrial Fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia in humans and is known to be associated with an increased risk of stroke, dementia, heart failure and mortality. Non-pharmacological therapy with ablation using either surgical or percutaneous techniques is recommended in drug refractory AF. Early attempts to devise procedures to ablate AF and restore sinus rhythm culminated with the Cox-Maze procedure, the first truly successful procedure. Since then, ablation surgery has been conducted predominately as a concomitant procedure. The Cox Maze procedure is complex and technically demanding and has, therefore, been extensively modified with new techniques for creating the linear ablation lines, new lesion sets, minimally invasive surgical techniques and most recently hybrid surgical-catheter ablation techniques. Surgical ablation techniques result in a marked reduction in atrial fibrillation when compared to conventional therapy with only a small increase in procedural risk. However, further research is required to more accurately quantify those benefits and to determine the optimal lesion sets, specific to the underlying arrhythmia mechanism and the optimal energy sources for ablation.

One-year mortality and costs associated with surgical ablation for atrial fibrillation concomitant to coronary artery bypass grafting.

While surgical ablation (SA) for persistent atrial fibrillation (AF) can reduce recurrence of AF, its impact on longitudinal survival and health-care costs remains controversial. This study defines the clinical outcomes and costs associated with SA in patients with prior AF undergoing coronary artery bypass grafting (CABG). A total of 3745 Medicare beneficiaries with prior AF who underwent CABG in 2013 were divided into 2 groups: those with and those without concomitant SA. Risk-adjusted early (0-90 days) and late (91-364 days) postoperative outcomes and inpatient costs were compared. SA was performed in 17% of CABG patients with prior AF. Preoperative characteristics favoured patients with SA: emergent presentation (15% vs 22%), heart failure in the 2 weeks prior to CABG (31% vs 36%), chronic lung disease (27% vs 33%) and renal failure (4% vs 7%) (all P < 0.05). Risk-adjusted operative mortality and perioperative stroke rates were similar in the 2 groups. Risk-adjusted survival was similar through 90 days, but significantly better with SA after 90 days [hazard ratio (HR) = 0.58; P = 0.03]. At 1 year, the risk-adjusted incidence of cardiovascular implantable electronic device implantation was greater with SA (HR = 1.20; P = 0.01). Risk-adjusted costs for the CABG admission (HR = 1.11; P < 0.01) and inpatient care through 1 year (HR = 1.06; P = 0.02) were also greater with SA. In the US Medicare population, SA was performed in 17% of CABG-AF patients in 2013. Operative risks for mortality and stroke did not increase with SA but costs did. Patients receiving SA, however, had significantly better risk-adjusted late survival.

WITHDRAWN: 2017 HRS/EHRA/ECAS/APHRS/SOLAECE Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation

WITHDRAWN: 2017 HRS/EHRA/ECAS/APHRS/SOLAECE Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation

Long-term outcomes of minimally invasive surgical ablation for atrial fibrillation: A single-center experience

Minimally invasive surgical atrial fibrillation (AF) ablation (MISAA) delivers radiofrequency energy via a thoracoscopic approach to perform pulmonary vein isolation and left atrial ganglionic plexi ablation. Data on long-term outcomes of MISAA are lacking. We report 5-year follow-up data from a prospective cohort of patients who underwent MISAA at a single center. One hundred nine consecutive patients (60 paroxysmal, 49 persistent; mean age 62.7 ± 9.3 years) underwent MISAA with left atrial appendage exclusion by a single surgeon between 2006 and 2012. Patients were followed with transtelephonic monitoring at 1, 6, and 12 months and annually thereafter for up to 5 years. Recurrence was defined as any atrial tachyarrhythmia lasting ≥30 seconds from 90 days after surgery onward. Mean follow-up duration was 1738.5 ± 661.5 days. Single-procedure success rate was 38% (37 of 98 patients). Atrial arrhythmias occurred in 22%, 42%, 55%, 59%, and 62% of patients by 1, 2, 3, 4, and 5 years. Seventy-eight (79.6%) patients remained AF free with or without additional interventions including catheter ablation, antiarrhythmic drugs, or cardioversion. There was no significant difference in AF-free survival between paroxysmal and persistent AF groups (P = .725). Multivariate analyses showed hypertension to be a significant predictor of AF recurrence (odds ratio 6.6, confidence interval 1.41-30.80; P= .016). Five (5.1%) patients had a stroke or transient ischemic attack during follow-up. AF-free survival was 38% at 5 years after MISAA. A total of 79.6% of patients remained AF free with or without additional intervention. Patients may have an ongoing risk of stroke even in the absence of AF recurrences.

Risk of Intraatrial Thrombi After Thoracoscopic Ablation in Absence of Heparin and Appendage Closure

Catheter and surgical ablation of atrial fibrillation (AF) can be associated with a risk of thromboembolic events. The goal of this study was to assess optimal anticoagulation management during thoracoscopic ablation of AF. Fifty-two patients with persistent or long-standing persistent AF underwent hybrid ablation consisting of thoracoscopic ablation followed by electrophysiologic (EP) evaluation and consecutive ablation if indicated. The thoracoscopic ablation was performed using three different anticoagulation protocols: (1) without periprocedural heparin and without occlusion of the left atrial appendage; (2) with periprocedural heparin but without left atrial appendage occlusion; and (3) with periprocedural heparin and left atrial appendage occlusion. Transesophageal echocardiography (TEE) was obligatorily used to screen for intraatrial thrombi before the surgical and EP procedure and before hospital discharge for patients in protocols 2 and3. In group 1 (n= 20), 1 patient (5%) had a postoperative stroke with persistent neurologic deficit, and 6 other patients (30%) had a new thrombus in the left atrial appendage seen on the pre-EP TEE. In group 2(n=6), 3 left atrial appendage thrombi occurred (50%; 2on predischarge TEE and 1 on pre-EP TEE). In group 3(n= 26), no intracardiac thrombi were found on predischarge and pre-EP TEE, and there were no strokes in this group of patients, namely, the rates of thrombus or stroke were significantly reduced when compared with groups 1and 2 (p= 0.001). Thoracoscopic ablation of AF can be associated with a risk of left atrial appendage thrombus formation and possibly also stroke. With administration of heparin during the ablation, followed by occlusion of the left atrial appendage as a part of the procedure, this risk can be effectively reduced.

Fifty-Third Annual Meeting, The Society of Thoracic Surgeons

Fifty-Third Annual Meeting, The Society of Thoracic Surgeons

Right atrium positioning for exposure of right pulmonary veins during off-pump atrial fibrillation ablation.

Concomitant surgical ablation of atrial fibrillation (AF) is recommended for patients undergoing off-pump coronary revascularization in the presence of this arrhythmia. Achievement of optimal visualization of pulmonary veins while maintaining stable haemodynamic conditions is crucial for proper completion of the ablation procedure. This study evaluates the safety and feasibility of right atrial positioning using a suction-based cardiac positioner as opposed to compressive manoeuvres for exposure during off-pump surgical ablation for AF. Thirty-four consecutive patients underwent pulmonary vein isolation, ganglionated plexi ablation and left atrial appendage occlusion during off-pump coronary artery bypass grafting. Right atrial suction positioning was used to visualize right pulmonary veins. Safety and feasibility end points were analysed intraoperatively and in the early postoperative course. In all patients, right atrial positioning created optimal conditions to complete transverse and oblique sinus blunt dissection, correct placement of a bipolar ablation probe, detection and ablation of ganglionated plexi and conduction block assessment. In all patients, this entire right-sided ablation procedure was completed with a single exposure manoeuvre. Feasibility end points were achieved in all study patients. This report documents the safety and feasibility of right atrial exposure using a suction-based cardiac positioner to complete ablation for AF concomitant with off-pump coronary revascularization. This technique may be widely adopted to create stable haemodynamic conditions and optimal visualization of the right pulmonary veins.

Mid-term outcomes of concomitant surgical ablation of atrial fibrillation in patients undergoing cardiac surgery for hypertrophic cardiomyopathy†.

Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and it is often poorly tolerated because of loss of atrial contraction and reduced filling time with rapid ventricular rates. Restoring sinus rhythm is of great clinical benefit to HCM patients. Very few data exist regarding surgical ablation of concomitant AF in this setting. The aim of this study was to evaluate the mid-term outcome of surgical AF ablation in patients who underwent cardiac surgery due to HCM. Thirty-one consecutive patients with primary HCM and drug-refractory symptomatic AF underwent surgical ablation with concomitant septal myectomy (77%) and/or mitral valve repair/replacement (39%). Follow-up was 97% complete with a median of 6.4 years [3.8-9.1]. Hospital mortality was 6% and the overall survival at 7 years was 87 ± 6.1%. No stroke and thromboembolic events were documented at follow-up. The arrhythmia-free survival off antiarrhythmic drugs was 82 ± 7.3% at 1 year and 52 ± 10.2% at 6 years. The 1- and 6-year arrhythmia control (maintenance of sinus rhythm with or without antiarrhythmic drugs) was 96 ± 3.5 and 80 ± 8.1%, respectively. The recurrent arrhythmia was AF in all patients. No predictors of AF recurrence were detected. Concomitant surgical ablation of AF is a reasonable treatment option for drug refractory AF in patients with HCM undergoing surgical myectomy and/or mitral valve surgery. However, chronic antiarrhythmic drugs are needed to achieve a satisfactory mid-term arrhythmia control.

Surgical Ablation for Atrial Fibrillation: Predictors for Long-Term Success

Surgical Ablation for Atrial Fibrillation: Predictors for Long-Term Success

Predictors of Long-term Success After Concomitant Surgical Ablation for Atrial Fibrillation

According to guidelines, atrial fibrillation (AF) ablation success should be measured by 24-hour Holter electrocardiogram (ECG). However, information on long-term success, especially obtained by 24-hour Holter ECG, is rare. We therefore analyzed rhythm course and long-term outcomes of our patients undergoing concomitant surgical AF ablation. Between January 2003 and April 2011, 486 patients underwent concomitant surgical AF ablation in our institution. Patients with 24-hour Holter ECG rhythm status available between 5 and 10 years postoperatively were included in this retrospective data analysis (n = 155). Ablation lesions were limited to either a pulmonary vein isolation (n = 31, 20%), a more complex left atrial lesion set (n = 89, 57%), or biatrial lesions (n = 35, 23%). Primary end point of the study was freedom from AF during long-term follow-up. Mean patient age was 68.1 ± 8.4 years; 57.4% were male. Mean follow-up time was 5.9 years. Surgical AF ablation provided freedom from AF rate of 56.6% during long-term follow-up, with significantly better results in patients with paroxysmal than in those with persistent AF (67.2% vs 51.8% P = 0.03). A stable rhythm course was observed during follow-up, without statistically significant differences between 12 months and latest follow-up (63.2% vs 56.6%; P = 0.25). In multivariate analysis, preoperative paroxysmal AF, duration of AF, and left atrial diameter were predictors of long-term ablation success. Surgical AF ablation provided freedom from AF rate of 56.6% during long-term follow-up. Statistically significant predictors of ablation success at latest follow-up were preoperative paroxysmal AF, duration of AF, and a preoperative smaller left atrial diameter.

Электрофизиологические особенности левопредсердных аритмий после хирургической аблации фибрилляции предсердий

Электрофизиологические особенности левопредсердных аритмий после хирургической аблации фибрилляции предсердий

Surgical Ablation of Atrial Fibrillation During Mitral Valve Surgery: A Systematic Review of the Literature

Surgical Ablation of Atrial Fibrillation During Mitral Valve Surgery: A Systematic Review of the Literature

Left Atrial Ganglionated Plexi Detection is Related to Heart Rate and Early Recurrence of Atrial Fibrillation after Surgical Ablation.

IntroductionLeft atrial ganglionated plexi ablation is an adjuvant technique used to increase the success rate of surgical ablation of atrial fibrillation. Ganglionated plexi ablation requires previous detection. We aimed to assess determinants of successful ganglionated plexi detection and to correlate range of ganglionated plexi ablation with risk of early atrial fibrillation recurrence.MethodsThe study involved 34 consecutive patients referred for surgical coronary revascularization with concomitant atrial fibrillation ablation. Ganglionated plexi detection was done by inducing vagal reflexes in the area of the pulmonary veins and left atrial fat pads.ResultsDetection of GP was successful in 85% of the patients. There was no difference in preoperative characteristics nor in atrial fibrillation type between patients in whom ganglionated plexi detection was successful and others. The number of detected ganglionated plexi correlated significantly only with preoperative resting heart rate. Significant negative correlation was found in patients with preoperative heart rate>75 beat/min in terms of total number of detected ganglionated plexi (P=0.04). Average number of detected ganglionated plexi was significantly higher in patients with in-hospital atrial fibrillation recurrence requiring electrical cardioversion (3.8±3) in comparison to rest of the study population (2±1.3; P=0.02). In patients in whom 4 or more ganglionated plexi were detected, significantly increased risk of in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI 1.5-164; P=0.003).ConclusionLeft atrial ganglionated plexi detection was unsuccessful in a considerable percentage of patients. Preoperative heart rate significantly influenced positive ganglionated plexi detection and number of ablated ganglia. Higher number of detected ganglionated plexi was related with early recurrence of atrial fibrillation.

Mid-Term Performance of Bipolar Radiofrequency Ablation for Isolated Atrial Fibrillation Through a Right Minithoracotomy

Catheter ablation is considered the first-line treatment for drug-refractory atrial fibrillation (AF). Minimally invasive epicardial pulmonary veins isolation may provide durable freedom from recurrent arrhythmia. However, evidence come from small studies. Aim of this study is to assess early- and mid-term performance of surgical bipolar ablation of AF through right minithoracotomy in a large cohort of patients. From September 2012 till September 2015, 126 consecutive patients with drug-refractory isolated AF, equally suitable for both surgical or catheter ablation, underwent bipolar minimally invasive surgical isolation of the pulmonary veins through right 3- to 4-cm minithoracotomy at our institution, and they were followed up for a median of 23.5 months (interquartile range = 20). There was a relatively low rate of postoperative complication with no perioperative death. One patient died at follow-up. The shape of the time-varying probability of AF was calculated, with 3 peaks approximately 6, 12, and 24 months after procedures. Three patients were lost at last follow-up; thus, it was 97.6% completed. Overall freedom from recurrent arrhythmia was 78.8%. However, freedom from antiarrhythmic drugs was very low because of gap in medication management. Quantitative but not qualitative measure of health outcome significantly improved at follow-up (P < 0.001). Bipolar radiofrequency ablation via right minithoracotomy was a safe procedure with acceptable early outcomes; however, mid-term results should be interpreted in a context of a very low freedom from antiarrhythmic drugs.

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

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

The Society of Thoracic Surgeons Mitral Valve Repair/Replacement Plus Coronary Artery Bypass Grafting Composite Score: A Report of The Society of Thoracic Surgeons Quality Measurement Task Force

The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed a composite performance measure for mitral repair/replacement (MVRR) with concomitant coronary artery bypass grafting (CABG). Data were acquired from the STS Adult Cardiac Surgery Database for 26,463 patients undergoing MVRR+ CABG operations between July 1, 2011, and June 30, 2014. Established STS risk models were applied, along with modifications enabling the inclusion of patients with concomitant closures of atrial septal defects and patent foramen ovale, surgical ablation for atrial fibrillation, and tricuspid valve repair (TVR). Participants with fewer than 10 eligible cases over 3 years were excluded. The MVRR+ CABG composite consisted of two domains: risk-adjusted mortality and the any-or-none occurrence of major morbidity (prolonged ventilation, deep sternal infection, permanent stroke, renal failure, and reoperation). Composite performance scores were calculated with the use of hierarchic regression models, and high-performing and low-performing outliers were determined with the use of 95% Bayesian credible intervals. There were 24,740 patients at 703 participant sites after exclusions. Two percent (14/703) of programs were classified as 1-star (lower than expected performance), 95% (666/703) were classified as 2-star (as-expected performance), and 3% (23/703) were classified as 3-star (higher than expected performance). The average unadjusted operative mortality was 6.2% (1,532/24,740), and a monotonic decline in both mortality and morbidity was observed as star rating scores increased. An STS composite performance measure was developed for MVRR+ CABG operations. This measure may be useful for outcome assessment, quality improvement, patient counseling, clinical research, and public reporting.

Impact of Surgical Ablation of Atrial Fibrillation on the Progression of Tricuspid Regurgitation and Right-Sided Heart Remodeling After Mitral-Valve Surgery: A Propensity-Score Matching Analysis.

BackgroundThis study assessed the role of surgical ablation for atrial fibrillation (AF) in decreasing tricuspid regurgitation (TR) and right‐sided heart remodeling in patients after mitral valve procedure.Methods and ResultsBetween 1994 and 2014, 1568 consecutive patients with AF undergoing mitral valve procedure were identified. In 26.0% (n=408), surgical ablation of AF was used. Propensity‐score matching (PSM) was performed on the basis of 41 known perioperative risk variables. Survival, reoperation, stroke, and moderate‐to‐severe TR, as well as echocardiography indices in long‐term follow‐up, were compared in 406 matched patient pairs (ablated and nonablated groups). The nonablated group showed significantly higher risks of death (hazard ratio [HR], 1.644; 95% CI, 1.081–2.501; P=0.020), reoperation (HR, 2.644; 95% CI, 1.299–5.466; P=0.008), and moderate‐to‐severe TR (HR, 1.436; 95% CI, 1.059–1.948; P=0.020), associated with a significantly deteriorated cardiac function, progression of TR, and right‐sided heart remodeling after 5‐year follow‐up. In a subgroup comparison of ablated patients with sinus rhythm versus AF recurrence, a PSM analysis was performed at the 5‐year follow‐up. The recurrent group showed significantly higher risks of moderate‐to‐severe TR (HR, 2.427; 95% CI, 1.261–4.671; P=0.008). AF recurrence was associated with progressive TR and significant deterioration in right‐sided heart remodeling.ConclusionsIn a retrospective PSM analysis, mitral valve disease with AF was associated with TR progression as well as right‐sided heart remodeling, which are alleviated by surgical ablation.

Joint European Atrial Fibrillation Guidelines Break New Ground

Joint European Atrial Fibrillation Guidelines Break New Ground