The Surgical Treatment of Concomitant Atrial Arrhythmias During Redo Cardiac Operations

Outcomes of Atrial Arrhythmia Surgery in Patients With Congenital Heart Disease: A Systematic Review

Background The improved life expectancy of patients with congenital heart disease is often accompanied by the development of atrial tachyarrhythmias. Similarly, the number of patients requiring redo operations is expected to continue to rise as these patients are aging. Consequently, the role of arrhythmia surgery in the treatment of atrial arrhythmias is likely to become more important in this population. Although atrial arrhythmia surgery is a well-established part of Fontan conversion procedures, evidence-based recommendations for arrhythmia surgery for macroreentrant atrial tachycardia and atrial fibrillation in other patients with congenital heart disease are still lacking. Methods and Results Twenty-eight studies were included in this systematic review. The median reported arrhythmia recurrence was 13% (interquartile range, 4%-26%) during follow-up ranging from 3 months to 15.2 years. A large variation in surgical techniques was observed. Based on the acquired data, biatrial lesions are more effective in the treatment of atrial fibrillation than exclusive right-sided lesions. Right-sided lesions may be more appropriate in the treatment of macroreentrant atrial tachycardia; evidence for the superiority of additional left-sided lesions is lacking. There are not enough data to support the use of exclusive left-sided lesions. Theoretically, prophylactic atrial arrhythmia surgery may be beneficial in this population, but evidence is currently limited. Conclusions To be able to provide recommendations for arrhythmia surgery in patients with congenital heart disease, future studies should report outcomes according to the type of preoperative arrhythmia, underlying congenital heart disease, lesion set, and energy source. This is essential for determining which surgical techniques should ideally be applied under which circumstances.

Recommendations for the use of electrophysiological study: Update 2018

The field of cardiac electrophysiology has greatly developed during the past decades. Consequently, the use of electrophysiological studies (EPSs) in clinical practice has also significantly augmented, with a progressively increasing number of certified electrophysiology centers and specialists. Since Zipes et al published the Guidelines for Clinical Intracardiac Electrophysiology and Catheter Ablation Procedures in 1995, no official document summarizing current EPS indications has been published. The current paper focuses on summarizing all relevant data of the role of EPS in patients with different types of cardiac pathologies and provides up-to-date recommendations on this topic. For this purpose, the PubMed database was screened for relevant articles in English up to December 2018 and ESC and ACC/AHA Clinical Practice Guidelines, and EHRA/HRS/APHRS position statements related to the current topic were analyzed. Current recommendations for the use of EPS in clinical practice are discussed and presented in 17 distinct cardiac pathologies. A short rationale, evidence, and indications are provided for each cardiac disease/group of diseases. In conclusion, because of its capability to establish a diagnosis in patients with a variety of cardiac pathologies, the EPS remains a useful tool in the evaluation of patients with cardiac arrhythmias and conduction disorders and is capable of establishing indications for cardiac device implantation and guide catheter ablation procedures.

Arrhythmia Surgery for Adults with Congenital Heart Disease

Patients with repaired or unrepaired congenital heart anomalies are at increased risk for arrhythmia development throughout their lives, often paralleling the need for reoperations for hemodynamic residua. The ability to incorporate arrhythmia surgery into reoperations can result in improvement in functional class and decreased need for antiarrhythmic medications. Every reoperation for congenital heart disease can be viewed as an opportunity to assess the electrical and arrhythmia substrates and to intervene to improve the arrhythmias and the hemodynamic condition of the patient. The authors review and summarize the operative techniques for arrhythmia surgery that are based on the arrhythmia mechanisms.

Prophylactic arrhythmia surgery in association with congenital heart disease

Certain congenital heart anomalies make patients more susceptible to arrhythmia development throughout their lives. This poses the question whether prophylactic arrhythmia surgery should be incorporated into reparative open heart procedures for congenital heart disease. There is currently no consensus on what constitutes a standard prophylactic procedure, owing to the questions that remain regarding lesions to be performed; energy sources to use; proximity of energy source or incisions to coronary arteries, sinoatrial node, atrioventricular node; circumstances for right atrial, left atrial, or biatrial appendectomy; and whether to perform a right, left, or biatrial maze procedure. These considerations are important because prophylactic arrhythmia procedures are performed without knowing if the patient will actually develop an arrhythmia in his or her lifetime. By reviewing and summarizing the literature, congenital heart disease patients who are at risk for developing atrial arrhythmias can be identified and lesion sets can be suggested in an effort to standardize experimental protocols for prophylactic arrhythmia surgery.

Surgical aspects of atrial arrhythmia : Right atrial ablation and anti-arrhythmic surgery in congenital heart disease

BACKGROUND

Atrial arrhythmias are frequently described in congenital heart disease.

OBJECTIVES

To provide a surgical perspective of anti-arrhythmic procedures and strategic approaches.

METHODS

Discussion of the history of anti-arrhythmic treatments in congenital heart disease.

RESULTS

Before the advent of the Maze procedure (first published in 1991), surgery mainly focused on patients with Wolff-Parkinson-White syndrome and also on arrhythmias in Ebstein's malformation. Atrial septal defects (ASD) subsequently received more attention, i.e., in terms of atrial arrhythmia in the natural prognosis and the surgically modified course and in terms of surgical versus transcatheter approaches. Based on the background of various atrial arrhythmia mechanisms of ASD, several surgical procedures have been reported, ranging from the bilateral full Maze procedure to simple modification of right atriotomy. The so-called right atrial Maze procedure occupies a special position from the viewpoint of cardiology in acquired heart disease, especially in cases of frequently occurring right heart failure. In hearts with more complex structural abnormalities, a detailed understanding of the conditions to improve overall surgical outcome and develop future "anti-arrhythmic" strategies is necessary.

CONCLUSIONS

It is important to precisely specify factors in the individual cases, not only morphological diversity but also technical and strategic variations and their consequences. A variety of anti-arrhythmic surgical procedures are currently available. How and when to use which procedure requires professional insight and cautious clinical decision-making.

Ascending aortic aneurysm repair and surgical ablation for atrial fibrillation

BACKGROUND

Although surgical ablation of atrial fibrillation is commonly performed during concomitant coronary or valve surgery, it is still only performed in a fraction these cases when indicated, and less often in patients undergoing aneurysm surgery. We describe our experience in patients undergoing ascending aneurysm repair and concomitant atrial fibrillation ablation.

METHODS

From January 2004 until November 2011, 40 patients underwent ascending aneurysm repair and atrial fibrillation ablation at our institution and were retrospectively analyzed.

RESULTS

Average age was 67.6 years (43-85). Root replacement was performed in 23 (57.5 %) and arch replacement with circulatory arrest in 18 (45 %). At an average of 41.8 months, 81 % of patients were in sinus rhythm. Operative survival was 100 %, with 1 and 5 year survival of 97.5 and 93.1 %, respectively. Kaplan-Meier analysis revealed improved overall survival in patients with rhythm success (log-rank test p = 0.037).

CONCLUSIONS

Aortic aneurysm repair with concomitant atrial fibrillation ablation is safe and efficacious despite the requirement for an already extensive procedure with rhythm success rates similar to those quoted in the setting of other procedures. Successful restoration of sinus rhythm improves long term survival and should be considered in patients presenting with aortic aneurysm and atrial fibrillation.

Prophylactic atrial arrhythmia surgical procedures with congenital heart operations: review and recommendations

Specific congenital heart anomalies significantly increase the risk for late atrial arrhythmias, raising the question whether prophylactic arrhythmia operations should be incorporated into reparative open heart procedures. Currently no consensus exists regarding standard prophylactic arrhythmia procedures. Questions remain concerning the arrhythmia-specific lesions to perform, energy sources to use, need for atrial appendectomy, and choosing a right, left, or biatrial Maze procedure. These considerations are important because prophylactic arrhythmia procedures are performed without knowing if the patient will actually experience an arrhythmia. This review identifies congenital defects with a risk for the development of atrial arrhythmias and proposes standardizing lesion sets for prophylactic arrhythmia operations.

Tachyarrhythmias and catheter ablation in adult congenital heart disease

Advances in surgical technique have had an immense impact on longevity and quality of life in patients with congenital heart disease. However, an inevitable consequence of these surgical successes is the creation of a unique patient population whose anatomy, surgical history and haemodynamics result in the development of a challenging and complex arrhythmia substrate. Furthermore, this patient group remains susceptible to the arrhythmias seen in the general adult population. It is through a thorough appreciation of the cardiac structural defect, the surgical corrective approach, and haemodynamic impact that the most effective arrhythmia care can be delivered. Catheter ablation techniques offer a highly effective management option but require a meticulous attention to the real-time integration of anatomical and electrophysiological information to identify and eliminate the culprit arrhythmia substrate. This review describes the current approach to the interventional management of patients with tachyarrhythmias in the context of congenital heart disease.

Management of late arrhythmias in adults with repaired congenital heart disease

OPINION STATEMENT

As survival of patients with congenital heart disease improves with surgery and the population of patients with repaired adult congenital heart disease (ACHD) age, understanding complications such as arrhythmias has become more important. Arrhythmias account for significant morbidity and mortality in the ACHD population. Atrial arrhythmias occur in 15 % of patients with ACHD and, in patients with severe congenital heart disease (CHD), more than 50 % develop atrial arrhythmias by the age of 65 years [1]. This article aims to give an overview of arrhythmias seen in the ACHD population and the treatment modalities available now.