Early Efficacy Analysis of Biatrial Ablation versus Left and Simplified Right Atrial Ablation for Atrial Fibrillation Treatment in Patients with Rheumatic Heart Disease

Two-incision totally thoracoscopic mitral valve repair combined with radiofrequency atrial fibrillation ablation in rheumatic mitral valve disease: Early results of a case series of 43 consecutive patients

BACKGROUND

Few studies have reported the outcomes of two-incision total thoracoscopic mitral valve repair (MVr) and concomitant radiofrequency atrial fibrillation ablation (RAFA) in patients with rheumatic mitral valve disease and atrial fibrillation (AF).

METHODS

We retrospectively analyzed 43 consecutive patients who underwent MVr and RAFA through two-incision total thoracoscopic technique from October 2018 to June 2022. We collected data on baseline characteristics, perioperative outcomes, and early-term results.

RESULTS

The mean age was 55.67 ± 7.64 years and 29 (67.4%) patients had New York Heart Association (NYHA) class III or IV. The mean cardiopulmonary bypass (CPB) time was 115.56 ± 8.53 min and aortic clamping time was 81.42 ± 7.54 min. There were no in-hospital deaths or strokes. The mean preoperative mitral valve orifice area (MVOA) was 0.95 (0.84-1.16) cm2 and increased to 2.56 (2.41-2.87) cm2 at discharge and 2.54 (2.44-2.76) cm2 at 3 months after surgery (P < .001). At discharge, 32 (74.4%) patients were in sinus rhythm, 7 (20.9%) were in junctional or atrial flutter rhythm, and 4 (9.3%) remained in AF. At 6 months, 35 (81.4%) patients were in sinus rhythm, 5 (11.63%) were in junctional or atrial flutter rhythm, and 3 (4.7%) were in AF.

CONCLUSIONS

Two-incision total thoracoscopic MVr and RAFA is a safe and effective procedure that can improve the MVOA and promote conversion of AF to sinus rhythm in patients with rheumatic mitral valve disease and AF. Further studies with larger sample size and longer follow-up are needed to confirm the long-term benefits of this approach.

Superiority of complete bi-atrial ablation procedure for atrial fibrillation in rheumatic mitral valve disease

INTRODUCTION

The necessity of complete bi-atrial lesion created by radiofrequency clamp and pen for nonparoxysmal atrial fibrillation (AF) in patients with rheumatic mitral valve disease (RMVD) remains unclear.

METHODS

From January 2014 to December 2018, patients with RMVD concomitant with nonparoxysmal AF who underwent mitral valve surgery concomitant surgical ablation were retrospectively enrolled. We divided patients into Group A (complete bi-atrial lesion set created by radiofrequency clamp and pen) and Group B (simplified lesion sets created by radiofrequency clamp alone including bi-atrial ablation with incomplete mitral isthmus line and stand-alone left atrial ablation) according to the surgical ablation lesion sets. Propensity score matching was applied to analyze freedom from atrial tachyarrhythmias between the two groups.

RESULTS

Two hundred eight (38.5%) and 332 (61.5%) patients were divided into Group A and Group B, respectively. In Group B, the proportion of patients with recurrent atrial flutter in the subgroup of bi-atrial ablation with incomplete mitral isthmus line was higher than that in Group A (p = .044). After propensity score matching, there were 203 patients in each group. Better freedom from atrial tachyarrhythmias without antiarrhythmic drugs was obtained in Group A (83.1%, 79.6%, and 65.4%) than Group B (73.1%, 68.4%, and 52.7%) at 12, 36, and 60 months after operation (p = .012).

CONCLUSION

The application of radiofrequency clamp and pen to create complete bi-atrial lesion set in surgical ablation for nonparoxysmal AF in RMVD was associated with superior long-term efficacy.

Bi-atrial versus left atrial ablation for patients with rheumatic mitral valve disease and non-paroxysmal atrial fibrillation (ABLATION): rationale, design and study protocol for a multicentre randomised controlled trial

INTRODUCTION

Atrial fibrillation (AF) is common in patients with rheumatic mitral valve disease (RMVD) and increase the risk of stroke and death. Bi-atrial or left atrial ablation remains controversial for treatment of AF during mitral valve surgery. The study aims to compare the efficacy and safety of bi-atrial ablation with those of left atrial ablation among patients with RMVD and persistent or long-standing persistent AF.

METHODS AND ANALYSIS

The ABLATION trial (Bi-atrial vs Left Atrial Ablation for Patients with RMVD and Non-paroxysmal AF) is a prospective, multicentre, randomised controlled study. The trial will randomly assign 320 patients with RMVD and persistent or long-standing persistent AF to bi-atrial ablation procedure or left atrial ablation procedure in a 1:1 randomisation. The primary end point is freedom from documented AF, atrial flutter or atrial tachycardia of >30 s at 12 months after surgery off antiarrhythmic drugs. Key secondary end point is the probability of freedom from permanent pacemaker implantation at 12 months after surgery. Secondary outcomes include the probability of freedom from any recurrence of atrial tachyarrhythmias with antiarrhythmic drugs, AF burden, incidence of adverse events and cardiac function documented by echocardiography at 12 months after operation.

ETHICS AND DISSEMINATION

The central ethics committee at Fuwai Hospital approved the ABLATION trial. The results of this study will be disseminated through publications in peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05021601.

Isolated left atrial cryoablation of atrial fibrillation in conventional mitral valve surgery

BACKGROUND

Recent trends of surgery for atrial fibrillation (AF) are towards more safe and effective energy sources, as well as to simplified sets of atrial lesions.

METHODS

One hundred eighteen (mean age, 67.4 ± 9.2 years) selected patients with paroxysmal/persistent AF and mitral valve (MV) disease underwent cryoablation of AF combined with conventional (not via mini-thoracotomy) MV surgery; the lesion set was limited to only the left atrium. Multivariable analyses identified predictors of cardiac rhythm at hospital discharge and follow-up.

RESULTS

There were 7 (5.9%) hospital deaths; 33 (28%) patients were discharged on AF. Higher values of preoperative left atrial volume index (odds ratio [OR] = 1.07, 95% confidence interval [95%CI]: 1.01-1.13) and mixed etiology of MV disease (OR = 4.19, 95%CI: 1.23-14.2) were predictors of hospital discharge on AF. Seventy-four (66.7%) patients were on stable sinus rhythm at follow-up (median period, 6.6 years); the 1, 5, and 10-year nonparametric estimates of adjusted freedom from AF were 98.1%, 89.2% and 45.6%, respectively. Higher values of preoperative systolic pulmonary artery pressure (hazard ratio [HR] = HR = 1.04, 95%CI: 1.01-1.08) and AF at hospital discharge (HR = 4.14, 95%CI: 1.50-11.4) were predictors of AF at follow-up.

CONCLUSIONS

During conventional MV surgery, a cryo-lesion set limited to only the left atrium may give good, immediate and long-term results. Left atrial dilation and mixed etiology of MV disease were predictors of hospital discharge on AF. Preoperative pulmonary hypertension and AF at discharge combined with an increased risk of AF at follow-up.

Safety and efficacy of biatrial vs left atrial surgical ablation during concomitant cardiac surgery: A meta-analysis of clinical studies with a focus on the causes of pacemaker implantation

INTRODUCTION

The latest STS guidelines recommend concomitant atrial fibrillation (AF) ablation not only during mitral surgery (Class IA) but also during other-than-mitral cardiac surgery procedures (Class IB) in patients with preoperative AF. Conventional Cox-Maze III/IV procedures are performed on both atria (BA), but several studies reported excellent results with left atrial only (LA) ablations: the scope of this study is to compare the safety and efficacy of BA vs LA approach.

METHODS AND RESULTS

Pubmed, Scopus, and WOS were searched from inception to November 2018: 28 studies including 7065 patients and comparing the performance of BA vs LA approaches were identified: of these, 16 (57.1%) enrolled exclusively patients with non-paroxysmal AF forms, 10 (35.7%) focused on mitral surgery as main procedure, and 16 (57.1%) regarded patients undergone Cox-Maze with radiofrequency. The 6- and 12-months prevalence of sinus rhythm were higher in the BA group (OR, 1.37, CI, 1.09-1.73, P = .008 and OR, 1.37, CI, 0.99-1.88, P = .05 respectively). Permanent pacemaker (PPM) implantation (OR, 1.85, CI, 1.38-2.49, P < .0001) and reopening for bleeding (OR, 1.70, CI, 1.05-2.75, P = .03) were higher in the BA group. Among patients undergone PPM implantation, BA group had a significantly higher risk of sinoatrial node dysfunction (OR, 3.01, CI, 1.49-6.07, P = .002).

CONCLUSIONS

Concomitant BA ablation appears superior to LA ablation in terms of efficacy but is associated with a higher risk of bleeding and of PPM implantation, more frequently due to sinoatrial node dysfunction. LA approach should be preferable in patients with a higher risk of bleeding or with perioperative risk factors for PPM implantation.

Biatrial versus Isolated Left Atrial Ablation in Atrial Fibrillation: A Systematic Review and Meta-Analysis

Objective

The outcomes of biatrial ablation (BA) and isolated left atrial ablation (LA) in atrial fibrillation remain inconclusive. In this meta-analysis, we assess the currently available evidence to compare outcomes between BA and LA.

Methods

Electronic searches were performed from database inception to December 2016, and relevant studies were accessed. Odds ratios and weight mean differences with 95% confidence intervals are reported. Twenty-one studies comprising 3609 patients were included in the present meta-analysis.

Results

The prevalence of sinus rhythm in the BA cohort was similar to that in the LA cohort at discharge, at 12 months, and after more than 1 year of follow-up. However, at 6 months, the prevalence of sinus rhythm was higher in the BA cohort than in the LA cohort. The rate of permanent pacemaker implantation was higher in the BA cohort than in the LA cohort. However, 30-day and late mortality and neurological events were similar between the BA and LA groups.

Conclusion

There was no significant difference in the rate of restored sinus rhythm, the risk of death, and cerebrovascular events between BA and LA, but BA had a higher rate of permanent pacemaker implantation.

The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation

EXECUTIVE SUMMARY

Surgical ablation for atrial fibrillation (AF) can be performed without additional risk of operative mortality or major morbidity, and is recommended at the time of concomitant mitral operations to restore sinus rhythm. (Class I, Level A) Surgical ablation for AF can be performed without additional operative risk of mortality or major morbidity, and is recommended at the time of concomitant isolated aortic valve replacement, isolated coronary artery bypass graft surgery, and aortic valve replacement plus coronary artery bypass graft operations to restore sinus rhythm. (Class I, Level B nonrandomized) Surgical ablation for symptomatic AF in the absence of structural heart disease that is refractory to class I/III antiarrhythmic drugs or catheter-based therapy or both is reasonable as a primary stand-alone procedure, to restore sinus rhythm. (Class IIA, Level B randomized) Surgical ablation for symptomatic persistent or longstanding persistent AF in the absence of structural heart disease is reasonable, as a stand-alone procedure using the Cox-Maze III/IV lesion set compared with pulmonary vein isolation alone. (Class IIA, Level B nonrandomized) Surgical ablation for symptomatic AF in the setting of left atrial enlargement (≥4.5 cm) or more than moderate mitral regurgitation by pulmonary vein isolation alone is not recommended. (Class III no benefit, Level C expert opinion) It is reasonable to perform left atrial appendage excision or exclusion in conjunction with surgical ablation for AF for longitudinal thromboembolic morbidity prevention. (Class IIA, Level C limited data) At the time of concomitant cardiac operations in patients with AF, it is reasonable to surgically manage the left atrial appendage for longitudinal thromboembolic morbidity prevention. (Class IIA, Level C expert opinion) In the treatment of AF, multidisciplinary heart team assessment, treatment planning, and long-term follow-up can be useful and beneficial to optimize patient outcomes. (Class I, Level C expert opinion).