Surgical Ablation Of Atrial Fibrillation Research Articles

Biochemical response to cryothermal and radiofrequency exposure of the human myocardium at surgical ablation of atrial fibrillation: a randomized controlled trial

BackgroundSurgical cryothermia and radiofrequency (RF) ablations for atrial fibrillation (AF) seem to result in similar sinus rhythm restoration, but the biochemical consequences of the two methods are unclear. We aimed to compare the biochemical responses to the two ablative methods in concomitant mitral valve surgery (MVS).MethodsSixty mitral valve surgery patients with AF were prospectively included. Forty-one patients planned for ablation were randomized to cryothermia (n = 20) or radiofrequency (n = 21) ablation and 19 served as controls. Markers for myocardial injury, inflammation, cell stress, apoptosis, and heart failure were analyzed pre- and postoperatively at different time points.ResultsTroponin T and creatine kinase isoenzyme MB (CK-MB) peak levels were significantly higher in the cryothermia group compared with the RF group (12,805 [6140–15,700] vs. 2790 [1880–4180] ng/L; P = 0.002 and 271 [217–357] vs. 79 [66–93] μg/L; P < 0.001, respectively). Both groups had significantly higher levels than the no-ablation group. There were no group differences in C-reactive protein (CRP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), but there were correlations between pre- and postoperative levels of both CRP (rs = 0.41, P = 0.001) and NT-proBNP (rs = 0.48, P < 0.001). Protease-activated receptor 1 (PAR-1) and heat shock protein 27 (HSP27) were significantly increased in the cryoablation group.ConclusionsCryoablation results in a larger myocardial injury and possibly more elevated apoptotic activity and cell stress compared with the RF technique. The type of ablation device did not have any significant influence on the postoperative inflammatory response nor on the early postoperative levels of NT-proBNP.Trial registrationDOI:https://doi.org/10.1186/ISRCTN14454361. Registered 16 November 2014 – Retrospectively registered, http://www.isrctn.com/ISRCTN14454361

Comparison of catheter and surgical ablation of atrial fibrillation: A systemic review and meta-analysis of randomized trials

ObjectiveTo compare both the beneficial and adverse effects of catheter ablation (CA) and surgical ablation (SA) on patients with atrial fibrillation (AF). MethodsWe searched MEDLINE and 4 additional databases for randomized controlled trials that compared CA with SA. Following data extraction, we conducted a meta-analysis to estimate the efficacy and safety of CA relative to SA. The primary end point of this study was the absence of AF during a 12-month follow-up period without the use of antiarrhythmic drugs. ResultsSeven trials comparing SA with CA met the inclusion criteria for efficacy outcome assessments. Following the meta-analysis, we obtained a summary odds ratio (OR) of achieving success 1 year after CA relative to SA was 0.37:1 (95% confidence interval [CI], 0.20-0.69). The result was robust in the subgroup analysis. CA was associated with a greater incidence of femoral vascular complications (OR, 5.81; 95% CI, 1.03-32.71), but a lower incidence of pneumothorax (OR, 0.09; 95% CI, 0.01-0.74) than SA. Statistically significant differences in the other safety outcomes were not observed between CA and SA. ConclusionsSA confers a moderate advantage over CA in 1-year efficacy outcomes and may be safely performed by experienced surgeons.

Exclusion versus preservation of the left atrial appendage in rheumatic mitral valve surgery

ObjectivesThis study aimed to evaluate the impact of left atrial appendage exclusion on clinical outcomes in patients with atrial fibrillation (AF) undergoing rheumatic mitral surgery.MethodsWe retrospectively reviewed 1226 consecutive patients...

The long-term outcomes and durability of the Cox-Maze IV procedure for atrial fibrillation

ObjectiveSurgical ablation of atrial fibrillation (AF) is indicated both in patients with AF undergoing concomitant cardiac surgery and in those who have not responded to medical and/or catheter-based ablation therapy. This study examined our long-term outcomes following the Cox-Maze IV procedure (CMP-IV). MethodsBetween May 2003 and March 2018, 853 patients underwent either biatrial CMP-IV (n = 765) or a left-sided CMP-IV (n = 88) lesion set with complete isolation of the posterior left atrium. Freedom from atrial tachyarrhythmia (ATA) was assessed for up to 10 years. Rhythm outcomes were compared in multiple subgroups. Predictors of recurrence were determined using Fine–Gray regression, allowing for death as the competing risk. ResultsThe majority of patients (513/853, 60%) had nonparoxysmal AF. Twenty-four percent of patients (201/853) had not responded to at least 1 catheter-based ablation. Prolonged monitoring was used in 76% (647/853) of patients during their follow-up. Freedom from ATA was 92% (552/598), 84% (213/253), and 77% (67/87) at 1, 5, and 10 years, respectively. By competing risk analysis, incidence of first ATA recurrence was 11%, 23%, and 35% at 1, 5, and 10 years, respectively. On Fine–Gray regression, age, peripheral vascular disease, nonparoxysmal AF, left atrial size, early postoperative ATAs, and absence of sinus rhythm at discharge were the predictors of first ATA recurrence over 10 years of follow-up. ConclusionsThe CMP-IV had an excellent long-term efficacy at maintaining sinus rhythm. At late follow-up, the results of the CMP-IV remained superior to those reported for catheter ablation and other forms of surgical ablation for AF. Age, left atrial size, and nonparoxysmal AF were the most relevant predictors of late recurrence.

Long-Term Survival Following Surgical Ablation for Atrial Fibrillation Concomitant to Isolated and Combined Coronary Artery Bypass Surgery-Analysis from the Polish National Registry of Cardiac Surgery Procedures (KROK).

The current investigation aimed to evaluate long-term survival in patients undergoing isolated and combined coronary artery bypass grafting (CABG) with concomitant surgical ablation for atrial fibrillation (AF). Procedural data from KROK (Polish National Registry of Cardiac Surgery Procedures) were retrospectively collected. Eleven thousand three hundred sixteen patients with baseline AF (72.4% men, mean age 69.6 ± 7.9) undergoing isolated and combined CABG surgery between 2006–2019 in 37 reference centers across Poland and included in the registry were analyzed. The median follow-up was four years (3.7 IQR 1.3–6.8). Over a 12-year study period, there was a significant survival benefit (Hazard Ratio (HR) 0.83; (95% Confidence Interval (CI): 0.73–0.95); p = 0.005) with concomitant ablation as compared to no concomitant ablation. After rigorous propensity matching (LOGIT model, 432 pairs), concomitant surgical ablation was associated with over 25% improved survival in the overall analysis: HR 0.74; (95% CIs: 0.56–0.98); p = 0.036. The benefit of concomitant ablation was maintained in the subgroups, yet the most benefit was appraised in low-risk patients (EuroSCORE < 2, p = 0.003) with the three-vessel disease (p < 0.001) and without other comorbidities. Ablation was further associated with significantly improved survival in patients undergoing CABG with mitral valve surgery (HR 0.62; (95% CIs: 0.52–0.74); p < 0.001) and in patients in whom complete revascularization was not achieved: HR 0.43; (95% CIs: 0.24–0.79); p = 0.006.

CPAP Effects on Oxygen Delivery in One-Lung Ventilation During Minimally Invasive Surgical Ablation for Atrial Fibrillation in The Supine Position

In minimally invasive surgical ablation for atrial fibrillation during video-assisted thoracoscopy surgery, one-lung ventilation (OLV) with a double- lumen tube is commonly employed. In contrast with the majority of thoracic procedures, the patient lies supine; thus, the protective effect of gravity is lost and intrapulmonary shunt remains high. To decrease intrapulmonary shunt and to increase oxygenation, many strategies are utilized: high inspiratory fraction of oxygen (FIO2), positive end-expiratory pressure on the ventilated lung, and continuous positive airway pressure (CPAP) on the deflated lung. The authors performed a prospective, single- center, randomized study to evaluate the effect of additional CPAP in the nonventilated lung on oxygen delivery during surgical ablation for atrial fibrillation via video-assisted thoracoscopy in the supine position. University hospital Centro Cardiologico Monzino IRCCS, Milano, Italy. Twenty-two patients scheduled for minimally invasive surgical ablation for atrial fibrillation. The patients underwent pressure-controlled ventilation, adjusting inspiratory pressure to obtain a tidal volume of 7 mL/kg while keeping FIO2 constantly 1.0, a respiratory rate to maintain arterial partial pressure of carbon dioxide (PaCO2) between 35 and 40 mmHg, and positive end-expiratory pressure of 5 cmH2O. During OLV, inspiratory pressure was reduced to obtain a tidal volume of 5 mL/kg, maintaining FIO2 of 1.0, a respiratory rate to maintain PaCO2 between 35 and 40 mmHg with capnothorax of 10 cmH2O. The patients were then randomized into the CPAP group (CPAP 10 cmH20 on deflated lung) and NO CPAP group. Inotropic agents (dopamine or dobutamine) were used if cardiac index fell below 1.5 L/min/m2. Twenty-two patients were enrolled, randomized, and completed the study. Median age was 62 years. The difference in arterial partial pressure of oxygen between the 2 groups was shy of significance, p = 0.16. Cardiac index progressively increased during OLV until the end of the procedure in both groups (p < 0.01) and was maintained above 1.5 mL/min/m2 during the whole study time. Arterial oxygen content remained stable during the entire procedure in both groups (p = 0.27). Oxygen delivery index (DO2I) increased significantly during the procedure (p < 0.01); nevertheless, the difference in DO2I between the CPAP and NO CPAP group was nonsignificant (p = 0.61). Intrapulmonary shunt (Qs/Qt) increased during OLV (p < 0.01 for the time effect) and remained high until total lung ventilation was reintroduced. No difference in Qs/Qt was observed between the CPAP and NO CPAP groups (p = 0.98). Similarly, mean pulmonary artery pressure increased significantly during OLV and remained high at the end of the procedure in both groups (time effect p < 0.01). During OLV for atrial fibrillation surgical ablation in the supine position, CPAP on the deflated lung seemed to be ineffective to reduce Qs/Qt or to increase arterial partial pressure of oxygen and DO2I, provided cardiac output was maintained above 1.5 L/min/m2.

Impact of age on atrial fibrillation recurrence following surgical ablation

ObjectivesThe incidence of atrial fibrillation (AF) in patients older than 75 years of age is expected to increase, and its treatment remains challenging. This study evaluated the impact of age on the outcomes of surgical ablation of AF. MethodsA retrospective review was performed of patients who underwent the Cox-maze IV procedure at a single institution between 2005 and 2017. The patients were divided into a younger (age <75 years, n = 548) and an elderly cohort (age ≥75 years, n = 148). Rhythm outcomes were assessed at 1 year and annually thereafter. Predictors of first atrial tachyarrhythmia (ATA) recurrence were determined using Fine–Gray regression, allowing for death as the competing risk. ResultsThe mean age of the elderly group was 78.5 ± 2.8 years. The majority of patients (423/696, 61%) had nonparoxysmal AF. The elderly patients had a lower body mass index (P < .001) and greater rates of hypertension (P = .011), previous myocardial infarction (P = .017), heart failure (P < .001), and preoperative pacemaker (P = .008). Postoperatively, the elderly group had a greater rate of overall major complications (23% vs 14%, P = .017) and 30-day mortality (6% vs 2%, P = .026). The percent freedom from ATAs and antiarrhythmic drugs was lower in the elderly patients at 3 (69% vs 82%, P = .030) and 4 years (65% vs 79%, P = .043). By competing risk analysis, the incidence of first ATA recurrence was greater in elderly patients (33% vs 20% at 5 years; Gray test, P = .005). On Fine–Gray regression adjusted for clinically relevant covariates, increasing age was identified as a predictor of ATAs recurrence (subdistribution hazard ratio, 1.03; 95% confidence interval, 1.02-1.05, P < .001). ConclusionsThe efficacy of the Cox-maze IV procedure was worse in elderly patients; however, the majority of patients remained free of ATAs at 5 years. The lower success rate in these greater-risk patients should be considered when deciding to perform surgical ablation.

Clinical course of sinus node dysfunction after thoracoscopic surgery for atrial fibrillation\u2014analysis of the Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery (AFACT) study

PurposeSinus node dysfunction (SND) may complicate thoracoscopic surgical atrial fibrillation (AF) ablation. Identifying patients at risk is important, as SND may require temporary or permanent pacing. To determine the incidence of postoperative SND and duration of symptoms in patients who underwent thoracoscopic surgical ablation.MethodsPatients with paroxysmal or persistent AF included in the Atrial Fibrillation Ablation and Autonomic Modulation via Thoracoscopic Surgery (AFACT) study underwent pulmonary vein isolation and additional left atrial ablations on indication. Patients were randomized to ganglion plexus ablation or control. SND was defined as symptomatic or asymptomatic junctional rhythm exceeding sinus rate within 30 days postoperatively. The SND risk was assessed by using a univariable logistic regression model. The rate of pacemaker implantation was determined.ResultsThe AFACT study included 240 patients. SND developed in 17 (7.1%) patients, not affected by randomized treatment, p = 0.18. SND patients more often had persistent AF (88.2%) than patients without SND (57.4%), p = 0.01. After univariable testing, persistent AF (OR 5.57 CI 1.52–35.90, p = 0.02) and additional left atrial ablations (OR 12.10 CI 2.40–220.20, p = 0.02) were associated with postoperative SND. Six (35.3%) patients needed temporary pacing for 1–7 days; permanent pacemakers (PMs) were implanted for SND in five (29.4%) patients.ConclusionAdditional left atrial ablations strongly increase the SND risk. The majority of SND was temporary, and sinus rhythm resolved within days, which indicates that a conservative approach with regard to pacemaker implantation should be considered.

Concomitant atrial fibrillation ablation in patients undergoing coronary artery bypass and cardiac valve surgery.

Surgical ablation of atrial fibrillation (AF) in conjunction with other cardiac surgery is now a class I guideline recommendation. Multiple studies have demonstrated that the concomitant surgical ablation of AF can be performed safely and effectively during valve and coronary artery bypass grafting (CABG) resulting in a return to sinus rhythm postoperatively and improved long-term results. However, the surgical ablation of AF at the time of other cardiac surgery is performed less often than it should be, especially in patients undergoing CABG and aortic valve surgery. Randomized-controlled trials designed to determine the effect of treating AF concomitantly with other cardiac surgical procedures have lacked long-term follow up, but multiple, large observational studies have demonstrated an improved quality of life, a decrease in long-term strokes, and improved late survival in patients who undergo AF ablation. However, the potential survival benefit of concomitant AF ablation was not addressed by either the Society of Thoracic Surgery or American Association for Thoracic Surgery guideline committees. Left atrial appendage closure is an important part of the surgical ablation of AF as it significantly reduces the long-term risk of stroke following cardiac surgery and improves the success of AF treatment. In this study, we update the electrophysiology and surgical community on the recommended surgical techniques for AF ablation and its effect on perioperative morbidity, perioperative mortality, as well as its long-term effects on stroke, quality of life, and survival.

Unilateral Left-sided Thoracoscopic Ablation of Atrial Fibrillation

Thoracoscopic surgical ablation has evolved into a valid and effective treatment option, especially in patients with more persistent forms of atrial fibrillation. A significant part of this development is due to the capability of biparietal bipolar radiofrequency clamps to create long-lasting transmural lesions. To date, all commercially available bipolar clamps require a bilateral thoracoscopic approach. Here, we describe the surgical technique of a unilateral left-sided thoracoscopic approach for surgical atrial fibrillation ablation on the beating heart.

The influence of epicardial and endocardial use of cryoenergy on the completeness of lesions in surgical ablation of atrial fibrillation.

IntroductionCryoenergy is the most commonly used method of lesion formation in patients who have undergone surgical ablation of atrial fibrillation. Despite frequent use, the clinical effect of cryoenergy in endocardial and epicardial approaches is unknown.AimTo compare the effect of various cryoenergy applications on the postoperative incidence of sinus rhythm and completeness of lesions performed.Material and methodsA total of 55 patients underwent concomitant atrial fibrillation surgical ablation using cryoenergy under various conditions: epicardially during cardiac arrest, epicardially on beating heart, and endocardially. In the postoperative period, patients were invited to attend an electrophysiological examination to assess the completeness of surgical ablation lesions and, if necessary, to complete catheter ablation.ResultsTwenty-four patients underwent epicardial ablation on the arrested heart (group 1), 12 patients underwent epicardial ablation on the beating heart (group 2), and 19 patients underwent endocardial ablation (group 3). In the electrophysiological examination, sinus rhythm was present in 71% vs. 83% vs. 89% of patients, respectively. The completeness of pulmonary vein isolation was confirmed in 31% vs. 25% vs. 95% of patients, complete box lesions in 15% vs. 0% vs. 79% of patients, respectively.ConclusionsDespite the similar clinical effect of surgical ablation in all three approaches, the morphologically most effective use of cryoenergy is endocardial ablation. This approach has a very good result. Our findings further support the endocardial use of cryoenergy during surgical ablation of atrial fibrillation.

Totally thoracoscopic surgical versus hybrid ablation of stand alone atrial fibrillation

Minimally invasive surgical treatment of lone atrial fibrillation (AF) is indicated in patient at risk of recurrence after catheter ablation of AF. We compared a surgical bilateral thoracoscopic ablation of AF with a hybrid surgical and endocavitary approach. Beteween January 2016 and November 2017, 10 patients underwent a bilateral thoracoscopic AF surgical ablation with the Atricure system (Group I). Ablation started with a right thoracoscopic approach, including right pulmonary vein isolation with a bipolar radiofrequency clamp (Sinergy Clamp, Fig. 1 a) and left atrium (LA) floor and roof isolation with a bipolar unidirectional catheter (CoolRail, Fig. 1 b). After creating the same pattern of lesions on left side, the left atrial appendage (LAA) was excluded with a clip (Atriclip Pro, Fig. 1 c). Between March 2018 and April 2019, 11 patients underwent a hybrid ablation of AF (Group II). Ablation started with a left thoracoscopic approach, including left pulmonary vein isolation, LA roof and floor lesion and LAA exclusion. Afterwards, an endocavitary mapping was realized with the Ensite Precision System and HD Grid catheter (St Jude), to check the surgical lesion set. Right pulmonary vein isolation and box completion ( Fig. 1 d) were realized with a Tacticath unipolar radiofrequency catheter. Preoperative characteristics of both groups are resumed in Table 1 . There were no postoperative major complications. Postoperative results are resumed in Table 1 . Mean follow-up was 12 months in Group I and 4 months in Group II. Seven patients in Group I vs. all patients of Group II were free from AF. Eight patients in Group I and 6 patients in Group II were under anticoagulant treatment with VKA or NOACS. Three patients in each group were under anti-arrhythmic drugs. Hybrid AF ablation seems to be more effective than an isolated surgical ablation. A longer follow-up is mandatory to confirm these results in the long-term.

Early complications in patients undergoing mitral valve replacement surgery: An observational study

Background: Rheumatic fever(RF) & Rheumatic Heart disease(RHD) present a problem in all parts of the world especially in developing countries. In India RHD accounts for 12%-65% hospital admissions related to cardiovascular disease. It is the most common cause of Mitral valve disease with associated morbidity and mortality. Mitral valve replacement (MVR) is the surgical treatment when conservative approach fails.Mitral stenosis(MS), Mitral regurgitation (MR) or both MS+MR are main indications for MVR. Material and Method: Despite a rise in the rate of success of total valve replacement, the procedure has been associated with complications inherent to prosthesis as well as to any intra cardiac procedure. Majority of authors have defined complications occuring within thirty days in post operative period as early complications. Observations and Results: In this observational study of 85 patients at a rural cardiac surgery center, who underwent MVR for Mitral valve disease with concomittant Maze-III procedure(modified) for the surgical ablation of Atrialfibrillation (AF) if present, the early complications observed were General complications( AF, Post operative excessive bleeding, haemolysis,Neurological-psychiatric-Thromboembolic complications, wound infection,respiratory complications, Renal complications,prolonged inotropic support& Mechanical ventillation, Prolonged hospital stay & early mortality and Prosthesis specific complications of Paravulvular regugitation( PVR), Obstruction to valve by thrombus,valve endocarditis. Conclusion: AF was the most common post operative complication observed in 24.7% patients,Acute delirium(psychosis) was seen in 21.17% patients,prolonged hospital stay(more than 10 days) was observed in 17.7% of patients, prolonged inotropic support was needed in 12.9% patients, pulmonary complications were observed in 10.5% patients. The rate for other isolated complications was less than 10% each. Overall mortality rate was 1.17%. Prosthetic Valve related complicaio.

Simultaneous Surgical Ablation of Atrial Fibrillation with Cardiac Surgery: A Review

Simultaneous Surgical Ablation of Atrial Fibrillation with Cardiac Surgery: A Review

Should concomitant surgical ablation for atrial fibrillation be performed in elderly patients?

ObjectiveThe incidence of atrial fibrillation increases with age, and therefore many elderly patients presenting for cardiac surgery have atrial fibrillation. In recent publications, increasing age has been recognized as a predictor for ablation failure. Furthermore, many surgeons are reluctant to perform a surgical ablation in elderly patients. We investigated the safety and efficacy of concomitant surgical atrial fibrillation ablation in elderly patients. MethodsBetween 2003 and 2013, 556 patients underwent concomitant surgical atrial fibrillation ablation at the University Heart Center Hamburg and served as our primary study cohort. During follow-up, rhythm monitoring was established by 24-hour Holter electrocardiogram (70.5%) or an implantable loop recorder (29.5%) at 3, 6, and 12 months postoperatively. The primary end point of the study was freedom from atrial fibrillation at 12 months follow-up and the detection of deviations from a linear association between age and risk of atrial fibrillation recurrence. A multiple logistic regression model including age as a linear term was used to identify predictors for rhythm outcome. ResultsMean patients’ age was 68.4 ± 9.07 years, and 67.3% of the patients were male. Mean duration of atrial fibrillation was 3.5 ± 3.3 years, and mean left atrium diameters were enlarged with 50.5 ± 8.8 mm. There were no major ablation-related complications. The 30-day and 1-year survivals were 97.7% and 95.8%, respectively. The overall rate of freedom from atrial fibrillation ranged from 62% to 72% and was independent of age. The age-dependent risk of atrial fibrillation at 12 months was significantly increased in elderly patients undergoing a concomitant coronary artery bypass grafting surgery. Multiple logistic regression model revealed double valve procedures (odds ratio, 3.48; P = .020), preoperative persistent atrial fibrillation (odds ratio, 2.43; P = .001), and coronary artery bypass grafting surgery in elderly patients (odds ratio, 2.03; P = .009) as risk factors for recurrence of atrial fibrillation. Sinus rhythm at discharge (odds ratio, 0.39; P < .001) and bipolar ablation (odds ratio, 0.32; P < .001) were significant predictors for successful ablation. ConclusionsSurgical atrial fibrillation ablation was safe and effective independently of age. Sinus rhythm at discharge and bipolar ablation were significant predictors for successful ablation, whereas double valve procedures, preoperative persistent atrial fibrillation, and coronary artery bypass grafting surgery in elderly patients were risk factors for recurrence of atrial fibrillation.

Ablation of atrial fibrillation during coronary artery bypass grafting: Late outcomes in a Medicare population

BackgroundThis study compares outcomes of patients with preoperative atrial fibrillation undergoing coronary artery bypass grafting (CABG) with or without concomitant atrial fibrillation ablation in a nationally representative Medicare cohort. ObjectivesThis study examined early and late outcomes in CABG patients with a preoperative history of atrial fibrillation to determine the correlation between surgical atrial fibrillation ablation to mortality and stroke or systemic embolization. MethodsIn the Medicare-linked Society of Thoracic Surgeons database, 361,138 patients underwent isolated CABG from 2006 to 2013; 34,600 (9.6%) had preoperative atrial fibrillation; 10,541 (30.5%) were treated with surgical ablation (ablation group), and 23,059 were not (no ablation group). Propensity score matching was performed using a hierarchical mixed model. Long-term survival was summarized using Kaplan-Meier curves and Cox regression models with robust variance estimation. The stroke or systemic embolization incidence was modeled using the Fine-Gray model. Median follow-up was 4 years. ResultsLong-term mortality in propensity score-matched CABG patients (mean age 74 years; Society of Thoracic Surgeons risk score, 2.25) receiving ablation versus no ablation was similar (log-rank P = .30). Stroke or systemic embolization occurred in 2.2% versus 2.1% at 30 days and 9.9% versus 12.0% at 5 years (Gray P = .0091). Landmark analysis from 2 to 5 years showed lower mortality (hazard ratio, 0.89; 95% confidence interval 0.82-0.97; P = .0358) and lower risk of stroke or systemic embolization (hazard ratio, 0.73; 95% confidence interval, 0.61-0.87; P = .0006) in the ablation group. ConclusionsConcomitant ablation in CABG patients with preoperative atrial fibrillation is associated with lower stroke or systemic embolization and mortality in patients who survive more than 2 years.

Different effects of additional ganglion plexus ablation on catheter and surgical ablation for atrial fibrillation: a systemic review and meta-analysis.

The effect of ganglion plexus (GP) ablation in addition to pulmonary veins isolation (PVI) for atrial fibrillation (AF) remained controversial between the catheter and surgical-based studies. Eleven studies (five randomized controlled trials and six nonrandomized studies) of 1750 patients were included in a meta-analysis to elucidate the incremental benefit of additional GP ablation in patients undergoing catheter or surgical ablation. Risk ratios were calculated for freedom from AF or AT recurrence after a single procedure. Additional GP ablation was associated with a better rhythm outcome for patients undergone catheter ablation but did not seem to increase freedom from AF/AT for surgical patients. Both paroxysmal and non-paroxysmal AF showed a positive outcome comparing additional GP ablation with PVI alone.

Surgical ablation for atrial fibrillation during isolated coronary artery bypass surgery.

Our goal was to evaluate early sequelae and long-term survival in patients undergoing isolated coronary artery bypass grafting (CABG) with concomitant surgical ablation for atrial fibrillation (AF). Procedural data from KROK (Polish National Registry of Cardiac Surgery Procedures) were collected. A total of 7879 patients with underlying AF underwent isolated CABG between 2006 and 2018 in 37 reference centres across Poland. The mean follow-up was 4.7 ± 3.5 years [median (interquartile range) 4.3 (1.7-7.4)]. Propensity score matching and Cox proportional hazards models were used to compare isolated CABG + ablation with isolated CABG. Of the included patients, 346 (4.39%) underwent surgical ablation. Patients in this group were significantly younger (66.4 ± 7.5 vs 69.2 ± 8.2; P < 0.001) but had a non-significant, different baseline surgical risk (EuroSCORE: 2.11 vs 2.50; P = 0.088). After a rigorous 1:3 propensity matching (LOGIT model: 306 cases of isolated CABG + ablation vs 918 of isolated CABG alone), surgical ablation was associated with a lower 30-day risk of death [risk ratio 0.37, 95% confidence interval (CI) 0.15-0.91; P = 0.032] and multiorgan failure (risk ratio 0.29, 95% CI 0.10-0.94; P = 0.029). In the long term, surgical ablation was associated with a significant 33% improved overall survival rate: hazard ratio 0.67, 95% CI 0.49-0.90; P = 0.008. The benefit of ablation was sustained in the subgroups but was most pronounced in lower risk older patients (age >70 years, P = 0.020; elective status, P = 0.011) with 3-vessel disease (P = 0.036), history of a cerebrovascular accident (P = 0.018) and preserved left ventricular function [left ventricular ejection fraction >50%; P = 0.017; no signs of heart failure (per New York Heart Association functional class); P = 0.001] and those undergoing on-pump CABG (P < 0.001). Surgical ablation for AF in patients undergoing isolated CABG is safe and associated with significantly improved long-term survival.

Left Atrial Function after Atrial Fibrillation Cryoablation Concomitant to Minimally Invasive Mitral Valve Repair: A Pilot Study on Long-Term Results and Clinical Implications.

Background and Objectives: Surgical atrial fibrillation (AF) ablation concomitant to minimally invasive mitral valve repair has been proven to offer improved short- and long-term sinus rhythm (SR) maintenance compared to mitral valve surgery only. The objective of the present study was to explore, by thorough echocardiographic assessment, long-term morphological and functional left atrial (LA) outcomes after this combined surgical procedure. Materials and Methods: From October 2006 to November 2015, 48 patients underwent minimally invasive mitral valve repair and concomitant surgical AF cryoablation. Results: After 3.8 ± 2.2 years, 30 (71.4%) of those completing the follow-up (n = 42, 87.5%) presented SR. During follow-up, four (9.5%) patients suffered from cerebrovascular accidents and two of these subjects had a long-standing persistent AF relapse and were in AF at the time of the event, while the other two were in SR. An echocardiographic study focused on LA characteristics was performed in 29 patients (69.0%). Atrial morphology and function (e.g., maximal LA volume indexed to body surface area and total LA emptying fraction derived from volumes) in patients with stable SR (60.6 ± 13.1 mL/mq and 25.1 ± 7.3%) were significantly better than in those with AF relapses (76.8 ± 16.2 mL/mq and 17.5 ± 7.4%; respectively, p = 0.008 and p = 0.015). At follow-up, patients who suffered from ischemic cerebral events had maximal LA volume indexed to body surface area 61 ± 17.8 mL/mq, with total LA emptying fraction derived from volumes 23.6 ± 13.7%; patients with strokes in SR showed very enlarged LA volume (>70 mL/mq). Conclusions: AF cryoablation concomitant with minimally invasive mitral valve repair provides a high rate of SR maintenance and this relates to improved long-term morphological and functional LA outcomes. Further prospective studies are needed to define the cut-off values determining an increase in the risk for thromboembolic complications in patients with restored stable SR.

Approach to catheter ablation of left atrial flutters.

Left atrial tachycardias (ATs) most commonly occur after catheter or surgical ablation of atrial fibrillation and in patients with atrial myopathies. Pre-existing scar in the left atrium (LA) can result in complex circuits, sometimes with narrow channels that can be detected with high-resolution mapping. The most common forms of macroreentrant AT from the LA are variants of peri-mitral and roof-dependent reentry. Localized reentrant rhythms occur in the setting of fibrosis that gives rise to slow conduction and may occur adjacent to areas of prior ablation. The approach to treating these ATs involves first identifying the left atrial origin, defining the tachycardia circuit - which can be facilitated by ultrahigh density mapping and entrainment - and selecting a suitable isthmus to target for ablation. An important endpoint in ablating left atrial flutters is to establish and confirm bidirectional line of the block. Challenges in ablating these ATs include the presence of multiple tachycardias, defining circuits with complex activation patterns and achieving durable lines of block, particularly in the lateral mitral isthmus. Progress in treating these arrhythmias has come from new mapping technologies and the recognition of epicardial connections that allow for persistent conduction across ablation lesions. Also, advances in delivering energy to obtain complete transmural lesions promise to improve the long-term success of ablating ATs from the LA.