Surgical ablation for treatment of atrial fibrillation in cardiac surgery: a cumulative meta-analysis of randomised controlled trials

Efficacy of surgical ablation and left atrial appendage occlusion in patients with AF undergoing coronary artery bypass grafting: A network meta-analysis

BACKGROUND

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia that greatly elevates the risk of stroke. This risk increases both during and after cardiac procedures, such as coronary artery bypass grafting (CABG). There is an increasing interest in non-pharmacological treatments such as left atrial appendage occlusion (LAAO) and surgical ablation, intending to enhance both immediate and long-term postoperative results.

OBJECTIVE

To investigate the efficacy of surgical ablation (SA), LAAO, or both in patients with AF undergoing CABG.

METHODS

We searched four electronic databases: PubMed, Scopus, Cochrane Library, and WOS. We analyzed data using R language and "netmeta" and "netrank" packages of meta-insight software. Pooled outcomes were reported as mean difference or risk ratio (RR) with 95 % confidence interval (CI) in a random effect method.

RESULTS

A total of 16 studies were included with 594,312 patients included. The 30-day mortality showed a non-statistically significant difference between CABG-LAAO compared to CABG alone and CABG-SA with RR of 1.70 (95%CI 0.38-7.61) and 0.62 (95%CI 0.10-3.94). However, compared to CABG alone, CABG-SA + LAAO, CABG-LAAO, and CABG-SA had significantly lower risk of long-term mortality with RR 0.75 (95%CI 0.57-0.98), 0.78 (95%CI 0.65-0.94), and 0.73 (95%CI 0.61-0.88), respectively. CABG-SA + LAAO, CABG-LAAO, and CABG-SA reduced the risk of short-term stroke compared to CABG alone with RR of 0.73 (95%CI 0.43-1.24), 0.93 (95%CI 0.78-1.11), and 1.01 (95%CI 0.75-1.36), respectively. Moreover, only CABG-SA + LAAO and CABG-LAAO showed a statistically significant reduction in long term stroke and hospitalization due to heart failure while CABG-SA showed no statistically significant difference. Furthermore, there was no statistically significant difference between our interventions in terms of 30-day rehospitalization, intra-aortic balloon pump support, and risk of hemorrhage.

CONCLUSION

Among patients with AF undergoing CABG, whether undergoing SA alone or LAAO alone or both showed significant clinical outcomes such as reduced risk of both short- and long-term mortality and short-term stroke.

The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation

The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation incorporate the most recent evidence for surgical ablation and left atrial appendage occlusion in different clinical scenarios. Substantial new evidence regarding the risks and benefits of surgical left atrial appendage occlusion and the long-term benefits of surgical ablation has been produced in the last 5 years. Compared with the 2017 clinical practice guideline, the current update has an emphasis on surgical ablation in first-time, nonemergent cardiac surgery and its long-term benefits, an extension of the recommendation to perform surgical ablation in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery, and a new class I recommendation for left atrial appendage occlusion in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery. Further guidance is provided for patients with structural heart disease and atrial fibrillation being considered for transcatheter valve repair or replacement, as well as patients in need of isolated left atrial appendage management who are not candidates for surgical ablation. The importance of a multidisciplinary team assessment, treatment planning, and long-term follow-up are reiterated in this clinical practice guideline with a class I recommendation, along with the other recommendations from the 2017 guidelines that remained unchanged in their class of recommendation and level of evidence.

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

Atrial Tachycardia Masquerading as Atrial Fibrillation Following Bi-Atrial MAZE Procedure

A 34-year-old woman presented with palpitations and paroxysmal atrial fibrillation (AF). Workup revealed anterior mitral valve prolapse with severe mitral regurgitation. She was referred for surgical repair and underwent a mitral valve replacement, tricuspid valve repair, and bi-atrial cryoMAZE procedure with left atrial appendage ligation. Her postoperative course was complicated by inferior wall myocardial infarction. She subsequently presented with palpitations and underwent electrophysiology study and ablation. This case illustrates pitfalls associated with the surgical MAZE procedure and highlights the challenges in postoperative atrial arrhythmias diagnosis and management.

Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Left atrial strain predicts the rhythm outcome in patients with persistent atrial fibrillation undergoing left atrial cryoablation during minimally invasive mitral valve repair

Objectives

Patients with atrial fibrillation (AF) have lower left atrial (LA) strain, which is a predictor for LA function. Here, we evaluated the prognostic value of LA strain to predict the rhythm outcome in patients with persistent AF undergoing LA cryoablation concomitant to minimally invasive mitral valve repair.

Methods

Between 01/2016 and 12/2020, 72 patients with persistent AF underwent LA cryoablation during minimally invasive mitral valve surgery. All patients received a complete LA lesion set and left atrial appendage (LAA) closure with a clip. All patients received preoperative transthoracic echocardiography (TTE) with LA and left ventricular strain measurements. Preoperative LA and LV strain analysis was correlated with postoperative rhythm outcome.

Results

The mean age of the patients was 66.9 ± 7.2 years, of whom 42 (58%) were male patients. No major ablation-related complications occurred in any of the patients. Successful LAA closure was confirmed by intraoperative echocardiography in all patients. The 1-year survival rate was 97%. Freedom from AF at 12 months was 72% and 68% off antiarrhythmic drugs. Preoperative LA strain values were statistically significantly higher in patients with freedom from AF at 12 months of follow-up (12.7% ± 6.9% vs. 4.9% ± 4.1%, p = 0.006). Preoperative LV strain value was not associated with postoperative rhythm outcome. In multivariate logistic regression analysis, LA strain (p < 0.001) and AF duration (p = 0.017) were predictors for freedom from AF at 12 months of follow-up.

Conclusions

In our study, LA strain analysis predicted the rhythm outcome in patients with persistent AF undergoing concomitant surgical AF ablation. In the future, LA strain might be a useful tool to guide decision-making on ablation strategies in patients with persistent AF.

Surgical ablation, left atrial appendage occlusion or both? Nationwide registry analysis of cardiac surgery patients with underlying atrial fibrillation

OBJECTIVES

The aim of this study was to evaluate in-hospital outcomes and long-term survival of patients undergoing cardiac surgery with preoperative atrial fibrillation (AF). We compared different strategies, including no-AF treatment, left atrial appendage occlusion (LAAO) alone, concomitant surgical ablation (SA) alone or both.

METHODS

A retrospective analysis using the KROK registry included all patients with preoperative diagnosis of AF who underwent cardiac surgery in Poland between between January 2012 and December 2022. Risk adjustment was performed using regression analysis with inverse probability weighting of propensity scores. We assessed 6-year survival with Cox proportional hazards models. Sensitivity analysis was performed based on index cardiac procedure.

RESULTS

Initially, 42 510 patients with preoperative AF were identified, and, after exclusion, 33 949 included in the final analysis. A total of 1107 (3.26%) received both SA and LAAO, 1484 (4.37%) received LAAO alone, 3921 (11.55%) SA alone and the remaining 27 437 (80.82%) had no AF-directed treatment. As compared to no treatment, all strategies were associated with survival benefit over 6-year follow-up. A gradient of treatment was observed with the highest benefit associated with SA + LAAO followed by SA alone and LAAO alone (log-rank P < 0.001). Mortality benefits were reflected when stratified by surgery type with the exception of aortic valve surgery where LAAO alone fare worse than no treatment.

CONCLUSIONS

Among patients with preoperative AF undergoing cardiac surgery, surgical management of AF, particularly SA + LAAO, was associated with lower 6-year mortality. These findings support the benefits of incorporating SA and LAAO in the management of AF during cardiac surgery.

Complete Left-Atrial Lesion Set versus Pulmonary Vein Isolation Only in Patients with Paroxysmal AF Undergoing CABG or AVR

Background and Objectives: In patients with paroxysmal atrial fibrillation (AF) undergoing CABG or aortic valve surgery, many surgeons are not willing to open the left atrium to perform a complete left-sided Cox-Maze lesion set. Pulmonary vein isolation (PVI) is often favored in those patients. We investigated the outcome of patients with isolated pulmonary vein isolation compared to those receiving an extended left atrial (LA) lesion set. Materials and Methods: Between 2003 and 2016, 817 patients received concomitant surgical AF ablation in our institution. A total of 268 patients with paroxysmal AF were treated by surgical ablation concomitant to AVR or CABG. Of those, 86 patients underwent a complete left-sided lesion set, while 182 patients were treated with an isolated pulmonary vein isolation. The primary endpoint was freedom from atrial fibrillation at 12 months' follow-up. Results: There were no statistically significant differences regarding baseline characteristics. No major ablation-related complications were observed in any of the groups. In the PVI group, three patients (1.6%) had an intraoperative stroke, while two (2.3%) patients experienced a stroke in the LA ablation group (p = 0.98). In-hospital mortality was 3.4% in the PVI group, and 2.8% in the extended LA group (p = 0.33). Freedom from AF at 12 months' follow-up was 76% in the extended LA ablation group and 70% in the PVI group, showing no statistically significant difference (p = 0.32). Conclusion: Surgical AF ablation concomitant to CABG or AVR in patients with paroxysmal AF is safe and effective. There was no statistically significant difference between the compared lesion sets in terms of freedom from AF, survival or stroke rate after 12 months.

Ten year experience with the concomitant Maze IV procedure for atrial fibrillation

OBJECTIVE

The Maze IV (M-IV) procedure is regarded as the golden standard in treatment for surgical ablation of atrial fibrillation (AF); however, long-term follow-up results are scarce. We present our institutional 10-year experience.

METHODS

We collected data of 117 consecutive patients who have undergone a concomitant M-IV procedure between April 2006 and April 2016. Primary endpoints are freedom of atrial arrhythmias and freedom of atrial arrhythmias off antiarrhythmic drugs (AAD).

RESULTS

Forty-seven patients (40.2%) had paroxysmal AF. Two-thirds of the procedures included mitral valve surgery. The average follow-up time per patient was 3.8 years (SD 2.8). Freedom of AF at 1 year was 79%, at 5 years freedom of AF was 69% and freedom of AF off AAD was 56%. Predictors of AF recurrence in multivariate analysis were age, preoperative pacemakers, redo cardiac surgery and in-hospital AF. Preoperative PVI ablation was found to be a protective factor.

CONCLUSIONS

The long-term outcomes of the M-IV procedure are good and remain stable over the years. Results could be improved if follow-up were to be intensified and recurrences dealt with aggressively. Key question: How many patients are free from AF in a 10-year period after concomitant M-IV surgical ablation? Key findings: In the long term around 70% of patients are free of AF with an increasing need for anti-arrhythmic drugs. Take home message: Early to midterm freedom from AF after concomitant M-IV procedure is high and remains stable after 3 years.

Efficiency and safety of ablation procedure for the treatment of atrial fibrillation in valve surgery: A PRISMA-compliant cumulative systematic review and meta-analysis

BACKGROUND

Atrial fibrillation is the main complication of patients who suffer from valvular heart disease (VHD), which may lead to an increased susceptibility to ventricular tachycardia, atrial dysfunction, heart failure, and stroke. Therefore, seeking a safe and effective therapy is crucial in prolonging the lives of patients with VHD and improving their quality of life.

METHODS

Our target database included PubMed, Web of Science, Embase, and Cochrane Library, from which published articles were retrieved from inception to June 2020. We retrieved all randomized controlled trials (RCTs) that compared patients undergoing valve surgery with (VSA) or without ablation (VS) procedure. Studies to be included were screened and data extraction was performed independently by 2 investigators. The Cochrane risk-of-bias table was used to evaluate the methodological quality of the included RCTs. The mean difference (MD) with 95% confidence interval (CI) and relative risk (RR) ratio was calculated to analyze the data. Heterogeneity was evaluated using I2 and chi-square tests. Egger test and the trim and fill analysis were used to further determine publication bias.

RESULTS

Fourteen RCTs that included 1376 patients were eventually selected for this meta-analysis. Surgical ablation was found to be effective in restoring sinus rhythm in valvular surgery patients at discharge (RR 2.91, 95% CI [1.17, 7.20], I2 97%, P = .02), 3 to 6 months (RR 2.85, 95% CI [2.27, 3.58], I2 49%, P < .00001), 12 months, and more than 1 year after surgery (RR 3.54, 95% CI [2.78, 4.51], I2 27%, P < .00001). All-cause mortality (RR 0.98, 95% CI [0.64, 1.51], I2 0%, P = .94) and stroke (RR 1.29, 95% CI [0.70, 2.39], I2 0%, P = .57) were similar in the VSA and VS groups. Compared with VS, VSA prolonged cardiopulmonary bypass time (MD 30.44, 95% CI [17.55, 43.33], I2 88%, P < .00001) and aortic cross-clamping time (MD 19.57, 95% CI [11.10, 28.03], I2 89%, P < .00001). No significant differences were found between groups with respect to the risk of bleeding (RR 0.64, 95% CI [0.37, 1.12], I2 0%, P = .12), heart failure (RR 1.11, 95% CI [0.63, 1.93], I2 0%, P = .72), and low cardiac output syndrome (RR 1.41, 95% CI [0.57, 3.46], I2 18%, P = .46). However, the demand for implantation of a permanent pacemaker was significantly higher in the VSA group (RR 1.84, 95% CI [1.15, 2.95], I2 0%, P = .01).

CONCLUSION

Although we found high heterogeneity in the restoration of sinus rhythm at discharge, we assume that the comparison is valid at this time, given the current state in the operating room. This study provides evidence of the efficacy and security of concomitant ablation intervention for patients with VHD and atrial fibrillation. Surgical ablation would increase the safety of implantation of a permanent pacemaker in the population that underwent valve surgery.

The German CArdioSurgEry Atrial Fibrillation Registry: In-Hospital Outcomes

BACKGROUND

 The aim of this study was to describe outcomes of patients undergoing surgical ablation for atrial fibrillation (AF) as either stand-alone or concomitant cardiosurgical procedures in Germany.

METHODS

 Patients with AF undergoing concomitant or stand-alone surgical ablation were included in the registry. Cardiac surgery centers across Germany were invited to participate and sought to enroll 1,000 consecutive patients. Data was obtained through electronic case report forms. The protocol mandated follow-up interviews at 1 year.

RESULTS

 Between January 2017 and April 2020, 17 centers enrolled 1,000 consecutive patients. Among concomitant surgical patients (n = 899), paroxysmal AF was reported in 55.4% patients. Epicardial radio frequency (RF) bilateral pulmonary vein isolation (PVI) with excision of the left atrial appendage (LAA) was the most common operative strategy. In the stand-alone cohort (n = 101), persistent AF forms were reported in 84.1% of patients. Moderate-to-severe symptoms were reported in 85.1%. Sixty-seven patients had previously underwent at least two failed catheter ablative procedures. Thoracoscopic epicardial RF bilateral PVI and completion of a "box-lesion" with LAA closure were frequently preformed. Major cardiac and cerebrovascular complications occurred in 38 patients (4.3%) in the concomitant group. No deaths were reported in the stand-alone group. At discharge, sinus rhythm was achieved in 88.1% of stand-alone and 63.4% concomitant patients.

CONCLUSION

 The CArdioSurgEry Atrial Fibrillation registry provides insights into surgical strategies for AF ablation in a considerable cohort across Germany. This in-hospital data demonstrates that concomitant and stand-alone ablation during cardiac surgery is safe and effective with low complication rates.

Atrial fibrillation and atrial cardiomyopathies

Atrial fibrillation (AF) is the most common arrhythmia among adults. While there have been incredible advances in the management of AF and its clinical sequelae, investigation of atrial cardiomyopathies (ACMs) is becoming increasingly more prominent. ACM refers to the electromechanical changes-appreciated subclinically and/or clinically-that underlie atrial dysfunction and create an environment ripe for the development of clinically apparent AF. There are several subtypes of ACM, distinguished by histologic features. Recent progress in cardiovascular imaging, including echocardiography with speckle-tracking (e.g., strain analysis), cardiovascular magnetic resonance imaging (CMR), and atrial 4-D flow CMR, has enabled increased recognition of ACM. Identification of ACM and its features carry clinical implications, including elevating a patient's risk for development of AF, as well as associations with outcomes related to catheter-based and surgical AF ablation. In this review, we explore the definition and classifications of ACM, its complex relationship with clinical AF, imaging modalities, and clinical implications. We propose next steps for a more unified approach to ACM recognition that can direct further research into this complex field.

The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation

The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.

Contemporary Surgical Management of Atrial Fibrillation

Atrial fibrillation is a common arrhythmia which may cause symptoms that significantly impact quality of life and is associated with increased risk of stroke, heart failure, and sudden death. Over the past three decades many surgical techniques as well as catheter-bases procedures have been developed to treat atrial fibrillation. In this review we describe the indications, treatments, outcomes, surgical techniques, and technical advances reported in the literature.

Cox-maze III procedure for atrial fibrillation during valve surgery: a single institution experience

Objectives

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in patients with heart valve disease. Our aim was to summarize our experience and evaluate the efficacy and safety of the Cox maze III procedure combined with valve surgery in patients with AF.

Methods

A retrospective, observational analysis was performed for all consecutive patients underwent maze III procedure combined with valve surgery between October 2015 and June 2019. In this trial, we used a monopolar radiofrequency (RF) ablation in addition to cut and sew technique to treat AF.

Results

66 patients (37 female, 56.1%) with persistent or long-lasting persistent AF associated with valve disease were identified. The mean age was 54.2 ± 8.4 years (range, 30 to 73 years). Overall hospital mortality was 3.0%. The duration of cardiopulmonary bypass and aortic cross clamping was 175.4 ± 32.9 and 115.6 ± 22.8 min respectively. The first 24 h drainage was 488.6 ± 293.3 ml. The postoperative hospital stay was 14.8 ± 8.3 days. The postoperative incidence of permanent pacemaker implantation, reoperation for bleeding, renal failure required hemodialysis, and stroke was 4.5, 1.5, 4.5% and 0 respectively. The frequency of sinus rhythm was 91.7, 93.1, 94.7, 93.3 and 89.5% at 1, 3, 6, 12, and 24 months respectively.

Conclusions

The Cox-Maze III procedure is safe in the surgical treatment of AF associated with valve disease, and efficacious for sinus rhythm maintenance, with low morbidity and mortality.

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

OBJECTIVES

This study aimed to evaluate the impact of left atrial appendage exclusion on clinical outcomes in patients with atrial fibrillation (AF) undergoing rheumatic mitral surgery.

METHODS

We retrospectively reviewed 1226 consecutive patients with AF (54.5±11.6 years; 68.2% females) who underwent rheumatic mitral valve (MV) surgery from 1997 to 2016. The left atrial appendage was preserved in 836 (68.2%) and excluded in 390 (31.8%) patients. Surgical AF ablation was performed in 506 (60.5%) and 304 (77.9%) patients with preserved and excluded left atrial appendage, respectively. For baseline adjustment, propensity matching was used.

RESULTS

During a median follow-up of 63.4 months (IQRs, 20-111 months), there were no significant intergroup differences in the risks of mortality (2.77% vs 3.03%/patient-years) and thromboembolic events (0.91% vs 1.02%/patient-years). In the 258 pairs of propensity-score matched patients, death (2.77% vs 3.03%/patient-years) and thromboembolism (1.36% vs 0.82%/patient-years) outcomes were comparable for both groups. In a subgroup undergoing ablation (n=810), there were no significant differences in the adjusted risks of death (HR, 0.67; 95% CI, 0.34 to 1.32) and thromboembolism (HR, 0.47; 95% CI, 0.18 to 1.26). In a subgroup not undergoing ablation (n=416), however, left atrial appendage preservation tended to have higher adjusted risks for death (HR, 2.24; 95% CI, 0.98 to 5.13) and thromboembolism (HR, 4.41; 95% CI, 0.97 to 20.1).

CONCLUSIONS

Left atrial appendage preservation did not seem to have greater risks of adverse clinical events in patients with AF undergoing rheumatic MV surgery particularly when ablation procedure is combined.

Atrial fibrillation surgery with a focus on patients with reduced left ventricular function and heart failure

This review article aims to give an overview on the different surgical treatment options for atrial fibrillation It includes concomitant- as well as stand-alone surgical ablation therapy and outlines the main issues in patients with heart failure and reduced LVEF.

Atrial fibrillation: Current and emerging surgical strategies

OBJECTIVE

(a) To provide a comprehensive review of current literature on the surgical management of atrial fibrillation (AF), highlighting surgical approaches and outcomes. (b) To summarize the latest guidelines pertinent to the surgical management of AF.

BACKGROUND

AF is associated with high rates of morbidity and mortality, primarily related to the associated risk of stroke. The mainstay of management is pharmacologic rate or rhythm control and catheter-based ablation. Surgical ablation (SA) is an alternative strategy that is effective in select patient populations. Recently, novel techniques and technologies have been introduced and this has expanded the surgical capacity to manage AF.

METHODS

A comprehensive review of the literature was conducted.

RESULTS

Surgery can be a highly effective alternative therapeutic option for the management of AF in the appropriate patient population. The need for permanent pacemaker implantation is controversial among patients undergoing surgical intervention for AF. Surgical outcomes are promising, with long-term control of AF and symptomatic relief achieved in select groups of patients.

CONCLUSIONS

This article provides a comprehensive review of the surgical management of AF. We have summarized the latest surgical outcomes and contextualized the most recent guidelines.

Atrial Fibrillation Ablation: Indications and Techniques

PURPOSE OF REVIEW

Atrial fibrillation (AF) predisposes to embolic strokes and reduced quality of life. Ablation (catheter-based or surgically performed) can be employed to promote the maintenance of sinus rhythm in a carefully selected subset of patients with AF. The goal of this review is to discuss the indications and techniques for AF ablation, as well as post-procedural outcomes.

RECENT FINDINGS

Atrial fibrillation ablation improves quality of life in patients with atrial fibrillation although no clear reduction in stroke or overall mortality has been shown. Familiarity with the indications for AF ablation is important for all cardiologists, as is having a sound understanding of the efficacy of the procedure and potential complications. Furthermore, acquiring a grasp of the different modalities of AF ablation (including percutaneous endocardial techniques and surgical ablation approaches) will help to facilitate effective and appropriate referrals.

Which Method to Use for Surgical Ablation of Atrial Fibrillation Performed Concomitantly with Mitral Valve Surgery: Radiofrequency Ablation versus Cryoablation

Objective

The effects of energy source on the maintenance of sinus rhythm and the contribution of demographic characteristics to the case selection in patients submitted to ablation performed concurrently with mitral valve surgery were analyzed.

Methods

Cryothermal (n=42; 43.8%) and radiofrequency (n=54; 56.3%) energy were employed in 96 patients submitted to mitral valve replacement and Cox maze IV procedure. Patients were called for control visits between 15 days and 12 months after discharge. The causal relationship between recurrence of atrial fibrillation and factors such as left atrial diameter, C-reactive protein, hypertension, left ventricular ejection fraction, chronic obstructive pulmonary disease, and body mass index was determined.

Results

Maintenance rates of the sinus rhythm with radiofrequency and cryoablation were 97.6% and 96.3%, respectively, in the first postoperative month, whereas at the 12^th postoperative month were 88.1% and 83.3%. No significant difference was found between groups in relation to the energy source. Sensitivity and specificity for left atrial diameter with a cut-off value of 50.5 mm were 85.7% and 70.7%, respectively. Sensitivity and specificity for C-reactive protein with a cut-off value of 12 mg/dL on the 15^th postoperative day were 83.3% and 88.9%, respectively. The effect of body mass index on atrial fibrillation recurrence was 3.2 times. Sensitivity and specificity for left ventricular ejection fraction 37% cut-off value were 96.3% and 11.4%, respectively. Atrial fibrillation in hypertensive cases was 5.3 times more. In patients with chronic obstructive pulmonary disease, recurrence of atrial fibrillation was 40%. The causal relation between recurrence of atrial fibrillation and the studied factors was established.

Conclusion

Demographic characteristics have a significant impact on ablation efficiency, while the type of energy source does not.

Is It Conceivable to Still Perform the Cut and Sew Cox Maze III Procedure in the Current Era?

To determine whether cut and sew Cox maze III procedure is still associated with adequate safety endpoints when performed in conjunction with other open-heart procedures. Between January 2008 and January 2015, 113 consecutive adult patients were submitted to cut and sew Cox maze III procedure in association with other operations for structural heart disease. Mean age was 49 years and 80 (70.8%) were females. Longstanding or persistent atrial fibrillation has occurred in 87.6% and rheumatic heart disease in 80.7%. Valve surgery was performed in 98.2%. The number of associated procedures was correlated with morbidity and hospital mortality. Overall mean cardiopulmonary bypass and aortic cross-clamping times were 129 ± 26 and 105 ± 23 minutes, respectively. Hospital mortality was 1.77%, re-exploration for bleeding 0.9%, cerebrovascular accident 1.8%, and acute renal failure requiring hemodialysis 2.6%. The greater number of associated procedures did not correlate with poorer safety outcomes. Permanent pacemaker was required in 18.2% of those with three associated procedures, as opposed to 4% with two procedures and no requirement with one procedure (P = .01). Frequency of sinus rhythm was 88%, 88%, and 85% at 6, 12, and 24 months, respectively. In a contemporary single-center cohort of predominantly rheumatic patients, the surgical treatment of atrial fibrillation associated with structural heart disease by means of cut and sew Cox maze III procedure is safe, with low morbidity and mortality rates. Surgical complexity, defined by number of associated procedures, did not translate into poorer safety endpoints, except for greater need of permanent pacemaker.

Surgical ablation for persistent atrial fibrillation in concomitant cardiac surgery: mid-long-term result

OBJECTIVES

Surgical ablation is an option for patients with atrial fibrillation (AF) undergoing concomitant cardiac surgery. This study aims to evaluate the outcome of surgical ablation during concomitant cardiac surgery and to identify the independent predictors for a primary end-point consisting of AF or atrial flutter (AFL) recurrence, death, permanent pacemaker implantation and necessity for anti-arrhythmic drugs and the effects of reintervention for AF/AFL recurrence.

METHODS

A retrospective analysis was performed for 1028 patients who underwent surgical ablation during concomitant cardiac surgery from October 2004 to April 2015. Nine hundred and twenty-seven of 1017 (91.2%) discharged patients were followed up. Sixty-three recurrent patients received reintervention. Predictors of ablation failure were identified using univariate analysis and the Cox regression model.

RESULTS

The mean follow-up length was 29.0 ± 22.7 months. The New York Heart Association class, ejection fraction, left atrial and right atrial diameters and left ventricular end-diastolic diameter were improved at follow-up compared with the preoperative status. The rate of freedom from the primary end-point at 1, 2 and 3 years was 86.8, 79.4 and 68.3%. Independent predictors of reaching the primary end-point were AF/AFL at discharge, preoperative right atrial diameter, hypertension, diabetes and smoking. The rate of sinus rhythm without anti-arrhythmic drugs at 12, 24 and 36 months after reintervention was 78.3, 62.8 and 49.9%, respectively.

CONCLUSIONS

Surgical ablation has a high success rate and may improve cardiac function postoperatively. AF/AFL at discharge, preoperative right atrial diameter, hypertension, diabetes and smoking are the major independent predictors for ablation failure. Reintervention in AF/AFL recurrent patients can achieve a favourable clinical outcome.

Left atrial concomitant surgical ablation for treatment of atrial fibrillation in cardiac surgery: A meta-analysis of randomized controlled trials

INTRODUCTION

Surgical ablation is a generally established treatment for patients with atrial fibrillation undergoing concomitant cardiac surgery. Left atrial (LA) lesion set for ablation is a simplified procedure suggested to reduce the surgery time and morbidity after procedure. The present meta-analysis aims to explore the outcomes of left atrial lesion set versus no ablative treatment in patients with AF undergoing cardiac surgery.

METHODS

A literature research was performed in six database from their inception to July 2017, identifying all relevant randomized controlled trials (RCTs) comparing left atrial lesion set versus no ablative treatment in AF patient undergoing cardiac surgery. Data were extracted and analyzed according to predefined clinical endpoints.

RESULTS

Eleven relevant RCTs were included for analysis in the present study. The prevalence of sinus rhythm in ablation group was significantly higher at discharge, 6-month and 1-year follow-up period. The morbidity including 30 day mortality, late all-cause mortality, reoperation for bleeding, permanent pacemaker implantation and neurological events were of no significant difference between two groups.

CONCLUSIONS

The result of our meta-analysis demonstrates that left atrial lesion set is an effective and safe surgical ablation strategy for AF patients undergoing concomitant cardiac surgery.

Effectiveness and safety of simultaneous hybrid thoracoscopic endocardial catheter ablation of atrial fibrillation in obese and non-obese patients

Background

We evaluated the safety and effectiveness of the hybrid thoracoscopic endocardial epicardial ablation technique for the treatment of atrial fibrillation (AF) in obese versus non-obese patients.

Methods

Between January 2010 and January 2015, a cohort of 61 patients were retrospectively identified to undergo ablation of AF as a stand-alone procedure using a thoracoscopic, hybrid epicardial-endocardial technique. All patients underwent continuous 7-day Holter monitoring at 3, 6 months, 1 year and yearly thereafter.

Results

A total of 40% of the obese cohort had persistent or long-standing AF, compared to 54.9% of the non-obese cohort. There were no deaths or conversion to cardiopulmonary bypass required. At 3-year follow-up, 60% of the obese group were in sinus rhythm (SR) with no episode of AF, atrial flutter or atrial tachycardia lasting 30 s off anti-arrhythmic drugs. This was compared to 70.6% in the non-obese group, with no significant difference between the groups (P=0.468). For success rates on anti-arrhythmic drugs, this was 80% in the obese group compared to 86% in the non-obese group at 3-year follow-up (P=0.637). No patient died and no thromboembolic/bleeding events or procedure-related complications occurred during the follow-up.

Conclusions

In a retrospective cohort with approximately half with persistent or long-standing AF, thoracoscopic hybrid epicardial endocardial ablation proved to be equally effective and safe in obese versus non-obese patients. Current preliminary findings require further validation in multi-institutional prospective studies with larger sample sizes.