Concurrent vs Staged Hybrid Ablation for Long-Standing Persistent Atrial Fibrillation: A Propensity-Matched Cohort Study

BACKGROUND

Long-term success rates of catheter ablation (CA) for long-standing persistent atrial fibrillation (LSPAF) are less than satisfactory. Further improvement of ablation methods is crucial for enhancing the treatment of LSPAF.

OBJECTIVE

This study sought to compare the outcomes of concurrent vs staged minimally invasive surgical-catheter hybrid ablation for LSPAF.

METHODS

From December 2015 to December 2021, 104 matched patients (concurrent and staged, 1:1) were included in study. In the concurrent group, both left unilateral thoracoscopic epicardial ablation (EA) and CA were performed simultaneously in one procedure. In the staged group, EA was performed at the first hospitalization. If the patients experienced atrial fibrillation (AF) recurrence, CA was performed between 3 months and 1 year after EA.

RESULTS

In the concurrent group, 4 patients were restored to sinus rhythm after EA, and 41 were patients restored to sinus rhythm during CA; 86.5% (45 of 52) achieved intraprocedural AF termination during concurrent hybrid ablation. In the staged group, all 52 patients underwent staged CA because of the recurrence of AF or atrial tachycardia (AT). Forty-seven (90.4%) patients achieved intraprocedural AF or AT termination during CA. Freedom from AF or AT off antiarrhythmic drugs at 2 years after hybrid ablation was 79.9% ± 5.7% in the concurrent group and 86.0% ± 4.9% in the staged group (P = 0.390). Failure of intraprocedural AF termination (HR: 14.378) was an independent risk factor for AF recurrence after hybrid ablation.

CONCLUSIONS

Both concurrent and staged hybrid ablation could be safely and effectively applied to treat LSPAF. Improving the intraprocedural AF termination rate predicted better outcomes.

Post-cardiopulmonary bypass hypoxaemia in paediatric patients undergoing congenital heart disease surgery: risk factors, features, and postoperative pulmonary complications

Background

Hypoxemia after cardiopulmonary bypass (CPB) is the quantifiable manifestation of pulmonary dysfunction. This retrospective study was designed to investigate the risk factors for post-cardiopulmonary bypass hypoxaemia and the features of hypoxaemia and pulmonary complications in paediatric congenital heart disease surgery involving CPB.

Methods

Data including demographics, preoperative pulmonary or cardiac parameters, and intraoperative interventions were retrospectively collected from 318 paediatric patients who underwent radical surgery with CPB for congenital heart disease. Among them, the factors that were significant by univariate analysis were screened for multivariate Cox regression. The lowest ratio of arterial oxygen tension and the inspiratory oxygen fraction (PaO₂/FiO₂), hypoxaemia (PaO₂/FiO₂ ≤ 300) insult time, duration of hypoxaemia, extubation time, and pulmonary complications were also analysed postoperatively.

Results

The morbidity of post-cardiopulmonary bypass hypoxaemia was 48.4% (154/318). Months (6 < months ≤ 12, 12 < months ≤ 36 and 36 < months compared with 0 ≤ months ≤ 6: HR 0.582, 95% CI 0.388–0.873; HR 0.398, 95% CI 0.251–0.632; HR 0.336, 95% CI 0.197–0.574, respectively; p < 0.01), preoperative intracardiac right-to-left shunting (HR 1.729, 95% CI 1.200–2.493, p = 0.003) and intraoperative pleural cavity entry (HR 1.582, 95% CI 1.128–2.219, p = 0.008) were identified as independent risk factors for the development of post-cardiopulmonary bypass hypoxaemia. Most hypoxaemia cases (83.8%, 129/154) occurred within 2 h, and the rate of moderate hypoxaemia (100 < PaO₂/FiO₂ ≤ 200) was 60.4% (93/154).

Conclusion

The morbidity of post-cardiopulmonary bypass hypoxaemia in paediatric congenital heart disease surgery was considerably high. Most hypoxaemia cases were moderate and occurred in the early period after CPB. Scrupulous management should be employed for younger infants or children with preoperative intracardiac right-to-left shunting or intraoperative pleural cavity entry.

Lung protective ventilation in infants undergoing cardiopulmonary bypass surgery for congenital heart disease: A prospective randomized controlled trial

BACKGROUND

Lung protective ventilation (LPV) has been applied to surgical adults with normal pulmonary function for optimizing mechanical ventilation and reducing postoperative pulmonary complications. Few studies have reported the use of LPV in infants undergoing cardiac surgery with cardiopulmonary bypass (CPB).

AIMS

To explore safety and effectiveness of LPV in infants undergoing CPB surgery for congenital heart disease (CHD).

METHODS

Included in this study were 77 infants who underwent CPB surgery for CHD from November 2017 to September 2018. They were randomized into the LPV group and conventional ventilation (CV) group. In the LPV group, small-tidal-volume (6-8 ml/kg) ventilation, lung recruitment by PEEP increment to the maximum level of 15 cm H₂ O after CPB, and individualized optimal PEEP titration were applied. In the CV group, traditional tidal volume (10-12 ml/kg with zero PEEP) was applied. The primary outcome was the ratio of arterial partial pressure of oxygen to inspiratory oxygen fraction (PaO₂ /FiO₂ ). The secondary outcomes were respiratory dynamic parameters, hypoxemia, prognostic indexes, and postoperative pulmonary complications.

RESULTS

PaO₂ /FiO₂ in the LPV group (416.86, 95%CI: 381.60-452.12) was significantly higher than that in the CV group (263.37, 95%CI: 227.65-299.09) after intervention (P < .001). There was a significant difference in the trend of change in dynamic compliance, alveolar-arterial oxygen difference, arterial-end-expired carbon dioxide difference, driving pressure, and respiratory index between the two groups at different time points from weaning from CPB to 2 hours after operation. There was no significant difference in PaO₂ /FiO₂ , alveolar-arterial oxygen difference, respiratory index, and dynamic compliance 2 hours postoperative and in the incidence of postoperative pulmonary complications, prognostic indexes between the two groups.

CONCLUSIONS

LPV could be used safely in infants undergoing CPB in that it can improve oxygenation, alveolar aeration, and dynamic compliance, and reduce driving pressure, pulmonary shunting, and dead space. Its effect on oxygenation, pulmonary gas exchange, and pulmonary compliance was relatively short, and had less impact on postoperative pulmonary complications and prognosis.