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Baqal O, Shafqat A, Kulthamrongsri N, Sanghavi N, Iyengar SK, Vemulapalli HS, El Masry HZ. Ablation Strategies for Persistent Atrial Fibrillation: Beyond the Pulmonary Veins. J Clin Med 2024; 13:5031. [PMID: 39274244 PMCID: PMC11396655 DOI: 10.3390/jcm13175031] [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: 07/24/2024] [Revised: 08/19/2024] [Accepted: 08/23/2024] [Indexed: 09/16/2024] Open
Abstract
Despite advances in ablative therapies, outcomes remain less favorable for persistent atrial fibrillation often due to presence of non-pulmonary vein triggers and abnormal atrial substrates. This review highlights advances in ablation technologies and notable scientific literature on clinical outcomes associated with pursuing adjunctive ablation targets and substrate modification during persistent atrial fibrillation ablation, while also highlighting notable future directions.
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Affiliation(s)
- Omar Baqal
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | | | - Neysa Sanghavi
- St. George's University School of Medicine, West Indies P.O. Box 7, Grenada
| | - Shruti K Iyengar
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Hema S Vemulapalli
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Hicham Z El Masry
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
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Lorenzo C, Ortiz-Gonzalez Y, Hill D, Kinaga J, Filart L, Bello D, Duran A, Bott J, Patel S, Sendin MJ, Filart R. Real-world evidence demonstrates an appropriate atrial fibrillation population for hybrid convergent approach versus stand-alone cryoballoon ablation: A long-term safety and efficacy study. J Cardiovasc Electrophysiol 2024; 35:1624-1632. [PMID: 38898656 DOI: 10.1111/jce.16327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 05/05/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION A hybrid convergent approach (endocardial and epicardial ablation) demonstrated superior effectiveness in a recent randomized study for long-standing persistent atrial fibrillation (LSPAF). Yet, there is a lack of real-world, long-term evidence as to which patients are best candidates for a hybrid convergent approach compared to standard endocardial cryoballoon pulmonary vein isolation (CB PVI). METHODS AND RESULTS This single-center, retrospective analysis spanning from 2010 to 2015 compared two distinctly different atrial fibrillation (AF) cohorts; one treated with stand-alone cryoablation and one treated with a hybrid convergent approach. Baseline characteristics described candidates for each approach. The following criteria were utilized to determine CB PVI candidacy: (1) paroxysmal AF (PAF) (stage 3A) with failed class I/III antiarrhythmic drug (AAD) or (2) persistent/LSPAF (stage 3B/3C/3D) with failed class I/III AAD unwilling to undergo hybrid procedure. Selection criteria for the hybrid procedure included: (1) PAF refractory to both class I/III AAD and prior CB PVI (stage 3D) or (2) persistent/LSPAF (stage 3B/3C/3D) with failed class I/III AAD agreeable to hybrid procedure. Prior sternotomy was excluded. Serial electrocardiograms and continuous monitoring evaluated primary efficacy outcome of time-to-first recurrence of atrial arrhythmia after a 90-day blanking period. Secondary outcomes were procedure-related complications and AAD use (at discharge, 12, and 36 months). Kaplan-Meier methods evaluated arrhythmia recurrence. Of 276 patients, 197 (64.2 ± 10.6 years old; 66.5% male; 74.1% 3A-PAF; 18.3% 3B/3D-persistent AF; 1.0% 3C-LSPAF; 6.6% undetermined) underwent CB PVI and 79 (61.4 ± 8.1 years old; 83.5% male; 41.8% 3D-PAF; 45.5% 3B/3D-persistent AF; 12.7% 3C/3D-LSPAF) underwent hybrid procedure. Arrhythmia freedom through 36 months was 55.2% for CB PVI and 50.4% for hybrid (p = .32). Class I AAD utilization at discharge occurred in 38 (19.3%) patients in the CB PVI group and 5 (6.3%) patients in the hybrid group (p = .01). CB PVI class I AAD utilization at 12 months occurred in 14 (9.0) patients versus 0 patients for hybrid convergent (p = .004). Patients with one or more adverse event were as follows: two (1.0%) in the CB PVI group (both transient phrenic nerve palsy) and three (3.7%) in the hybrid group (two with significant bleeding and one with wound infection) (p = .14). CONCLUSION This study demonstrated that patients with more complex forms of AF (3D-PAF or 3B/3C/3D-persistent/LSPAF) could be well managed with a convergent approach. In a real-world evaluation, outcomes match safety and efficacy thresholds achieved for patients with earlier, less complex AF etiologies treated by CB PVI alone.
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Affiliation(s)
- Christian Lorenzo
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Yahaira Ortiz-Gonzalez
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Dustin Hill
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Jennifer Kinaga
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Lauren Filart
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - David Bello
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Aurelio Duran
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Jeffery Bott
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Shivangi Patel
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Mary Janette Sendin
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
| | - Roland Filart
- Department of Cardiology and Electrophysiology, Orlando Health Heart and Vascular Institute, Orlando, Florida, USA
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Wyler von Ballmoos MC, Hui DS, Mehaffey JH, Malaisrie SC, Vardas PN, Gillinov AM, Sundt TM, Badhwar V. The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. Ann Thorac Surg 2024; 118:291-310. [PMID: 38286206 DOI: 10.1016/j.athoracsur.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/08/2024] [Accepted: 01/13/2024] [Indexed: 01/31/2024]
Abstract
The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation incorporate the most recent evidence for surgical ablation and left atrial appendage occlusion in different clinical scenarios. Substantial new evidence regarding the risks and benefits of surgical left atrial appendage occlusion and the long-term benefits of surgical ablation has been produced in the last 5 years. Compared with the 2017 clinical practice guideline, the current update has an emphasis on surgical ablation in first-time, nonemergent cardiac surgery and its long-term benefits, an extension of the recommendation to perform surgical ablation in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery, and a new class I recommendation for left atrial appendage occlusion in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery. Further guidance is provided for patients with structural heart disease and atrial fibrillation being considered for transcatheter valve repair or replacement, as well as patients in need of isolated left atrial appendage management who are not candidates for surgical ablation. The importance of a multidisciplinary team assessment, treatment planning, and long-term follow-up are reiterated in this clinical practice guideline with a class I recommendation, along with the other recommendations from the 2017 guidelines that remained unchanged in their class of recommendation and level of evidence.
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Affiliation(s)
| | - Dawn S Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - J Hunter Mehaffey
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Panos N Vardas
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Thoralf M Sundt
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
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Rove JY, Cain MT, Hoffman JR, Reece TB. Noteworthy in Cardiothoracic Surgery 2023. Semin Cardiothorac Vasc Anesth 2024; 28:100-105. [PMID: 38631341 DOI: 10.1177/10892532241246037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Noteworthy in Cardiothoracic Surgery 2023 summarizes a few of the most high-impact trials and provocative trends in cardiothoracic surgery and transplantation this past year. Transplantation using organs procured from donation after circulatory death (DCD) continues to increase, and the American Society of Transplant Surgeons released recommendations on best practices in 2023. We review a summary of data on the impact of DCD on heart and lung transplantation. There has been increased interest in extracorporeal life support (ECLS), particularly after the COVID-19 pandemic, and we review the results of the highly discussed ECLS-SHOCK trial, which randomized patients in cardiogenic shock with planned revascularization to ECLS vs usual care. With improving survival outcomes in complex aortic surgery, there is a need for higher-quality evidence to guide which cooling and cerebral perfusion strategies may optimize cognitive outcomes in these patients. We review the short-term outcomes of the GOT ICE trial (Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest), a multicenter, randomized controlled trial of three different nadir temperatures, evaluating outcomes in cognition and associated changes in functional magnetic resonance imaging. Finally, both the Society of Thoracic Surgeons (STS) and the American College of Cardiology, American Heart Association, American College of Chest Physicians and Heart Rhythm Society (ACC/AHA/ACCP/HRS) updated atrial fibrillation guidelines in 2023, and we review surgically relevant updates to the guidelines and the evidence behind them.
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Affiliation(s)
- Jessica Y Rove
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Michael T Cain
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jordan R Hoffman
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - T Brett Reece
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Schena S, Lindemann J, Carlson A, Wilcox T, Oujiri J, Berger M, Gasparri M. Robotic-enhanced hybrid ablation for persistent and long-standing atrial fibrillation: Early assessment of feasibility, safety, and efficacy. JTCVS Tech 2024; 25:81-93. [PMID: 38899102 PMCID: PMC11184487 DOI: 10.1016/j.xjtc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 06/21/2024] Open
Abstract
Objectives To assess feasibility, safety, and early efficacy of robotic-enhanced epicardial ablation (RE-EA) as first stage of a hybrid approach to patients with persistent (PsAF) and long-standing atrial fibrillation (LSAF). Methods Single-center, retrospective analysis of patients with documented PsAF and LSAF who underwent RE-EA followed by catheter-guided endocardial ablation. Postoperatively, patients were monitored for major adverse events and underwent rhythm follow-up at 3 and 12 months. Results Between January 2021 and June 2023, we performed RE-EA in 64 patients (73.5% male, CHA2DS2-VASc 2.7 ± 1.6, BMI 34.1 ± 6.3 kg/m2). Mean AF preoperative duration and left atrial volume index were, respectively, 85 months and 47.5 mL/m2. Through the robotic approach, the intended lesion set was completed in all patients without cardiopulmonary bypass support, conversion to thoracotomy/sternotomy, blood transfusions, or perioperative mortality. The average LOS was 1.7 days, with only 1 patient requiring intensive care unit admission and >65% of patients discharged within 24 hours. At follow-up, 2 (3.1%) patients experienced new left pleural effusion or hemidiaphragm paralysis requiring treatment. There were no readmissions related to AF, stroke, thromboembolic events, or deaths. The mean interval between the epicardial and endocardial stages of the procedure was 5.9 months. Rhythm follow-up showed AF resolution in 73.4% and 71.9% of patients at 3 and 12 months, respectively. Conclusions RE-EA is a feasible and safe, first-stage approach for the treatment of patients with PsAF and LSAF. It improves exposure of the intended targets, favors short hospital stay, and facilitates return to activity with satisfactory AF treatment in the short term.
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Affiliation(s)
- Stefano Schena
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Jacob Lindemann
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Anne Carlson
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Trisha Wilcox
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - James Oujiri
- Division of Cardiology/Electrophysiology, Medical College of Wisconsin, Milwaukee, Wis
| | - Marcie Berger
- Division of Cardiology/Electrophysiology, Medical College of Wisconsin, Milwaukee, Wis
| | - Mario Gasparri
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis
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Juliá J, Manoharan K, Mann I, McCready J, Muthurajah J, Silberbauer J. Assessment of pericardial adhesions by means of the EpiCO 2 technique: Brighton Adhesion Classification. Heart Rhythm 2024:S1547-5271(24)02551-7. [PMID: 38734228 DOI: 10.1016/j.hrthm.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/30/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Epicardial ablation complications are more frequent in patients with preexisting pericardial adhesions. As opposed to the dry puncture technique, the coronary vein exit and carbon dioxide (CO2) insufflation (EpiCO2) technique allows diagnosing pericardial adhesions before subxiphoid puncture. OBJECTIVE This study aimed to evaluate the efficacy of the EpiCO2 technique in diagnosing pericardial adhesions prior to subxiphoid puncture. METHODS Following coronary vein exit, contrast was injected in the pericardial space, and adhesions classified using our novel Brighton Adhesion Classification (BAC) into BAC-0 (no adhesions), BAC-1 (dispersed adhesions), and BAC-2 (dense adhesions extending to the entire assessed area). CO2 insufflation allowed subclassification of BAC-1 adhesions into BAC-1a (not preventing epicardial access or restricting catheter movement) and BAC-1b (either preventing epicardial access or significantly limiting catheter movement). RESULTS Intentional coronary vein exit (right atrial appendage exit in 1 case) was achieved in all 235 consecutive epicardial ablation procedures undertaken at our center. A diagnosis of BAC-0 was made in 219 cases (93.2%), BAC-1a in 9 cases (3.8%), BAC-1b in 2 cases (0.9%), and BAC-2 in 5 cases (2.1%). This led to not attempting subxiphoid puncture in 6 cases (2.6%) and abandoning epicardial mapping because of limited catheter movement in 1 case (0.4%). Access-related complications occurred in 7 cases (3%) only in the BAC-0 group. CONCLUSION The EpiCO2 technique allows assessment of the presence of pericardial adhesions prior to attempting subxiphoid puncture for epicardial access, which may lead to a reduction in the procedural complications within this subset of patients.
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Affiliation(s)
- Justo Juliá
- Sussex Cardiac Centre, Brighton, United Kingdom.
| | | | - Ian Mann
- Sussex Cardiac Centre, Brighton, United Kingdom
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Rosati F, Baudo M, D’Alonzo M, Di Bacco L, Arabia G, Muneretto C. Hybrid strategies for stand-alone surgical ablation of atrial fibrillation. Ann Cardiothorac Surg 2024; 13:44-53. [PMID: 38380141 PMCID: PMC10875201 DOI: 10.21037/acs-2023-afm-0120] [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: 07/27/2023] [Accepted: 10/17/2023] [Indexed: 02/22/2024]
Abstract
Atrial fibrillation (AF) has been reported as a major cause of cardiac morbidity and mortality, and significantly reduces the quality of life in symptomatic patients. Current guidelines recommend antiarrhythmic drugs and catheter ablation (CA) as first-line therapy. Despite CA showed to be associated with lower incidence of peri-procedural complications, rhythm outcomes are far from optimal. Indeed, patients undergoing CA frequently require multiple AF ablation procedures, especially in those with persistent and long-standing persistent AF. While surgical ablation can provide transmural lesions, surgical invasiveness has limited the widespread use of this approach due to the increased perioperative complications. The development of minimally invasive thoracoscopic approaches has renewed the interest towards surgical ablation, thus favoring more simplified ablation sets. Therefore, the concept of "hybrid" ablation has emerged in order to theoretically enhance advantages of both minimally invasive and CA procedures while seeking to improve rhythm outcomes and reduce invasiveness and incidence of perioperative complications. On one hand, it provides the effectiveness of a surgical ablation, on the other, electrical mapping during CA can identify and treat any ablation gap or provide additional ablation lines, thus improving the chance of a stable sinus rhythm restoration at long-term follow-up. Three main thoracoscopic strategies are currently available. All of them can be performed in conjunction with the "catheter ablation procedure": the "Fusion" technique, the bipolar clamp technique, and the most recent "convergent" technique. CA can be performed either simultaneously or with a staged approach after a blanking period in order to allow the ablation lesion to stabilize. Excellent results of the hybrid procedures have been reported in terms of rhythm outcomes and incidence of perioperative complications. This narrative review aims to discuss the rationale behind the concept of hybrid ablation for the treatment of AF regarding different available strategies, results and expert opinions.
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Affiliation(s)
- Fabrizio Rosati
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Massimo Baudo
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Michele D’Alonzo
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Lorenzo Di Bacco
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Gianmarco Arabia
- Division of Electrophysiology, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Claudio Muneretto
- Division of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
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De Lurgio DB. Selection of patients for hybrid ablation procedure. J Cardiovasc Electrophysiol 2023; 34:2179-2187. [PMID: 37003267 DOI: 10.1111/jce.15901] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 03/07/2023] [Accepted: 03/26/2023] [Indexed: 04/03/2023]
Abstract
Catheter ablation for treatment of symptomatic non-paroxysmal atrial fibrillation remains challenging. Clinical failure and need for continued medical therapy or repeat ablation is common, especially in more advanced forms of atrial fibrillation. Hybrid ablation has emerged as a more effective and safe therapy than endocardial-only ablation particularly for longstanding persistent atrial fibrillation as demonstrated by the randomized controlled CONVERGE trial. Hybrid ablation requires collaboration of electrophysiologists and cardiac surgeons to develop specific workflows. This review describes the Hybrid Convergent approach in the context of available ablation options and offers guidance for workflow development and patient selection.
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Affiliation(s)
- David B De Lurgio
- Emory St. Joseph's Hospital Suite 300, Emory University, Atlanta, Georgia, USA
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Doll N, Weimar T, Kosior DA, Bulava A, Mokracek A, Mönnig G, Sahu J, Hunter S, Wijffels M, van Putte B, Rüb N, Nemec P, Ostrizek T, Suwalski P. Efficacy and safety of hybrid epicardial and endocardial ablation versus endocardial ablation in patients with persistent and longstanding persistent atrial fibrillation: a randomised, controlled trial. EClinicalMedicine 2023; 61:102052. [PMID: 37425372 PMCID: PMC10329123 DOI: 10.1016/j.eclinm.2023.102052] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/02/2023] [Accepted: 06/02/2023] [Indexed: 07/11/2023] Open
Abstract
Background Endocardial catheter ablation (CA) has limited long-term benefit for persistent and longstanding persistent atrial fibrillation (PersAF/LSPAF). We hypothesized hybrid epicardial-endocardial ablation (HA) would have superior effectiveness compared to CA, including repeat (rCA), in PersAF/LSPAF. Methods CEASE-AF (NCT02695277) is a prospective, multi-center, randomized controlled trial. Nine hospitals in Poland, Czech Republic, Germany, United Kingdom, and the Netherlands enrolled eligible participants with symptomatic, drug refractory PersAF and left atrial diameter (LAD) > 4.0 cm or LSPAF. Randomization was 2:1 to HA or CA by an independent statistician and stratified by site. Treatment assignments were masked to the core rhythm monitoring laboratory. For HA, pulmonary veins (PV) and left posterior atrial wall were isolated with thoracoscopic epicardial ablation including left atrial appendage exclusion. Endocardial touch-up ablation was performed 91-180 days post-index procedure. For CA, endocardial PV isolation and optional substrate ablation were performed. rCA was permitted between days 91-180. Primary effectiveness was freedom from AF/atrial flutter/atrial tachycardia >30-s through 12-months absent class I/III anti-arrhythmic drugs except those not exceeding previously failed doses. It was assessed in the modified intention-to-treat (mITT) population who had the index procedure and follow-up data. Major complications were assessed in the ITT population who had the index procedure. Thirty-six month follow-up continues. Findings Enrollment began November 20, 2015 and ended May 22, 2020. In 154 ITT patients (102 HA; 52 CA), 75% were male, mean age was 60.7 ± 7.9 years, mean LAD was 4.7 ± 0.4 cm, and 81% had PersAF. Primary effectiveness was 71.6% (68/95) in HA versus 39.2% (20/51) in CA (absolute benefit increase: 32.4% [95% CI 14.3%-48.0%], p < 0.001). Major complications through 30-days after index procedures plus 30-days after second stage/rCA were similar (HA: 7.8% [8/102] versus CA: 5.8% [3/52], p = 0.75). Interpretation HA had superior effectiveness compared to CA/rCA in PersAF/LSPAF without significant procedural risk increase. Funding AtriCure, Inc.
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Affiliation(s)
| | - Timo Weimar
- Eberhard Karls University School of Medicine, Tuebingen, Germany
| | - Dariusz A. Kosior
- Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
- Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland
| | - Alan Bulava
- Ceske Budejovice Hospital, Ceske Budejovice, Czech Republic and Faculty of Health and Social Sciences, University of South Bohemia in Ceske Budejovice, Czech Republic
| | - Ales Mokracek
- Ceske Budejovice Hospital, Ceske Budejovice, Czech Republic and Faculty of Health and Social Sciences, University of South Bohemia in Ceske Budejovice, Czech Republic
| | | | | | | | | | | | - Norman Rüb
- RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Petr Nemec
- Center of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Tomas Ostrizek
- Center of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Piotr Suwalski
- National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
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Baqal O, El Masry HZ. Ablative Management of Persistent Atrial Fibrillation (PeAF) with Posterior Wall Isolation (PWI): Where Do We Stand? J Cardiovasc Dev Dis 2023; 10:273. [PMID: 37504529 PMCID: PMC10380213 DOI: 10.3390/jcdd10070273] [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: 05/31/2023] [Revised: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
Atrial fibrillation is a diverse clinical entity, with persistent atrial fibrillation (PeAF) being particularly challenging to manage. Through this paper, we discuss notable developments in our understanding of ablative strategies for managing PeAF, with a special focus on posterior wall isolation (PWI).
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Affiliation(s)
- Omar Baqal
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Hicham Z El Masry
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA
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