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van der Heijden CAJ, Aerts L, Chaldoupi SM, van Cruchten C, Kawczynski M, Heuts S, Bidar E, Luermans JGLM, Maesen B. Hybrid atrial fibrillation ablation. Ann Cardiothorac Surg 2024; 13:54-70. [PMID: 38380145 PMCID: PMC10875200 DOI: 10.21037/acs-2023-afm-0129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/17/2023] [Indexed: 02/22/2024]
Abstract
In this state-of-the art review on hybrid atrial fibrillation (AF) ablation, we briefly focus on the pathophysiology of AF, the rationale for the hybrid approach, its technical aspects and the efficacy and safety outcomes after hybrid AF ablation, both from meta-analyses and randomized control trial data. Also, we performed a systematic search to provide a provisional overview of real-world hybrid AF ablation efficacy and safety outcomes. Furthermore, we give an insight into the 'Maastricht approach', an approach that allows us to tailor the ablation procedure to the individual patient. Finally, we reflect on future perspectives with the objective to continue improving our thoracoscopic hybrid AF ablation approach. Based on the review of the available literature, we believe it is fair to state that thoracoscopic hybrid AF ablation is a valid alternative to catheter ablation for the treatment of patients with more persistent forms of AF.
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Affiliation(s)
| | - Luca Aerts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sevasti-Marisevi Chaldoupi
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Cas van Cruchten
- Department of Plastic Surgery, VieCuri Medical Center, Venlo, The Netherlands
| | - Michal Kawczynski
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Justin G. L. M. Luermans
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute (CARIM), Maastricht University, Maastricht, The Netherlands
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Wong CX, Buch EF, Beygui R, Lee RJ. Hybrid Endo-Epicardial Therapies for Advanced Atrial Fibrillation. J Clin Med 2024; 13:679. [PMID: 38337373 PMCID: PMC10856493 DOI: 10.3390/jcm13030679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/27/2023] [Accepted: 01/17/2024] [Indexed: 02/12/2024] Open
Abstract
Atrial fibrillation (AF) is a growing health problem that increases morbidity and mortality, and in most patients progresses to more advanced diseases over time. Recent research has examined the underlying mechanisms, risk factors, and progression of AF, leading to updated AF disease classification schemes. Although endocardial catheter ablation is effective for early-stage paroxysmal AF, it consistently achieves suboptimal outcomes in patients with advanced AF. Identification of the factors that lead to the increased risk of treatment failure in advanced AF has spurred the development and adoption of hybrid ablation therapies and collaborative heart care teams that result in higher long-term arrhythmia-free survival. Patients with non-paroxysmal AF, atrial remodeling, comorbidities, or AF otherwise deemed difficult to treat may find hybrid treatment to be the most effective option. Future research of hybrid therapies in advanced AF patient populations, including those with dual diagnoses, may provide further evidence establishing the safety and efficacy of hybrid endo-epicardial ablation as a first line treatment.
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Affiliation(s)
- Christopher X. Wong
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide 5001, Australia
- Cardiac Electrophysiology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Eric F. Buch
- Cardiac Arrhythmia Center, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Ramin Beygui
- Cardiothoracic Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Randall J. Lee
- Cardiac Electrophysiology, University of California San Francisco, San Francisco, CA 94143, USA
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Pešl M, Kulík T, Ostřížek T, Horváth V, Souček F, Melajová K, Doležalová K, Žáková D, Jadczyk T, Lehar F, Jež J, Stárek Z. Mid-term success rate of single stage hybrid ablation of persistent and long-term persistent atrial fibrillation. VNITRNI LEKARSTVI 2022; 68:20-26. [PMID: 36283813 DOI: 10.36290/vnl.2022.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Single stage thoracoscopic radiofrequency ablation (RFA) is a treatment method for persistent and long-term persistent atrial fibrillation (AF) offering the possibility for patients otherwise inconsolable by conventional catheter RFA. We present a pilot group of patients after the introduction of the new method at our clinical center. Patients group: A total of 52 patients aged 61.82 ± 9.7 years underwent single stage hybrid ablation (thoracoscopic isolation of pulmonary veins and box lesion followed by catheter verification of the surgical procedure effectivness) for symptomatic persistent and long-term persistent AF with significantly dilated left atrium 57.9 ± 11.0mm in the period September 2016-March 2019. RESULTS The median duration of the procedure was 232 minutes and the median duration of hospitalization was 10 days. At discharge, 52 patients (100%) had sinus rhythm. 48 of 52 patients (92.3%) had a 6-month follow-up. 41 of 48 (85.4%) and 38 of 44 (86.4%) of patients were AF free at 3-month and 6-month follow-up, respectively. Acute complications were: one left atrial perforation resolved successfully by suture and one transient ischaemic attack without permanent sequelae. Late complications involved one massive pulmonary embolization and an atrioesophageal fistula. There was no periprocedural myocardial infarction or stroke with permanent sequelae. CONCLUSION Hybrid thoracoscopic-catheter ablation performed during one procedure is an effective and relatively safe mini-invasive method of treatment for long-term persistent atrial fibrillation.
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Chaumont C, Suffee N, Gandjbakhch E, Balse E, Anselme F, Hatem SN. Epicardial origin of cardiac arrhythmias: clinical evidences and pathophysiology. Cardiovasc Res 2021; 118:1693-1702. [PMID: 34152392 PMCID: PMC9215195 DOI: 10.1093/cvr/cvab213] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/18/2021] [Indexed: 11/16/2022] Open
Abstract
Recent developments in imaging, mapping, and ablation techniques have shown that the epicardial region of the heart is a key player in the occurrence of ventricular arrhythmic events in several cardiac diseases, such as Brugada syndrome, arrhythmogenic cardiomyopathy, or dilated cardiomyopathy. At the atrial level as well, the epicardial region has emerged as an important determinant of the substrate of atrial fibrillation, pointing to common underlying pathophysiological mechanisms. Alteration in the gradient of repolarization between myocardial layers favouring the occurrence of re-entry circuits has largely been described. The fibro-fatty infiltration of the subepicardium is another shared substrate between ventricular and atrial arrhythmias. Recent data have emphasized the role of the epicardial reactivation in the formation of this arrhythmogenic substrate. There are new evidences supporting this structural remodelling process to be regulated by the recruitment of epicardial progenitor cells that can differentiate into adipocytes or fibroblasts under various stimuli. In addition, immune-inflammatory processes can also contribute to fibrosis of the subepicardial layer. A better understanding of such ‘electrical fragility’ of the epicardial area will open perspectives for novel biomarkers and therapeutic strategies. In this review article, a pathophysiological scheme of epicardial-driven arrhythmias will be proposed.
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Affiliation(s)
- Corentin Chaumont
- Cardiology Department, Rouen University Hospital, Rouen, France.,FHU REMOD-VHF, UNIROUEN, INSERM U1096, F76000, France
| | - Nadine Suffee
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Estelle Gandjbakhch
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Elise Balse
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Anselme
- Cardiology Department, Rouen University Hospital, Rouen, France.,FHU REMOD-VHF, UNIROUEN, INSERM U1096, F76000, France
| | - Stéphane N Hatem
- INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Sorbonne University, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
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5
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Montgomery JA. Mapping and ablation of non-pulmonary vein drivers of persistent atrial fibrillation: Has a STAR been born? J Cardiovasc Electrophysiol 2021; 32:210-211. [PMID: 33368814 DOI: 10.1111/jce.14854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 12/19/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Jay A Montgomery
- Arrhythmia Section, Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Division of Cardiology, Department of Medicine, Nashville Veterans Affairs Hospital, Tennessee Valley Health System, Nashville, Tennessee, USA
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Matteucci F, Maesen B, Vernooy K, De Asmundis C, Maessen JG, La Meir M, Gelsomino S. One-Stage Versus Sequential Hybrid Radiofrequency Ablation: An In Vitro Evaluation. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 15:338-345. [DOI: 10.1177/1556984520930070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To compare lesion size and depth between a 1-step, a sequential, and a delayed radio-frequency ablation in a hybrid setup. Methods Left atrium tissues obtained from fresh porcine hearts were mounted into the ABLABOX simulator. Based on the time differences between the index epicardial (epi) and consequent endocardial (endo) ablation, 3 study groups were compared: a 1-stage (SEQ- 0) group (0-minute delay), an SEQ 1 group (60-minute delay), and an SEQ 2 group (240-minute delay). During the experiment, a constant epicardial (300 gr) and endocardial (30 gr) force were applied. Per group, 20 samples were studied, and the resulting lesion size and depth were quantified with morphometric evaluation. Results Overall, no transmural lesion was obtained. Lesions in SEQ 0 had better maximum and minimum diameters ( P < 0.001), a larger total area ( P < 0.001), and volume ( P < 0.001) than SEQ 1 and SEQ 2. There was no statistical difference in morphometric parameters (all, P > 0.05) between the delayed procedures (SEQ 1 and SEQ 2). Conclusions In our in vitro model, different time sequences of combined epi–endo ablation did not result in transmural lesions. However, simultaneous epi–endo ablation produced broader and deeper lesions. Our findings need to be confirmed by further research.
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Affiliation(s)
| | - Bart Maesen
- Cardiothoracic Department Maastricht University Hospital, The Netherlands
| | - Kevin Vernooy
- Cardiothoracic Department Maastricht University Hospital, The Netherlands
| | | | - Jos G. Maessen
- Cardiothoracic Department Maastricht University Hospital, The Netherlands
| | - Mark La Meir
- Cardiothoracic Department Maastricht University Hospital, The Netherlands
- Cardiothoracic Department Brussels University Hospital, Belgium
| | - Sandro Gelsomino
- Cardiothoracic Department Maastricht University Hospital, The Netherlands
- Cardiothoracic Department Brussels University Hospital, Belgium
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Khan Z, Hamandi M, Khan H, DiMaio JM, Evans M. Convergent epicardial-endocardial ablation for treatment of long-standing persistent atrial fibrillation: A review of literature. J Card Surg 2020; 35:1306-1313. [PMID: 32333456 DOI: 10.1111/jocs.14562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/26/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIM OF STUDY The convergent procedure (CVP) is a hybrid ablation technique via a subxiphoid incision that has recently emerged as a treatment option for non-paroxysmal atrial fibrillation (npAF). By combining endocardial and epicardial ablation into a simultaneous or staged procedure, the pulmonary vein and posterior left atrium can be isolated with transmural lesion sets while minimizing the risk of proarrhythmic gaps that are a known limitation with endocardial linear lesion sets. We reviewed the 12-month outcomes in patients who underwent CVP compared to those who underwent endocardial catheter ablation (CA) and surgical ablation (SA). METHODS A literature search was conducted using the PubMed database for publications related to CVP. Selected studies included detailed 12-month follow-up of patients, patient characteristics, periprocedural complications, use of antiarrhythmic drugs (AADs), and monitoring method. RESULTS Five studies with 340 patients who underwent CVP between January 2009 and March 2017 were selected for this review. A total of 8.5% of patients had paroxysmal AF (pAF), 42.2% had persistent AF (peAF), and 49.1% had long-standing persistent AF (lspAF). At 12 months, 81.9% of patients were in sinus rhythm, while 54.1% of patients were in sinus rhythm while not taking AADs. The overall complication rate was 10%. CONCLUSION CVP had better 1-year efficacy in eliminating AF when compared to CA. However, SA, specifically the Cox Maze IV, had lower rates of AF recurrence in the npAF patient population. Despite its promising 1-year efficacy rates, the periprocedural complication rate for CVP was significantly higher than both CA and SA.
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Affiliation(s)
- Zoheb Khan
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Mohanad Hamandi
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Hafiza Khan
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - John Michael DiMaio
- Cardiovascular Research, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Matthew Evans
- Electrophysiology, Baylor Scott & White The Heart Hospital, Denton, Texas
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Rollin A, Mandel F, Grunenwald E, Mondoly P, Monteil B, Marcheix B, Maury P. Hybrid surgical ablation for persistent or long standing persistent atrial fibrillation: A French single centre experience. Ann Cardiol Angeiol (Paris) 2020; 69:86-92. [PMID: 32241522 DOI: 10.1016/j.ancard.2020.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/04/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hybrid ablation for the treatment of atrial fibrillation is a single combined procedure consisting in a minimally thoracoscopic surgical ablation followed by a catheter ablation. This promising technique is recommended in persistent atrial fibrillation according to the current guidelines but is not routinely performed in France, mainly due to the absence of reimbursement by the French National Health Insurance. AIMS The aim of this prospective and single-centre study was to analyse, for the first time in France, the feasibility, efficacy and complication rates of hybrid ablation in patients with persistent atrial fibrillation. METHODS Hybrid ablation was performed in 15 consecutive patients (13 men, mean age 61±6 years) with persistent (7 patients) or long standing persistent (8 patients) atrial fibrillation. RESULTS Hybrid ablation was completed in 14/15 patients. Eleven patients returned in sinus rhythm during the procedure. Two patients (13%) had major per-procedural complications and 2 had minor complications. During an average follow-up of 25±6 months, 6 patients (40%) underwent a redo catheter ablation because of atrial tachycardia, mainly peri-mitral atrial flutter. At 1 year follow up, 14/15 patients were in sinus rhythm, including 11 free of antiarrhythmic drugs.
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Affiliation(s)
- A Rollin
- Hôpital Rangueil, CHU Toulouse, Toulouse, France.
| | - F Mandel
- Hôpital Rangueil, CHU Toulouse, Toulouse, France
| | - E Grunenwald
- Service de chirurgie cardiaque, hôpital Rangueil, CHU Toulouse, Toulouse, France
| | - P Mondoly
- Hôpital Rangueil, CHU Toulouse, Toulouse, France
| | - B Monteil
- Hôpital Rangueil, CHU Toulouse, Toulouse, France
| | - B Marcheix
- Service de chirurgie cardiaque, hôpital Rangueil, CHU Toulouse, Toulouse, France
| | - P Maury
- Hôpital Rangueil, CHU Toulouse, Toulouse, France
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9
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Sharma E, Bussa-Rao C, Sergot A, Ratnasigham K, Thomas GP. Small bowel obstruction secondary to diaphragmatic herniation following transabdominal cardiac ablation. Ann R Coll Surg Engl 2019; 102:e57-e59. [PMID: 31660767 DOI: 10.1308/rcsann.2019.0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report an unusual case of strangulated diaphragmatic hernia secondary to a pericardial ablation, which resulted in necrosis of the incarcerated small bowel. Through a literature search, we have found a limited number of similar cases introducing a case series for this rare but potentially fatal condition.
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Affiliation(s)
- E Sharma
- Department of Surgery, Ashford and Saint Peter's Hospitals NHS Trust, Lyne, Chertsey, UK
| | - C Bussa-Rao
- University College London Medical School, London, UK
| | - A Sergot
- Department of Surgery, Ashford and Saint Peter's Hospitals NHS Trust, Lyne, Chertsey, UK
| | - K Ratnasigham
- Department of Surgery, Ashford and Saint Peter's Hospitals NHS Trust, Lyne, Chertsey, UK
| | - G P Thomas
- Department of Surgery, Ashford and Saint Peter's Hospitals NHS Trust, Lyne, Chertsey, UK
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Gwag HB, Jeong DS, Hwang JK, Park SJ, Park KM, Kim JS, On YK. Additional cavotricuspid isthmus ablation may reduce recurrent atrial tachyarrhythmia after total thoracoscopic ablation for persistent atrial fibrillation. Interact Cardiovasc Thorac Surg 2019; 28:177-182. [PMID: 30060163 DOI: 10.1093/icvts/ivy236] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 06/24/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Unlike catheter ablation, little is known about the benefits of cavotricuspid isthmus (CTI) ablation in total thoracoscopic ablation (TTA) of atrial fibrillation (AF). This study aimed to investigate the incidence of recurrent atrial tachyarrhythmia (ATa) according to additional CTI ablation after TTA in patients with persistent AF. METHODS Among 208 consecutive patients who underwent TTA for persistent AF at the Samsung Medical Center from February 2012 to January 2016, a total of 63 patients with CTI ablation and 91 patients without CTI ablation were included in the final analysis. CTI ablation was performed in patients who had long-standing AF or atrial flutter episodes during the admission period. RESULTS There was no difference in baseline characteristics between the CTI ablation and non-CTI ablation groups, except for a higher number of male patients in the CTI ablation group. The CTI ablation group showed a significantly higher survival rate free from recurrent ATa than that of the non-CTI ablation group at 5 years (52.5% vs 41.4%, P = 0.046). In the multivariable analysis, CTI ablation (hazard ratio 0.46, 95% confidence interval 0.217-0.971; P = 0.042) and left atrial volume index (hazard ratio 1.05, 95% confidence interval 1.029-1.070; P < 0.001) were significantly correlated with recurrent ATa. CONCLUSIONS Patients with CTI ablation showed a better survival rate free from recurrent ATa compared with the non-CTI ablation group. The additional CTI ablation may reduce recurrent ATa after TTA in patients with documented atrial flutter or long-standing AF.
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Affiliation(s)
- Hye Bin Gwag
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Kyung Hwang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung-Min Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Soo Kim
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Keun On
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Hybrid thoracoscopic surgical and transvenous catheter ablation versus transvenous catheter ablation in persistent and longstanding persistent atrial fibrillation (HARTCAP-AF): study protocol for a randomized trial. Trials 2019; 20:370. [PMID: 31221218 PMCID: PMC6585003 DOI: 10.1186/s13063-019-3365-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 04/15/2019] [Indexed: 11/25/2022] Open
Abstract
Background Success rates with conventional transvenous endocardial pulmonary vein isolation in patients with persistent and longstanding persistent atrial fibrillation (AF) are variable due to advanced electrical and structural remodeling of the atria. As a consequence, more extensive endocardial lesions, minimally invasive thoracoscopic surgical techniques, and hybrid ablation (combining thoracoscopic epicardial surgical and endocardial catheter ablation) have been developed. Hypothesis The HARTCAP-AF trial hypothesizes that hybrid AF ablation is more effective than (repeated) transvenous endocardial catheter ablation in (longstanding) persistent AF, without increasing the number of associated major adverse events. Methods This randomized controlled trial will include 40 patients with persistent or longstanding persistent AF who will be 1:1 randomized to either hybrid ablation or (repeated) catheter ablation. The procedures and follow-up are conducted according to the guidelines. The primary effectiveness endpoint is freedom from any supraventricular arrhythmia lasting longer than 5 min without the use of Vaughan-Williams class I or III antiarrhythmic drugs through 12 months of follow-up after the last procedure. In the catheter ablation arm, a second procedure planned within 6 months after the index procedure is allowed for obtaining the primary endpoint. Additionally, adverse events, cost-effectiveness, and quality of life data will be recorded. Trial registration ClinicalTrials.gov, NCT02441738. Registered on 12 May 2015. Electronic supplementary material The online version of this article (10.1186/s13063-019-3365-9) contains supplementary material, which is available to authorized users.
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Gwag HB, Jeong DS, Hwang JK, Park SJ, On YK, Kim JS, Park KM. Characteristics of symptomatic recurrent tachyarrhythmia after thoracoscopic ablation for persistent atrial fibrillation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:686-693. [PMID: 30919458 DOI: 10.1111/pace.13667] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 02/19/2019] [Accepted: 03/19/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Recurrent atrial tachyarrhythmia (ATa) is a challenge in all ablation procedures for atrial fibrillation (AF). However, data on ATa after totally thoracoscopic ablation (TTA) is lacking. This study aimed to investigate the mechanisms and outcomes of recurrent ATa after TTA. METHODS Eligible patients for the present study were those who underwent electrophysiologic study and catheter-based radiofrequency ablation (RFA) at least 3 months after TTA for symptomatic recurrent ATa that was refractory to antiarrhythmic drugs and/or cardioversion. Follow-up outcomes included recurrent ATa after first or repeated RFA. RESULTS A consecutive 154 TTA patients were evaluated. A total of 24 patients showed symptomatic recurrent ATa after TTA, and 22 underwent RFA. Half of the patients (11/22, 50%) had AF as a form of recurrent ATa. Nonpulmonary vein (PV)-related mechanisms of ATa were noted in half of patients. PV gaps showed a characteristic distribution: most gaps in right PVs were located at the posterior ridge (71.4%) with the posterior ridge of left PVs saved in all patients. Post-RFA recurrence rate was 27.3% during a median follow-up of 9.1 months, with all recurrences except for one occurring within 3 months after first RFA. CONCLUSIONS During a median of 17.8 months after TTA, 24 patients (24/154, 15.6%) developed symptomatic recurrent ATa, and 22 patients underwent RFA. Post-RFA recurrence rate was 27.3%, which mostly occurred within 3 months after RFA. Catheter-based ablation of recurrent arrhythmias may be effective, but challenging.
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Affiliation(s)
- Hye Bin Gwag
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Seoul, Republic of Korea
| | - Jin Kyung Hwang
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Seung-Jung Park
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Young Keun On
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - June Soo Kim
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Kyoung-Min Park
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Seoul, Republic of Korea
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Cox JL, Churyla A, Malaisrie SC, Pham DT, Kruse J, Kislitsina ON, McCarthy PM. A Hybrid Maze Procedure for Long-Standing Persistent Atrial Fibrillation. Ann Thorac Surg 2018; 107:610-618. [PMID: 30118714 DOI: 10.1016/j.athoracsur.2018.06.064] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 06/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Catheter ablation (CA) for long-standing persistent atrial fibrillation (LSPAF) is suboptimal, and open surgical ablation, although more successful, is too invasive to be a first-line therapy. Less invasive hybrid procedures that combine thoracoscopic surgery (TS) with CA have been only marginally more successful for LSPAF than CA alone. METHODS Joint hybrid procedures for LSPAF are based on the assumption that AF surgery and CA procedures can be guided by intraoperative mapping. However, intraoperative mapping is not always dependable because of the transient nature of the sustaining reentrant drivers. The best results in patients with LSPAF have been attained with the non-guided, anatomy-based surgical Maze-III and Maze-IV procedures. Likewise, a staged TS/CA hybrid procedure that creates a combination of lesions that adhere to the concept of a Maze pattern, that is, a Hybrid Maze-IV procedure, should be more effective for LSPAF. RESULTS Initial TS includes all lesions of the Maze-IV procedure except the mitral line, coronary sinus lesion, and one right atrial lesion. Follow-up CA at 3 months includes touching up any incomplete TS lesions, a cavotricuspid isthmus lesion, and a mitral line/coronary sinus lesion in the 10% to 15% of patients with post-TS perimitral flutter. This combination of TS and CA lesions creates a complete Maze-IV procedure. CONCLUSIONS It is possible to create the complete lesion pattern of a Maze-IV procedure with a staged TS/CA hybrid procedure. The success of this Hybrid Maze procedure in patients with LSPAF should be the same as that attained with an open surgical Maze-IV procedure.
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Affiliation(s)
- James L Cox
- Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Andrei Churyla
- Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - S Chris Malaisrie
- Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Duc Thinh Pham
- Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jane Kruse
- Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Olga N Kislitsina
- Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Patrick M McCarthy
- Bluhm Cardiovascular Institute, Division of Cardiac Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Bulava A. Hybrid procedures for persistent atrial fibrillation: necessity and timing of the catheter ablation stage. J Thorac Dis 2018; 10:E83-E86. [PMID: 29601058 DOI: 10.21037/jtd.2017.12.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alan Bulava
- Department of Cardiology, Budweis Hospital, Ceske Budejovice, Czech Republic.,Faculty of Medicine and Dentistry, Palacký University Olomouc, Olomouc, Czech Republic.,Faculty of Health and Social Sciences, University of South Bohemia in Ceske Budejovice, Ceske Budejovice, Czech Republic
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15
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Furniss GO, Panagopoulos D, Kanoun S, Davies EJ, Tomlinson DR, Haywood GA. The Effect of Atrial Fibrillation Ablation Techniques on P Wave Duration and P Wave Dispersion. Heart Lung Circ 2018; 28:389-396. [PMID: 29501465 DOI: 10.1016/j.hlc.2018.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/10/2018] [Accepted: 02/04/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND A reduction in surface electrocardiogram (ECG) P wave duration and dispersion is associated with improved outcomes in atrial fibrillation ablation. We investigated the effects of different ablation strategies on P wave duration and dispersion, hypothesising that extensive left atrial (LA) ablation with left atrial posterior wall isolation would give a greater reduction in P wave duration than more limited ablation techniques. METHODS A retrospective analysis of ECGs from patients who have undergone atrial fibrillation (AF) ablation was performed and pre-procedural sinus rhythm ECGs were compared with the post procedure ECGs. Maximal P wave duration was measured in leads I or II, minimum P wave duration in any lead and values were calculated for P wave duration and dispersion. Left atrial dimensions and medications at the time of ECG were documented. Ablation strategies compared were; pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) and the persistent AF (PsAF) ablation strategies of pulmonary vein isolation plus additional linear lesions (Lines), left atrial posterior wall isolation via catheter (PWI) and left atrial posterior wall isolation via staged surgical and catheter ablation (Hybrid). RESULTS Sixty-nine patients' ECGs were analysed: 19 PVI, 21 Lines, 14 PWI, 15 Hybrid. Little correlation was seen between pre-procedure left atrial size and P wave duration (r=0.24) but LA size and P wave duration was larger in PsAF patients. A significant difference was seen in P wave reduction driven by Hybrid AF ablation (p<0.005) and Lines (<0.02). There was no difference amongst P wave dispersion between groups but the largest reduction was seen in the Hybrid ablation group. CONCLUSIONS P wave duration increased with duration of continuous atrial fibrillation. Hybrid AF ablation significantly reduced P wave duration and dispersion compared to other ablation strategies including posterior wall isolation via catheter despite this being the same lesion set.
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Affiliation(s)
- Guy O Furniss
- Musgrove Park Hospital, Taunton, UK; University of Plymouth, Plymouth, UK; Southwest Cardiothoracic Centre, Derriford Hospital, Plymouth, UK.
| | | | - Sadeek Kanoun
- Southwest Cardiothoracic Centre, Derriford Hospital, Plymouth, UK
| | - Edward J Davies
- Southwest Cardiothoracic Centre, Derriford Hospital, Plymouth, UK
| | | | - Guy A Haywood
- Southwest Cardiothoracic Centre, Derriford Hospital, Plymouth, UK
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16
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Zhang Y, Guo H. Surgical perspective on hybrid ablation for non-paroxysmal atrial fibrillation. J Thorac Dis 2018; 9:4937-4940. [PMID: 29312696 DOI: 10.21037/jtd.2017.11.146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yuyuan Zhang
- Department of Adult Cardiac Surgery, Guangdong General Hospital, Guangdong Provincial Cardiovascular Institute, Guangzhou 510100, China
| | - Huiming Guo
- Department of Adult Cardiac Surgery, Guangdong General Hospital, Guangdong Provincial Cardiovascular Institute, Guangzhou 510100, China
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17
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The safety and efficacy of hybrid ablation for the treatment of atrial fibrillation: A meta-analysis. PLoS One 2018; 13:e0190170. [PMID: 29298352 PMCID: PMC5752005 DOI: 10.1371/journal.pone.0190170] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/08/2017] [Indexed: 12/11/2022] Open
Abstract
Introduction Hybrid ablation, an emerging therapy that combines surgical intervention and catheter ablation, has become a viable option for the treatment of persistent atrial fibrillation. In this analysis, we aimed to evaluate the safety and efficacy of hybrid ablation, as well as compare the outcomes of one-step and staged approaches. Methods We conducted a search in major online databases and selected the studies that met the inclusion criteria. The primary endpoint was defined as no episode of atrial fibrillation or atrial tachycardia lasting longer than 30 seconds without administration of antiarrhythmic drugs. Results Sixteen studies including 785 patients (paroxysmal atrial fibrillation, n = 83; persistent atrial fibrillation, n = 214; long-standing persistent atrial fibrillation, n = 488) were selected. Average history of atrial fibrillation was (5.0±1.6) years. The pooled proportion of patients who were arrhythmia-free at the primary endpoint was 73% (95% CI, 64%–81%, Cochran’s Q, P<0.001; I2 = 81%). The pooled rate of severe short-term complications was 4% (95% CI, 2%–7%, Cochran’s Q, P = 0.01; I2 = 51%). The success rate after one-step procedures (69%) was lower than that after staged procedures (78%). The staged approach could ultimately prove to be safer, although complication rates were relatively low for both approaches (2% and 5%, respectively). Conclusions Hybrid ablation is an effective and generally safe procedure. The current data suggest that staged hybrid ablation could be the optimal approach, as it is associated with a higher success rate and a seemingly lower complication rate. Additional randomized controlled trials are necessary to confirm these results.
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Umbrain V, Verborgh C, Chierchia GB, de Asmundis C, Brugada P, Meir ML. One-stage Approach for Hybrid Atrial Fibrillation Treatment. Arrhythm Electrophysiol Rev 2017; 6:210-216. [PMID: 29326837 PMCID: PMC5739889 DOI: 10.15420/2017.36.2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 11/16/2017] [Indexed: 01/13/2023] Open
Abstract
The one-stage approach for hybrid atrial fibrillation involves the simultaneous and close cooperation of different medical specialties. This review attempts to describe its challenging issues, exposing a plan to balance thrombotic risk and bleeding risk. It describes the combined surgical-electrophysiological procedure. Specific topics, involving hemodynamic, fluid and respiratory management during surgery are considered, and problems related to postoperative pain are surveyed.
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Affiliation(s)
- Vincent Umbrain
- Department of Anaesthesiology and Perioperative Medicine, University Hospital Brussels,Free University of Brussels, Belgium
| | - Christian Verborgh
- Department of Anaesthesiology and Perioperative Medicine, University Hospital Brussels,Free University of Brussels, Belgium
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, University Hospital Brussels,Free University of Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, University Hospital Brussels,Free University of Brussels, Belgium
| | - Pedro Brugada
- Heart Rhythm Management Centre, University Hospital Brussels,Free University of Brussels, Belgium
| | - Mark La Meir
- Department of Cardiac Surgery, University Hospital Brussels,Free University of Brussels, Belgium
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Ad N, Holmes SD, Friehling T. Minimally Invasive Stand-Alone Cox Maze Procedure for Persistent and Long-Standing Persistent Atrial Fibrillation. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005352. [PMID: 29138143 DOI: 10.1161/circep.117.005352] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/13/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Niv Ad
- From the Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown (N.A.); Washington Adventist Hospital, Takoma Park, MD (N.A.); Inova Fairfax Hospital, Falls Church, VA (N.A.); WVU Heart and Vascular Institute, West Virginia University, Morgantown (S.D.H.); and Inova Medical Group, Fairfax, VA (T.F.)
| | - Sari D. Holmes
- From the Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown (N.A.); Washington Adventist Hospital, Takoma Park, MD (N.A.); Inova Fairfax Hospital, Falls Church, VA (N.A.); WVU Heart and Vascular Institute, West Virginia University, Morgantown (S.D.H.); and Inova Medical Group, Fairfax, VA (T.F.)
| | - Ted Friehling
- From the Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown (N.A.); Washington Adventist Hospital, Takoma Park, MD (N.A.); Inova Fairfax Hospital, Falls Church, VA (N.A.); WVU Heart and Vascular Institute, West Virginia University, Morgantown (S.D.H.); and Inova Medical Group, Fairfax, VA (T.F.)
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20
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Midterm outcomes of two-staged hybrid ablation of persistent and long-standing persistent atrial fibrillation using the versapolar epicardial surgical device and subsequent catheter ablation. J Interv Card Electrophysiol 2017; 50:187-194. [DOI: 10.1007/s10840-017-0286-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
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21
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Batul SA, Gopinathannair R. Atrial Fibrillation in Heart Failure: a Therapeutic Challenge of Our Times. Korean Circ J 2017; 47:644-662. [PMID: 28955382 PMCID: PMC5614940 DOI: 10.4070/kcj.2017.0040] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/27/2017] [Indexed: 11/11/2022] Open
Abstract
Atrial fibrillation (AF) and heart failure (HF) are growing cardiovascular disease epidemics worldwide. There has been an exponential increase in the prevalence of AF and HF correlating with an increased burden of cardiac risk factors and improved survival rates in patients with structural heart disease. AF is associated with adverse prognostic outcomes in HF and is most evident in mild-to-moderate left ventricular (LV) dysfunction where the loss of "atrial kick" translates into poorer quality of life and increased mortality. In the absence of underlying structural heart disease, arrhythmia can independently contribute to the development of cardiomyopathy. Together, these 2 conditions carry a high risk of thromboembolism due to stasis, inflammation and cellular dysfunction. Stroke prevention with oral anticoagulation (OAC) remains a mainstay of treatment. Pharmacologic rate and rhythm control remain limited by variable efficacy, intolerance and adverse reactions. Catheter ablation for AF has resulted in a paradigm shift with evidence indicating superiority over medical therapy. While its therapeutic success is high for paroxysmal AF, it remains suboptimal in persistent AF. A better mechanistic understanding of AF as well as innovations in ablation technology may improve patient outcomes in the future. Refractory cases may benefit from atrioventricular junction ablation and biventricular pacing. The value of risk factor modification, especially with regard to obesity, sleep apnea, hypertension and diabetes, cannot be emphasized enough. Close interdisciplinary collaboration between HF specialists and electrophysiologists is an essential component of good long-term outcomes in this challenging population.
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Affiliation(s)
- Syeda Atiqa Batul
- Division of Cardiology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY USA
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22
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Bulava A, Mokracek A, Hanis J, Eisenberger M, Kurfirst V, Dusek L. Correlates of Arrhythmia Recurrence After Hybrid Epi- and Endocardial Radiofrequency Ablation for Persistent Atrial Fibrillation. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005273. [DOI: 10.1161/circep.117.005273] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/07/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Alan Bulava
- From the Department of Cardiology (A.B., J.H., M.E.) and Department of Cardiac Surgery (A.M., V.K.), Budweis Hospital, České Budějovice, Czech Republic; Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic (A.B.); Faculty of Health and Social Sciences, University of South Bohemia in České Budějovice, Czech Republic (A.B., A.M.); and Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic (L.D.)
| | - Ales Mokracek
- From the Department of Cardiology (A.B., J.H., M.E.) and Department of Cardiac Surgery (A.M., V.K.), Budweis Hospital, České Budějovice, Czech Republic; Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic (A.B.); Faculty of Health and Social Sciences, University of South Bohemia in České Budějovice, Czech Republic (A.B., A.M.); and Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic (L.D.)
| | - Jiri Hanis
- From the Department of Cardiology (A.B., J.H., M.E.) and Department of Cardiac Surgery (A.M., V.K.), Budweis Hospital, České Budějovice, Czech Republic; Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic (A.B.); Faculty of Health and Social Sciences, University of South Bohemia in České Budějovice, Czech Republic (A.B., A.M.); and Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic (L.D.)
| | - Martin Eisenberger
- From the Department of Cardiology (A.B., J.H., M.E.) and Department of Cardiac Surgery (A.M., V.K.), Budweis Hospital, České Budějovice, Czech Republic; Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic (A.B.); Faculty of Health and Social Sciences, University of South Bohemia in České Budějovice, Czech Republic (A.B., A.M.); and Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic (L.D.)
| | - Vojtech Kurfirst
- From the Department of Cardiology (A.B., J.H., M.E.) and Department of Cardiac Surgery (A.M., V.K.), Budweis Hospital, České Budějovice, Czech Republic; Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic (A.B.); Faculty of Health and Social Sciences, University of South Bohemia in České Budějovice, Czech Republic (A.B., A.M.); and Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic (L.D.)
| | - Ladislav Dusek
- From the Department of Cardiology (A.B., J.H., M.E.) and Department of Cardiac Surgery (A.M., V.K.), Budweis Hospital, České Budějovice, Czech Republic; Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic (A.B.); Faculty of Health and Social Sciences, University of South Bohemia in České Budějovice, Czech Republic (A.B., A.M.); and Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic (L.D.)
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Electrophysiological findings after surgical ablation of atrial fibrillation using AtriCure system. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2017.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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24
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Bulava A, Mokráček A, Eisenberger M, Kurfirst V, Dušek L. Middle-term results of hybrid atrial fibrillation ablation using AtriCure system. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2017.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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25
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Budera P, Osmančík P, Talavera D, Kraupnerová A, Rizov V, Fojt R, Straka Z. Thoracoscopic ablation of atrial fibrillation - Should we still be concerned about periprocedural complications? COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2017.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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26
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Budera P, Kurfirst V, Černý Š, Němec P, Pirk J, Lindner J, Rohn V, Mokráček A, Hájek T, Pojar M, Brát R, Šantavý P, Branny P, Benešová K, Jarkovský J, Straka Z. Reality of surgical treatment of atrial fibrillation in the Czech Republic - Data from the National Register of Cardiac Surgery (2010-2015). COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2017.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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27
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Wojtaszczyk A, Buchta P, Myrda K, Gąsior M, Kowalski O, Kalarus Z, Filipiak K, Zembala M, Zembala MO. Hybrid dual stage closed chest ablation of persistent atrial fibrillation. COR ET VASA 2017. [DOI: 10.1016/j.crvasa.2017.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Budera P, Osmancik P, Talavera D, Kraupnerova A, Fojt R, Zdarska J, Vanek T, Straka Z. Two-staged hybrid ablation of non-paroxysmal atrial fibrillation: clinical outcomes and functional improvements after 1 year. Interact Cardiovasc Thorac Surg 2017; 26:77-83. [DOI: 10.1093/icvts/ivx248] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 07/03/2017] [Indexed: 12/23/2022] Open
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Margulescu AD, Mont L. Persistent atrial fibrillation vs paroxysmal atrial fibrillation: differences in management. Expert Rev Cardiovasc Ther 2017; 15:601-618. [PMID: 28724315 DOI: 10.1080/14779072.2017.1355237] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common human arrhythmia. AF is a progressive disease, initially being nonsustained and induced by trigger activity, and progressing towards persistent AF through alteration of the atrial myocardial substrate. Treatment of AF aims to decrease the risk of stroke and improve the quality of life, by preventing recurrences (rhythm control) or controlling the heart rate during AF (rate control). In the last 20 years, catheter-based and, less frequently, surgical and hybrid ablation techniques have proven more successful compared with drug therapy in achieving rhythm control in patients with AF. However, the efficiency of ablation techniques varies greatly, being highest in paroxysmal and lowest in long-term persistent AF. Areas covered: In this review, we discuss the fundamental differences between paroxysmal and persistent AF and the potential impact of those differences on patient management, emphasizing the available therapeutic strategies to achieve rhythm control. Expert commentary: Treatment to prevent AF recurrences is suboptimal, particularly in patients with persistent AF. Emerging technologies, such as documentation of atrial fibrosis using magnetic resonance imaging and documentation of electrical substrate using advanced electrocardiographic imaging techniques are likely to provide valuable insights about patient-specific tailoring of treatments.
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Affiliation(s)
- Andrei D Margulescu
- a University of Medicine and Pharmacy 'Carol Davila' Bucharest , Bucharest , Romania.,b Department of Cardiology , University and Emergency Hospital of Bucharest , Bucharest , Romania.,c Unitat de Fibril·lació Auricular (UFA), Hospital Clinic , Universitat de Barcelona , Barcelona , Spain
| | - Lluis Mont
- c Unitat de Fibril·lació Auricular (UFA), Hospital Clinic , Universitat de Barcelona , Barcelona , Spain.,d Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS) , Barcelona , Spain.,e Centro de Investigación Biomédica en Red (CIBER Cardiovascular) , Barcelona , Spain
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Bulava A, Mokracek A, Kurfirst V. Delayed Electroanatomic Mapping After Surgical Ablation for Persistent Atrial Fibrillation. Ann Thorac Surg 2017; 104:2024-2029. [PMID: 28760469 DOI: 10.1016/j.athoracsur.2017.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/07/2017] [Accepted: 05/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Long-term efficacy of catheter-based treatment of persistent atrial fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently but their true efficacy has never been systematically tested. METHODS Seventy patients (median age 63.5 years) with persistent atrial fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein (PV) isolation, linear ablation, Marshal ligament disruption, and exclusion of the left atrial appendage. The procedure was followed by electroanatomic mapping 2 to 3 months later. RESULTS Only 76% of patients were in sinus rhythm at the beginning of electroanatomic mapping. Right PVs were found isolated in a higher proportion of patients compared with left PVs (75.7% versus 91.4%, p < 0.001). All four PVs and the left atrial posterior wall were isolated in 68.6% and 22.9% of patients, respectively. Most of the gaps around left PVs were localized in the superior and anterior quadrants, whereas in right PVs, the gaps were found predominantly on the roof and posterior wall. A typical site of reconduction on the inferior connecting line was the segment adjacent to the right inferior PV. No typical reconduction sites were found on the roof line, as 58.5% of patients required completion of the roof line along its full length. CONCLUSIONS Epicardial PV isolation was successful in the majority of patients, but was underwhelming with regard to isolation of the left PVs. Effective epicardially placed linear lines were rare. Our results highlight the significant limitations associated with a single-stage surgical approach and underline the necessity for a two-staged hybrid approach in the treatment of persistent atrial fibrillation.
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Affiliation(s)
- Alan Bulava
- Department of Cardiology, Budweis Hospital, Ceske Budejovice, Czech Republic; Faculty of Medicine and Dentistry, Palacky University Olomouc, Olomouc, Czech Republic; Faculty of Health and Social Sciences, University of South Bohemia, Ceske Budejovice, Czech Republic.
| | - Ales Mokracek
- Department of Cardiac Surgery, Budweis Hospital, Ceske Budejovice, Czech Republic; Faculty of Health and Social Sciences, University of South Bohemia, Ceske Budejovice, Czech Republic
| | - Vojtech Kurfirst
- Department of Cardiac Surgery, Budweis Hospital, Ceske Budejovice, Czech Republic
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Marchlinski F, Kumareswaran R. Hybrid Ablation for Atrial Fibrillation: Better or Just Different? JACC Clin Electrophysiol 2017; 3:350-352. [PMID: 29759447 DOI: 10.1016/j.jacep.2016.12.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 12/08/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Francis Marchlinski
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Ramanan Kumareswaran
- Cardiac Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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32
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Osmancik P, Budera P. The future of hybrid ablation: an emerging need for an anticoagulation protocol for thoracoscopic ablation. J Thorac Dis 2017; 9:E322-E326. [PMID: 28449532 DOI: 10.21037/jtd.2017.02.95] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The midterm efficacy of hybrid ablation of atrial fibrillation (AF) reported in recent papers is about 70% in terms of sinus rhythm maintenance without antiarrhythmic drugs. Bearing in mind that the majority of patients enrolled are patients with persistent and long-standing persistent AF, the reported efficacies seem to be very good. Despite the high efficacies, safety remains a critical issue in hybrid, and especially thoracoscopic ablations. The frequency of complications during thoracoscopic ablations is more than 10% in the majority of reports. Most are short-term with no sequelae (such as pneumothorax or pneumonia); however, life-threatening complications have also been described, e.g., a sternotomy in response to a laceration of the left atrium (LA). One of the most serious ablation complications is stroke. The rate of strokes, which has been reported during or shortly after thoracoscopic ablation, seems to be higher than the rate reported after catheter ablation. This is especially true in papers describing thoracoscopic ablations that were not immediately followed by a catheter ablation. A possible explanation is differences in anticoagulation management during the two procedures. During catheter endocardial procedures, a standard anticoagulation protocol exists and is routinely applied; however, there is no such set of recommendations for anticoagulation during the thoracoscopic-phase of an ablation. It seems probable that, in many cases, no anticoagulation is used during thoracoscopic ablations. Moreover, whatever anticoagulation protocol is used during thoracoscopic ablations often goes unreported. A discussion about the best anticoagulation strategy during thoracoscopic ablation is urgently needed. In the future, standards of anticoagulation during thoracoscopic ablation should be clearly reported, just as they are now for catheter ablations.
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Affiliation(s)
- Pavel Osmancik
- Cardiocenter, Third Faculty of Medicine, Charles University Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Budera
- Clinic of Cardiac Surgery, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
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Kaufman AJ, Kahn ET, Villena-Vargas J, Steele JG, Flores RM. Laparoscopic Repair of an Intrapericardial Diaphragmatic Hernia After Convergent Maze Procedure. Ann Thorac Surg 2017; 103:e541-e543. [PMID: 28163037 DOI: 10.1016/j.athoracsur.2017.01.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/04/2017] [Indexed: 11/29/2022]
Abstract
The convergent maze procedure (CMP) is a new minimally invasive technique for the surgical treatment of atrial fibrillation (AF). Recently, multiple groups have published excellent results and few adverse events with CMP. However, we now report the second case of an intrapericardial diaphragmatic hernia with small bowel obstruction that resulted from CMP. This adverse event was managed successfully by laparoscopic repair of the hernia and the use of a polytetrafluoroethylene mesh closure with hepatic buttress, achieving an excellent result. With the expanding use of CMP for the treatment of AF, awareness of this adverse event and its appropriate management are increasingly important.
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Affiliation(s)
| | | | | | | | - Raja M Flores
- Icahn School of Medicine at Mount Sinai, New York, New York
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