Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Surgical Therapy

Comparison of Early Complications of Oral Anticoagulants after Totally Thoracoscopic Ablation: Warfarin versus Non-vitamin K Antagonist Oral Anticoagulants

Background

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia. Totally thoracoscopic ablation (TTA) is a surgical treatment showing a high success rate as a hybrid procedure with radiofrequency catheter ablation to control AF. This study compared the early complications of warfarin and non-vitamin K antagonist oral anticoagulants (NOACs) in patients who underwent TTA.

Methods

This single-center retrospective cohort study enrolled patients who underwent planned TTA for AF from February 2012 to October 2020. All patients received postoperative anticoagulation, either with warfarin or a NOAC (apixaban, rivaroxaban, dabigatran, or edoxaban). Propensity score matching was performed for both groups. Early complications were assessed at 12 weeks after TTA and were divided into efficacy and safety outcomes. Both efficacy and safety outcomes were compared in the propensity score-matched groups.

Results

Early complications involving efficacy outcomes, such as stroke and transient ischemic attack, were seen in 5 patients in the warfarin group and none in the NOAC group. Although the 2 groups differed in the incidence of efficacy outcomes, it was not statistically significant. In safety outcomes, 11 patients in the warfarin group and 24 patients in the NOAC group had complications, but likewise, the between-group difference was not statistically significant.

Conclusion

Among patients who underwent TTA, those who received NOACs had a lower incidence of thromboembolic complications than those who received warfarin; however, both groups showed a similar bleeding complication rate. Using a NOAC after TTA does not reduce efficacy and safety when compared to warfarin.

Contemporary Atrial Fibrillation Management: A Comparison of the Current AHA/ACC/HRS, CCS, and ESC Guidelines

In this article we compare and contrast the current recommendations, and highlight the important differences, in the American College of Cardiology/American Heart Association/Heart Rhythm Society, European Society of Cardiology, and Canadian Cardiovascular Society atrial fibrillation (AF) guidelines. Although many of the recommendations of the various societies are similar, there are important differences in the methodologies underlying their development and the specific content. Specifically, key differences can be observed in: (1) the definition of nonvalvular AF, which subsequently affects anticoagulation choices and candidacy for non-vitamin K antagonist oral anticoagulants; (2) the symptom score used to guide management decisions and longitudinal patient profiling; (3) the stroke risk stratification algorithm used to determine indications for oral anticoagulant therapy; (4) the role of acetylsalicylic acid in stroke prevention in AF; (5) the antithrombotic regimens used in the context of coronary artery disease, acute coronary syndromes, and percutaneous coronary intervention; (6) the rate control target and medications recommended to achieve the target; and (7) the role of "first-line" catheter ablation, open surgical ablation, and left atrial appendage exclusion.

Variations in Anticoagulation Practices Following the Maze Procedure

The current real-world anticoagulation practices following left atrial appendectomy in the context of the Maze procedure are unknown. This is a cohort study of all patients who underwent the Maze procedure with amputation of the left atrial appendage from June 2005 to November 2012. Data was prospectively collected at regular intervals with an interview and Holter monitoring. All patients received anticoagulation for 3 months. Those then kept on anticoagulation and those for whom anticoagulation was stopped were compared in terms of death, bleeding and incidence of stroke. In total, there were 113 patients, of whom 66 were treated with anticoagulation (Group A) and 47 were not (Group B). There were no significant baseline differences between the two groups, including the presence of atrial fibrillation (A:19.7%, B:10.6%, p=0.30), CHADS2 score (A:1.41±1.05, B:1.15±1.08, p=0.19), and left atrial size (A:48.3±7.1mm, B:47.6±7.8 mm, p=0.57). There were 275 patient-years of follow-up, with an average of 2.43 years per patient. Only two patients experienced strokes, both in Group A (p=0.27). Of the 5 bleeding events, 4 occurred in the first 3 months while on anticoagulation and the remaining event occurred in Group A at 3 years post-operatively (p=0.10). No standardized approach to anticoagulation after the Maze procedure is apparent in real-world practice in an urban Canadian setting. Patients who undergo the Maze procedure with amputation of the left atrial appendage are at a low risk of stroke, but the optimal anticoagulation strategy requires further investigation.

Practice implications of the Atrial Fibrillation Guidelines

Atrial fibrillation is one of the most common and complex cardiac arrhythmias. Using currently available evidence, leading medical societies have established recommendations for the optimal management of atrial fibrillation. These guidelines have recently been updated by 4 consensus groups: the European Society of Cardiology, the American College of Chest Physicians, the Canadian Cardiovascular Society, and a task force of 3 societies from the United States: the American College of Cardiology Foundation, the American Heart Association, and the Heart Rhythm Society. The present review focused on the similarities and differences among these recently updated guidelines. Key revisions included updated information on newer treatments for rhythm control, treatment options to reduce atrial fibrillation complications, and updated anticoagulant management for thromboprophylaxis.

[Progress in cardiac electrophysiology and arrhythmias]

This article contains a review of the most important publications in the field of cardiac electrophysiology and arrhythmias that have appeared in the last year. Publications were selected because they reported important scientific developments or significant improvements in the devices or invasive techniques used for the treatment of arrhythmias.

Management of atrial fibrillation around the world: a comparison of current ACCF/AHA/HRS, CCS, and ESC guidelines

New guidelines for the management of atrial fibrillation (AF) have recently been published by the American College of Cardiology Foundation/American Heart Association, and Heart Rhythm Society (ACCF/AHA/HRS) task force on practice guidelines, the Canadian Cardiovascular Society (CCS), and the European Society of Cardiology (ESC). Although they all refer to the same scientific data and agree in the majority of AF management, interpretation, and weighing of study results are quite different in some aspects. While recommendations for stroke risk assessment and prophylaxis are rather conservative in the ESC guidelines, the CCS guideline recommendations are more conservative with regard to lenient rate control and the ACCF/AHA/HRS recommendations are rather strict with regard to rhythm management.

Strategies in the surgical management of atrial fibrillation

Atrial fibrillation (AF) is associated with substantial morbidity, mortality, and economic burden and confers a lifetime risk of up to 25%. Current medical management involves thromboembolism prevention, rate, and rhythm control. An increased understanding of AF pathophysiology has led to enhanced pharmacological and medical therapies; however this is often limited by toxicity, variable symptom control, and inability to modulate the atrial substrate. Surgical AF ablation has been available since the original description of the Cox Maze procedure, either as a standalone or concomitant intervention. Advances in novel energy delivery systems have allowed the development of less technically demanding procedures potentially eliminating the need for median sternotomy and cardiopulmonary bypass. Variations in the definition, duration, and reporting of AF have produced methodological limitations impacting on the validity of interstudy comparisons. Standardization of these parameters may, in future, allow us to further evaluate clinical endpoints and establish the efficacy of these techniques.

Canadian Cardiovascular Society atrial fibrillation guidelines 2010: prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter

The stroke rate in atrial fibrillation is 4.5% per year, with death or permanent disability in over half. The risk of stroke varies from under 1% to over 20% per year, related to the risk factors of congestive heart failure, hypertension, age, diabetes, and prior stroke or transient ischemic attack (TIA). Major bleeding with vitamin K antagonists varies from about 1% to over 12% per year and is related to a number of risk factors. The CHADS(2) index and the HAS-BLED score are useful schemata for the prediction of stroke and bleeding risks. Vitamin K antagonists reduce the risk of stroke by 64%, aspirin reduces it by 19%, and vitamin K antagonists reduce the risk of stroke by 39% when directly compared with aspirin. Dabigatran is superior to warfarin for stroke prevention and causes no increase in major bleeding. We recommend that all patients with atrial fibrillation or atrial flutter, whether paroxysmal, persistent, or permanent, should be stratified for the risk of stroke and for the risk of bleeding and that most should receive antithrombotic therapy. We make detailed recommendations as to the preferred agents in various types of patients and for the management of antithrombotic therapies in the common clinical settings of cardioversion, concomitant coronary artery disease, surgical or diagnostic procedures with a risk of major bleeding, and the occurrence of stroke or major bleeding. Alternatives to antithrombotic therapies are briefly discussed.

From guidelines to bench: implications of unresolved clinical issues for basic investigations of atrial fibrillation mechanisms

The 2011 Canadian Cardiovascular Society Atrial Fibrillation (AF) Guidelines provide detailed recommendations for AF management, as well as extensive background information. The Guidelines documents highlight many important unresolved questions and areas of clinical need that could benefit from basic research investigations. This article discusses basic research priorities emanating from the Guidelines reflections. Topics addressed include forms of AF and their interrelations, limitations of the presently available experimental models of AF, genetic factors, determinants of drug efficacy for pharmacologic cardioversion, mechanisms of AF-related thromboembolism, ventricular rate control, drugs for rhythm control, upstream therapy, mechanisms by which catheter ablation controls AF, mechanisms of postoperative AF, and the possibility of novel patient-based surgical procedures. A guidelines-to-bench approach to research may allow for the development of important, clinically relevant new knowledge with impacts on patient management and future AF guidelines.