Intraoperative Inducibility of Atrial Fibrillation Does Not Predict Early Postoperative Atrial Fibrillation

Steps to improve the outcome of a single ablation procedure for paroxysmal atrial fibrillation: Significance of a burst stimulation-guided ablation strategy

BACKGROUND

The outcome of a single ablation procedure for paroxysmal atrial fibrillation (PAF) is suboptimal. The value of burst stimulation and additional ablation following the isolation of pulmonary vein (PV) and superior vena cava (SVC) remains unclear.

OBJECTIVE

The aim of this study was to optimize the ablation strategy and improve the outcome of a single procedure for PAF.

METHODS

This retrospective study involved 404 PAF patients who underwent radiofrequency ablation, and were divided into Group 1 (PV + SVC isolation, n = 81) and Group 2 (PV + SVC isolation + burst stimulation-guided ablation, n = 323). In Group 2, additional linear ablation was performed if atrial fibrillation (AF) or atrial flutter (AFL) persisted or was induced by burst stimulation after PV and SVC isolation.

RESULTS

In Group 1, 20 (24.69 %) patients experienced recurrences of AF (n = 16) and AFL (n = 4) during an average follow-up period of 733.60 days. In Group 2, 76 (23.53 %) patients experienced persistent arrhythmias (n = 25) or arrhythmias induced by burst stimulation (n = 51) after PV and SVC isolation, including AF (n = 27) and AFL (n = 49). Ablation along the left atrial roofline, mitral isthmus, and tricuspid isthmus was performed in 37, 34, and 49 patients, respectively. During the average follow-up duration of 660.80 days, the recurrence rate (29/323, 8.98 %) of AF/AFL was significantly lower in Group 2 than that in Group 1 (p < 0.001).

CONCLUSION

Additional stepwise linear ablation guided by burst stimulation significantly improved the outcome of a single ablation procedure for PAF.

Development and external validation of a novel model for predicting new clinically important atrial fibrillation after thoracoscopic anatomical lung cancer surgery: a multicenter retrospective cohort study

BACKGROUND

New clinically important postoperative atrial fibrillation (POAF) is the most common arrhythmia after thoracoscopic anatomical lung cancer surgery and is associated with increased morbidity and mortality. The full spectrum of predictors remains unclear, and effective assessment tools are lacking. This study aimed to develop and externally validate a novel model for predicting new clinically important POAF.

METHODS

This retrospective study included 14 074 consecutive patients who received thoracoscopic anatomical lung cancer surgery from January 2016 to December 2018 in Shanghai Chest Hospital. Based on the split date of 1 January 2018, we selected 8717 participants for the training cohort and 5357 participants for the testing cohort. For external validation, we pooled 2941 consecutive patients who received this surgical treatment from July 2016 to July 2021 in Shanghai Ruijin Hospital. Independent predictors were used to develop a model and internally validated using a bootstrap-resampling approach. The area under the receiver operating characteristic curves (AUROCs) and Brier score were performed to assess the model discrimination and calibration. The decision curve analysis (DCA) was used to evaluate clinical validity and net benefit. New clinically important POAF was defined as a new-onset of POAF that causes symptoms or requires treatment.

RESULTS

Multivariate analysis suggested that age, hypertension, preoperative treatment, clinical tumor stage, intraoperative arrhythmia and transfusion, and operative time were independent predictors of new clinically important POAF. These seven candidate predictors were used to develop a nomogram, which showed a concordance statistic (C-statistic) value of 0.740 and good calibration (Brier score; 0.025). Internal validation revealed similarly good discrimination (C-statistic, 0.736; 95% CI: 0.705-0.768) and calibration. The decision curve analysis showed positive net benefits with the threshold risk range of 0-100%. C-statistic value and Brier score were 0.717 and 0.028 in the testing cohort, and 0.768 and 0.012 in the external validation cohort, respectively.

CONCLUSIONS

This study identified seven predictors of new clinically important POAF, among which preoperative treatment, intraoperative arrhythmia, and operative time were rarely reported. The established and externally validated model has good performance and clinical usefulness, which may promote the application of prevention and treatment in high-risk patients, and reduce the development and related adverse outcomes of this event.

Effect of electrophysiological mapping on non-transmural annulus ablation and atrial fibrillation recurrence prediction after 6 months of Cox-Maze IV procedure

OBJECTIVE

The objective of this study was to observe the safety and efficacy of electrophysiological mapping following the Cox-Maze IV procedure and to investigate whether a correlation exists between recurrence of atrial fibrillation (AF) with the completeness of bidirectional electrical isolation and the inducibility of AF immediately after the Cox-Maze IV procedure.

METHODS

Totally, 80 consecutive patients who suffered from aortic valve or mitral valve disease and persistent AF were randomly enrolled into the control group and electrophysiological mapping following the Cox-Maze IV group (Electrophysio-Maze group). In the Electrophysio-Maze group, patients underwent concomitant Cox-Maze procedure and following electrophysiological mapping of ablation lines in mitral isthmus, left atrial "box," and tricuspid annulus. If the bidirectional electrical isolation of tricuspid annulus ablation line is incomplete, whether to implement supplementary ablation will be independently decided by the operator. Before and after the Cox-Maze IV procedure, AF induction was performed. All patients in both groups were continuously followed-up and underwent electrocardiogram Holter monitoring after 6 months.

RESULTS

In total, 42 Electrophysio-Maze patients and 38 controls were enrolled. Compared with patients in the control group, there were shorter hospital stay, better cardiac remodeling changes, and higher relief from AF during the follow-up period of 6 months in the Electrophysio-Maze group. Within the Electrophysio-Maze group, the rate of incomplete the bidirectional electrical isolation of "box" ablation lines was zero, and the rate of incomplete bidirectional electrical isolation of mitral isthmus ablation line or tricuspid annulus ablation line was 23.8%. After two cases of successful complementary ablation on the tricuspid annulus ablation line, the final incomplete bidirectional electrical isolation of annulus ablation lines was 19.0%. There were correlations between late AF recurrence after 6 months with incomplete bidirectional electrical isolation of annulus ablation lines and AF induction immediately after the Cox-Maze IV procedure.

CONCLUSION

Electrophysiological mapping following the Cox-Maze procedure is safe and effective. Electrophysiological mapping in the Cox-Maze procedure can find out the non-transmural annulus ablation lines by assessing the completeness of bidirectional electrical isolation of ablation lines, guide supplementary ablation, and predict AF recurrence after 6 months.

The effects of paravertebral blockade usage on pulmonary complications, atrial fibrillation and length of hospital stay following thoracoscopic lung cancer surgery

STUDY OBJECTIVE

Although combined thoracic paravertebral blockade (TPVB)-general anesthesia (GA) could improve pain control compared to GA alone after thoracoscopic lung cancer surgery, it has not been established whether this improvement in pain control could reduce associated adverse outcomes. Thus, this study aimed to explore the association between TPVB usage and adverse outcomes after thoracoscopic lung cancer surgery.

DESIGN

Retrospective cohort study from a prospective database.

SETTING

A high-volume thoracic center in China.

PATIENTS

13966 consecutive patients who received thoracoscopic lung cancer surgery from January 2016 to December 2018 in Shanghai Chest Hospital were enrolled.

MEASUREMENTS

With a 1:1 propensity score matching (PSM) analysis, adverse outcomes between GA alone and GA-TPVB were investigated. Multivariate and multiple linear regression analysis were used to identify factors and calculate odds radio (OR) for adverse outcomes.

RESULTS

The rate of TPVB usage was 14.8% (2070 out of 13,966). TPVB combined with GA was associated with lower rates of postoperative pulmonary complications (PPCs) (30.4% vs 33.5%, P = 0.005) and postoperative atrial fibrillation (POAF) (2.1% vs 2.9%, P = 0.041), and shorter length of hospital stay (LOS) (Median [IQR]; 5[4-5] vs 5[4-6]) days, P < 0.001) compared to GA alone. After a 1:1 PSM analysis, we investigated adverse outcomes in 2640 (1320 pairs) patients with or without TPVB usage, and this association remained existed, namely, the rates of PPCs (29.8% vs 34.2%, P = 0.014) and POAF (2.2% vs 3.6%, P = 0.028) were lower and LOS was shorter (5[4-5] vs 5[4-6] days, P < 0.001) in the GA-TPVB group. In multivariate analysis, the combination of GA plus TPVB was independent predictor for PPCs (OR = 0.879, 95%CI, 0.793-0.974, P = 0.014) and POAF (OR = 0.714, 95%CI, 0.516-0.988, P = 0.042), respectively. However, in multiple linear analysis, lower rates of PPCs and POAF associated with TPVB usage, rather than TPVB usage, were responsible for the reduced LOS.

CONCLUSIONS

The usage of TPVB may be a feasible and adjustable approach to reduce the rates of PPCs and POAF and associated LOS in thoracoscopic lung cancer surgery.

Preoperative Electrocardiogram and Perioperative Methods for Predicting New-Onset Atrial Fibrillation During Lung Surgery

OBJECTIVE

To investigate if preoperative electrocardiogram scores and perioperative surgical methods could predict new-onset atrial fibrillation during lung surgery.

DESIGN

Retrospective observational case-control study.

SETTING

The First Affiliated Hospital of Nanjing Medical University, China.

PARTICIPANTS

Eighty adult patients (40 with new-onset atrial fibrillation, 40 without) who underwent lung surgery.

INTERVENTIONS

The authors compared and analyzed the relationship among preoperative electrocardiogram scores, clinical variables, and surgical variables with new-onset atrial fibrillation during lung surgery.

MEASUREMENTS AND MAIN RESULTS

Clinical data and demographics involving 80 adult patients (40 with new-onset atrial fibrillation, 40 without) who underwent lung surgery were retrieved from the Medical Records of the First Affiliated Hospital of Nanjing Medical University. Patients with prior atrial fibrillation were excluded. Preoperative electrocardiograms were collected from medical records and checked by two independent blinded researchers. Preoperative clinical variables (age, sex, body mass index, American Society of Anesthesiologists Class) were selected for a multivariate preoperative clinical model (model C). Perioperative surgical methods (thoracoscopy or open-chest surgery, lymph node dissection, left or right pneumonectomy, extent of pulmonary resection) were selected for a multivariate surgical methods model (model S). Five electrocardiogram variables (PR interval, P-wave duration, the longest interval measured between the onset of Q-wave and the J-point (QRS) duration, left atrial enlargement, and left ventricular hypertrophy) were included in a multivariate electrocardiogram model (model E). A combined clinical and electrocardiogram model (Model CE) and a combined univariate significant variables model (Model CSE) were formed. Left atrial enlargement, QRS duration, American Society of Anesthesiologists Class, and open-chest surgery were risk factors of new-onset atrial fibrillation. The result showed that the predictive ability of Model E was significantly higher than Models C and S. Model CSE showed the highest prediction of all models. Fifty percent of patients with one risk element will develop new-onset atrial fibrillation, and 100% of patients with two or more risk elements of Model CSE will develop new-onset atrial fibrillation.

CONCLUSIONS

Preoperative electrocardiogram markers can be used together with surgical methods as strong predictors to identify those patients at a high risk for new-onset atrial fibrillation during lung surgery.