Surgical and Concomitant Epicardial-Endocardial (Hybrid) Ablation of Persistent and Long-Standing Persistent Atrial Fibrillation

Rationale and Outcomes of Cryoballoon Ablation of the Left Atrial Posterior Wall in Conjunction with Pulmonary Vein Isolation

There is strong evidence in support of pulmonary vein isolation (PVI) with concomitant left atrial (LA) posterior wall (PW) isolation (PWI) for the treatment of patients with persistent atrial fibrillation (persAF). While this may be achieved using surgical and catheter-based strategies, there is growing interest in performing this approach using the cryoballoon. There are several potential advantages to this strategy. First, lesions created using the current-generation cryoballoons are typically large and durable. Second, cryoballoon ablation offers a simple technique to directly ablate and debulk the LAPW. Moreover, some consider cryoenergy a safer modality specifically with regard to collateral structures (ie, the esophagus). Based on the available data, cryoballoon PVI + PWI is associated with greater intraprocedural AF terminations and reductions in long-term AF recurrence (typically by ~20%), as compared to PVI alone in patients with persAF, but with similar rates of adverse events. As such, PVI + PWI has emerged as a significant predictor of freedom from recurrent AF (odds ratio: 3.67, 95% confidence interval: 1.44-9.34; p = 0.006) as well as all atrial arrhythmias (hazard ratio: 2.04, 95% confidence interval: 1.15-3.61; p = 0.015). Adjunct radiofrequency ablation to complete PWI is required in at least one-third of the patients, and this need is highly predicted by the LA size (significantly increased with an LA diameter > 48 mm). LAPW reconnection also seems to be associated with LA dimension, particularly an LA diameter greater than 48 mm (negative predictive value: 89.7%). Nevertheless, based on the analysis of patients who underwent repeat electrophysiology study for arrhythmia recurrences, cryoballoon PVI + PWI yields acceptable long-term durability (> 80%).

Hybrid and surgical procedures for the treatment of persistent and longstanding persistent atrial fibrillation

INTRODUCTION

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The incidence of AF increases with age and is associated with increased stroke, heart failure and mortality. Persistent and long standing persistent AF is difficult to treat and often refractory to medical therapy and catheter ablation. Areas covered: This article reviews the historical development of the surgical Cox-MAZE procedure and current hybrid and minimally invasive surgical approaches for the treatment of persistent and long standing persistent AF. The role of concomitant pulmonary vein isolation and left atrial appendage (LAA) exclusion will also be reviewed. Expert commentary: An ablation pattern emulating the Cox-Maze surgical procedure is commonly needed to obtain maintenance of sinus rhythm in patients with persistent and long standing persistent atrial fibrillation. Minimally invasive bilateral thorascopic surgical procedures can achieve a similar Cox-Maze lesion set, but are associated with increased adverse events compared to catheter ablation. Future prospective randomized studies are required to confirm whether the recently developed hybrid subxyphoid epicardial/endocardial procedure and percutaneous LAA ligation and catheter ablation are indeed as effective as surgical options with less adverse events.

Pericardial Herniation of Small Bowel Post Minimally Invasive Hybrid Maze of Atrial Fibrillation

BACKGROUND

Herniation of intraabdominal contents into the pericardial cavity is exceptionally rare, and when seen, it is most often the result of trauma, postsurgical complication, or genetic defect. There have been only a few case reports describing spontaneous bowel herniation into the pericardium in minimally invasive cardiac procedures like cardiac ablation, pacemaker placement, and minimally invasive coronary artery bypass graft.

CASE REPORT

We report the case of a 65-year-old man who presented to an urgent care center complaining of abdominal and chest pain. This patient had recently undergone a laparoscopic hybrid maze procedure and ultimately had an incarcerated loop of small bowel herniate into the pericardial sac. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the diagnosis of a pericardial hernia in patients presenting with gastrointestinal or cardiorespiratory symptoms after surgical procedures involving the diaphragm.

Atrial flutter after surgical maze: incidence, diagnosis, and management

PURPOSE OF REVIEW

The prevalence of atrial fibrillation is increasing and surgical ablation is becoming more common, both as a stand-alone procedure and when performed concomitantly with other cardiac surgery. Although surgical ablation is effective, with it unique challenges arise, including iatrogenic macroreentrant tachycardias that are often highly symptomatic and difficult to manage conservatively.

RECENT FINDINGS

Postsurgical ablation, localization of the arrhythmic circuit is difficult to determine using surface ECG alone because of alterations in the atrial myocardium, and multiple different pathways are often present. Most, however, localize to the left atrium, and percutaneous catheter ablation is emerging as an effective treatment modality.

SUMMARY

Patients with complex postoperative arrhythmias should be referred to a dedicated atrial fibrillation center when possible and symptomatic arrhythmias mapped and ablated. Knowledge of the previously performed surgical lesion set is of vital importance in understanding the mechanism of the arrhythmia and increasing procedural success rates.

VIDEO ABSTRACT

http://links.lww.com/HCO/A31.