Efficiency of radiofrequency ablation for surgical treatment of chronic atrial fibrillation in rheumatic valvular disease

Outcome of tailored therapy in rheumatic heart disease with persistent atrial fibrillation (RHD-AF)

INTRODUCTION

Rheumatic heart disease with persistent atrial fibrillation (RHD-AF) is associated with increased morbidity. However, there is no standardized approach for the maintenance of sinus rhythm (SR) in them. We aimed to determine the utility of a stepwise approach to achieve SR in RHD-AF.

METHODS

Consecutive patients with RHD-AF from July 2021 to August 2023 formed the study cohort. The stepwise approach included pharmacological rhythm control and/or electrical cardioversion (Central illustration). In patients with recurrence, additional options included AF ablation or pace and ablate strategy with conduction system pacing or biventricular pacing. Clinical improvement, NT-proBNP, 6-Minute Walk Test (6MWT), heart failure (HF) hospitalizations, and thromboembolic complications were documented during follow-up.

RESULTS

Eighty-three patients with RHD-AF (mean age 56.13 ± 9.51 years, women 72.28%) were included. Utilizing this approach, 43 (51.81%) achieved and maintained SR during the study period of 11.04 ± 7.14 months. These patients had improved functional class, lower NT-proBNP, better distance covered for 6MWT, and reduced HF hospitalizations. The duration of AF was shorter in patients who achieved SR, compared to those who remained in AF (3.15 ± 1.29 vs 6.93 ± 5.23, p = 0.041). Thirty-five percent (29) maintained SR after a single cardioversion over the study period. Only one underwent AF ablation. Of the 24 who underwent pace and ablate strategy, atrial lead was implanted in 22 (hybrid approach), and 50% of these achieved and maintained SR. Among these 24, none had HF hospitalizations, but patients who maintained SR had further improvement in clinical and functional parameters.

CONCLUSIONS

RHD-AF patients who could achieve SR with a stepwise approach, had better clinical outcomes and lower HF hospitalizations.

Injectable Mesh-Like Conductive Hydrogel Patch for Elimination of Atrial Fibrillation

Irregular electrical impulses in atrium are the leading cause of atrial fibrillation (AF), resulting in fatal arrhythmia and sudden cardiac death. Traditional medication and physical therapies are widely used, but generally suffer problems in serious physical damage and high surgical risks. Flexible and soft implants have great potential to be a novel approach for heart diseases therapy. A conductive hydrogel-based mesh cardiac patch is developed for application in AF elimination. The designed mesh patch with rhombic-shaped structure exhibits excellent flexibility, surface conformability, and deformation compliance, making it fit well with heart surface and accommodate to the deformation during heart beating. Moreover, the mechanical elastic and shape-memory properties of the mesh patch enable a minimally invasive injection of the patch into living animals. The mesh patch is implanted on the atrium surface for one month, indicating good biocompatibility and stability. Furthermore, the conductive patch can effectively eliminate AF owing to the conductivity and high charge storage capability (CSC) of the hydrogel. The proposed scheme of cardiac bioelectric signal modulation using conductive hydrogel brings new possibility for the treatment of arrhythmia diseases.

Surgical Ablation for Atrial Fibrillation During Mitral Valve Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Although surgical ablation has been shown to produce excellent outcomes at follow-up for patients with atrial fibrillation who underwent mitral valve replacement/repair (MVR), this procedure is not commonly performed. Our objective was to conduct a systematic review and meta-analysis to evaluate the outcomes of concomitant surgical ablation during MVR. Three databases were systematically reviewed for randomized clinical trials published by August 2022. The primary outcome was sinus rhythm (SR) at 12 months. Secondary outcomes included SR at discharge and 6 months, all-cause mortality, permanent pacemaker implantation, and stroke and thromboembolic events. A random-effects meta-analysis was performed, calculating odds ratios (ORs) for each outcome. Thirteen studies were included, involving 1,089 patients comparing patients who underwent either isolated MVR ("MVR-only") or concomitant surgical ablation during MVR ("MVR+Ablation"). The odds of SR were significantly higher in the MVR+Ablation group at discharge (OR 9.62, 95% confidence interval [CI] 4.87 to 19.02, I2 = 55%), at 6-month follow-up (OR 7.21, 95% CI 4.30 to 12.11, I2 = 34%), and at 1-year follow-up (OR 8.41, 95% CI 5.14 to 13.77, I2 = 48%). All-cause mortality was not different in the groups, as were stroke and thromboembolic events, whereas the odds of permanent pacemaker implantation were slightly higher in the MVR+Ablation group (OR 1.87, 95% CI 1.11 to 3.17, I2 = 0%). Concomitant surgical ablation during MVR showed excellent outcomes at short-term follow-up, despite a slightly higher rate of permanent pacemaker implantation. Further studies with longer follow-ups are needed to assess if the SR is maintained over the years.

Three Ablation Techniques for Atrial Fibrillation during Concomitant Cardiac Surgery: A Systematic Review and Network Meta-Analysis

Atrial fibrillation (AF) ablation is a frequent procedure used in concomitant cardiac surgery. However, uncertainty still exists concerning the optimal extent of lesion sets. Hence, the objective of this study was to assess the results of various ablation techniques, aiming to offer a reference for clinical decision making. This review is listed in the prospective register of systematic reviews (PROSPERO) under ID CRD42023412785. A comprehensive search was conducted across eight databases (Scopus, Google Scholar, EBSCOHost, PubMed, Medline, Wiley, ProQuest, and Embase) up to 18 April 2023. Studies were critically appraised using the Cochrane Risk of Bias 2.0 for randomized control trials (RCTs) and the Newcastle Ottawa Scale adapted by the Agency for Healthcare Research and Quality (AHRQ) for cohort studies. Forest plots of pooled effect estimates and surface under the cumulative ranking (SUCRA) were used for the analysis. Our analysis included 39 studies and a total of 7207 patients. Both bi-atrial ablation (BAA) and left atrial ablation (LAA) showed similar efficacy in restoring sinus rhythm (SR; BAA (77.9%) > LAA (76.2%) > pulmonary vein isolation (PVI; 66.5%); LAA: OR = 1.08 (CI 0.94-1.23); PVI: OR = 1.36 (CI 1.08-1.70)). However, BAA had higher pacemaker implantation (LAA: OR = 0.51 (CI 0.37-0.71); PVI: OR = 0.52 (CI 0.31-0.86)) and reoperation rates (LAA: OR = 0.71 (CI 0.28-1.45); PVI: OR = 0.31 (CI 0.1-0.64)). PVI had the lowest efficacy in restoring SR and a similar complication rate to LAA, but had the shortest procedure time (Cross-clamp (Xc): PVI (93.38) > LAA (37.36) > BAA (13.89)); Cardiopulmonary bypass (CPB): PVI (93.93) > LAA (56.04) > BAA (0.03)). We suggest that LAA is the best surgical technique for AF ablation due to its comparable effectiveness in restoring SR, its lower rate of pacemaker requirement, and its lower reoperation rate compared to BAA. Furthermore, LAA ranks as the second-fastest procedure after PVI, with a similar CPB time.

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.

Comparison of the Efficacy and Safety Endpoints of Five Therapies for Atrial Fibrillation: A Network Meta-Analysis

Introduction

Atrial fibrillation (AF) is a prevalent arrhythmia that occurs in 2–4% of adults and poses a threat to human health. Thus, comparison of the efficacy and safety of therapies for AF is warranted. Here, we used network analysis to compare efficacy (arrhythmia recurrence and re-hospitalization) and safety (ischemic cerebral vascular events, all-cause mortality, and cardiovascular mortality) endpoints among five major therapies for AF.

Methods

The PubMed, Cochrane, and Embase databases were searched, and relevant literature was retrieved. Only studies that made comparisons among the therapies of interest and involved patients with AF were included. Pairwise comparisons and frequentist method (SUCRA plot) analyses were conducted.

Results

In total, 62 studies were included in the pooled analysis. In pairwise comparisons, atrioventricular nodal ablation plus permanent pacemaker (AVN + PPM) was associated with a significantly higher risk of atrial arrhythmia recurrence than surgical ablation [odds ratio (OR): 23.82, 95% confidence interval (CI): 1.97–287.59, fixed-effect model; 3.82, 95% CI: 1.01–559.74, random-effects model]. Furthermore, radiofrequency ablation was associated with a significantly lower risk of cardiovascular mortality than medication in pairwise comparison (OR: 0.49, 95% CI: 0.29–0.83, fixed-effect model; OR: 0.49, 95% CI: 0.27–0.9, random-effects model). Frequentist analysis indicated that AVN + PPM had the best performance in reducing the risk of safety and efficacy endpoints.

Conclusion

Non-pharmaceutical therapies showed superior performance to traditional drug therapy in lowering the risk of safety and efficiency endpoint events. AVN + PPM performed best in reducing the risk of safety and efficacy endpoints.

Efficiency and safety of ablation procedure for the treatment of atrial fibrillation in valve surgery: A PRISMA-compliant cumulative systematic review and meta-analysis

BACKGROUND

Atrial fibrillation is the main complication of patients who suffer from valvular heart disease (VHD), which may lead to an increased susceptibility to ventricular tachycardia, atrial dysfunction, heart failure, and stroke. Therefore, seeking a safe and effective therapy is crucial in prolonging the lives of patients with VHD and improving their quality of life.

METHODS

Our target database included PubMed, Web of Science, Embase, and Cochrane Library, from which published articles were retrieved from inception to June 2020. We retrieved all randomized controlled trials (RCTs) that compared patients undergoing valve surgery with (VSA) or without ablation (VS) procedure. Studies to be included were screened and data extraction was performed independently by 2 investigators. The Cochrane risk-of-bias table was used to evaluate the methodological quality of the included RCTs. The mean difference (MD) with 95% confidence interval (CI) and relative risk (RR) ratio was calculated to analyze the data. Heterogeneity was evaluated using I2 and chi-square tests. Egger test and the trim and fill analysis were used to further determine publication bias.

RESULTS

Fourteen RCTs that included 1376 patients were eventually selected for this meta-analysis. Surgical ablation was found to be effective in restoring sinus rhythm in valvular surgery patients at discharge (RR 2.91, 95% CI [1.17, 7.20], I2 97%, P = .02), 3 to 6 months (RR 2.85, 95% CI [2.27, 3.58], I2 49%, P < .00001), 12 months, and more than 1 year after surgery (RR 3.54, 95% CI [2.78, 4.51], I2 27%, P < .00001). All-cause mortality (RR 0.98, 95% CI [0.64, 1.51], I2 0%, P = .94) and stroke (RR 1.29, 95% CI [0.70, 2.39], I2 0%, P = .57) were similar in the VSA and VS groups. Compared with VS, VSA prolonged cardiopulmonary bypass time (MD 30.44, 95% CI [17.55, 43.33], I2 88%, P < .00001) and aortic cross-clamping time (MD 19.57, 95% CI [11.10, 28.03], I2 89%, P < .00001). No significant differences were found between groups with respect to the risk of bleeding (RR 0.64, 95% CI [0.37, 1.12], I2 0%, P = .12), heart failure (RR 1.11, 95% CI [0.63, 1.93], I2 0%, P = .72), and low cardiac output syndrome (RR 1.41, 95% CI [0.57, 3.46], I2 18%, P = .46). However, the demand for implantation of a permanent pacemaker was significantly higher in the VSA group (RR 1.84, 95% CI [1.15, 2.95], I2 0%, P = .01).

CONCLUSION

Although we found high heterogeneity in the restoration of sinus rhythm at discharge, we assume that the comparison is valid at this time, given the current state in the operating room. This study provides evidence of the efficacy and security of concomitant ablation intervention for patients with VHD and atrial fibrillation. Surgical ablation would increase the safety of implantation of a permanent pacemaker in the population that underwent valve surgery.

Safety and efficacy of concomitant ablation for atrial fibrillation in rheumatic mitral valve surgery: A meta-analysis

OBJECTIVES

This review aimed to evaluate the safety and efficacy of concomitant surgical ablation (SA) for patients with atrial fibrillation (AF) undergoing rheumatic mitral valve (MV) surgery.

METHODS

A systematic search of relevant studies focusing on SA for patients with AF undergoing rheumatic MV surgery was performed. The primary outcomes included mortality, efficacy, and complications.

RESULTS

Four randomized controlled trials (RCTs) and four observational studies covering 1931 patients met the inclusion criteria. In RCTs, no significant differences in reoperation for bleeding, low cardiac output syndrome, thromboembolic events, and early (risk ratio [RR], 2.07; 95% confidence intervals [CI], 0.37-11.40; p = .41) and midterm all-cause death (RR, 1.07; 95% CI, 0.40-2.88; p = .89) were noted between the SA group and the nonablation group. These results were similar to those obtained from observational studies. However, ablation was associated with a higher incidence of permanent pacemaker implantation (RR, 2.44; 95% CI, 1.15-5.18; p = .02) in observational studies but not in RCTs (RR, 2.03; 95% CI, 0.19-21.26; p = .56). Furthermore, additional SA was significantly more effective in sinus rhythm (SR) restoration than MV surgery alone at discharge and at the 12-month and 3-year follow-ups.

CONCLUSIONS

Concomitant SA during rheumatic MV surgery does not increase perioperative adverse events. In addition, SA promotes considerable restoration of SR. Although some evidence exists that permanent pacemaker implantation is more common after ablation, not all studies support this notion.

Bi-atrial or left atrial ablation of atrial fibrillation during concomitant cardiac surgery: A Bayesian network meta-analysis of randomized controlled trials

OBJECTIVE

Surgical ablation of atrial fibrillation (AF) has become a routine procedure during concomitant cardiac surgery, however, the extension of lesion sets remain controversial. We sought to compare the relative benefit and risk of different lesion sets through a Bayesian network meta-analysis (NMA).

METHODS

Pubmed, Embase, and Cochrane Trials databases were searched for randomized controlled trials (RCTs) comparing the rhythm outcome of AF patients undergoing pulmonary vein isolation (PVI), left atrial Maze (LAM), bi-atrial Maze (BAM), or no ablation during concomitant cardiac surgery. An NMA was conducted to explore the difference of over 1 year AF freedom as well as risks for early mortality and permanent pacemaker implantation (PPMI).

RESULTS

A total of 2031 patients of 19 RCTs were included. PVI, LAM, and BAM (OR [95% Cr.I]: 5.02 [2.72, 10.02], 7.97 [4.93, 14.29], 8.29 [4.90, 14.86], p < .05) demonstrated higher freedom of AF compared with no ablation, however, no significant difference of rhythm outcome was found among the three ablation strategies based on the random-effects model. BAM was associated with an increase in early mortality when compared with no ablation (OR [95% Cr.I]: 4.08 [1.23, 17.30], p < .05), while none of the remaining comparisons reached statistical difference in terms of early mortality and PPMI.

CONCLUSION

Bi-atrial ablation is not superior to left atrial ablation strategies in reducing AF recurrence for un-selected surgical patients. BAM has a higher risk of early mortality than no ablation, but no difference was found between bi-atrial and left atrial ablation in regard to early mortality and PPMI based on the current evidence.

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.

Comparison of two radiofrequency ablation devices for atrial fibrillation concomitant with a rheumatic valve procedure

BACKGROUND

Perioperative and median-term follow-up outcomes have not been compared among procedures using radiofrequency ablation devices for permanent atrial fibrillation with concomitant rheumatic valve disease. We compared the sinus rhythm restoration efficacy of "non-irrigation" ablation forceps and an "irrigation" ablation device in patients with rheumatic valve disease undergoing a modified Cox maze radiofrequency ablation procedure due to permanent atrial fibrillation.

METHODS

Data of 278 patients with rheumatic valve disease from the Cardiac Surgery Department of Sichuan Provincial People's Hospital who underwent the modified Cox maze radiofrequency ablation procedure between May 2013 and May 2017 were reviewed. The procedure was performed using "non-irrigation" ablation forceps (AtriCure, group A) in 149 patients and an "irrigation" ablation device (Medtronic, group M) in 129 patients. Data were collected prospectively, and follow-up was documented and compared between the groups.

RESULTS

The radiofrequency procedure duration was 28.9 ± 3.8 min in group A and 29.5 ± 2.8 min in group M (t = 1.623, P = 0.106). The predicted radiofrequency time to the left atrium diameter was (Ya = 0.4964 X + 0.3762, R = 0.74) in group A and (Ym = 0.4331 X + 4.3563, R = 0.8435) in group M. The sinus rhythm (SR) conversion rate without use of anti-arrhythmic drugs was similarly good in groups A and M, with 75.2%, 72.5%, and 70.5% vs. 73.6%, 71.3%, and 69.8% at discharge, 6 and 12 months, respectively (F = 0.084, F = 0.046, F = 0.046, P > 0.05, respectively).

CONCLUSION

Two types of radiofrequency ablation devices characteristic of "non-irrigation" and "irrigation" bipolar ablation forceps were similarly efficient at SR restoration.

Amaze: a double-blind, multicentre randomised controlled trial to investigate the clinical effectiveness and cost-effectiveness of adding an ablation device-based maze procedure as an adjunct to routine cardiac surgery for patients with pre-existing atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) can be treated using a maze procedure during planned cardiac surgery, but the effect on clinical patient outcomes, and the cost-effectiveness compared with surgery alone, are uncertain.

OBJECTIVES

To determine whether or not the maze procedure is safe, improves clinical and patient outcomes and is cost-effective for the NHS in patients with AF.

DESIGN

Multicentre, Phase III, pragmatic, double-blind, parallel-arm randomised controlled trial. Patients were randomised on a 1 : 1 basis using random permuted blocks, stratified for surgeon and planned procedure.

SETTING

Eleven acute NHS specialist cardiac surgical centres.

PARTICIPANTS

Patients aged ≥ 18 years, scheduled for elective or in-house urgent cardiac surgery, with a documented history (> 3 months) of AF.

INTERVENTIONS

Routine cardiac surgery with or without an adjunct maze procedure administered by an AF ablation device.

MAIN OUTCOME MEASURES

The primary outcomes were return to sinus rhythm (SR) at 12 months and quality-adjusted life-years (QALYs) over 2 years after randomisation. Secondary outcomes included return to SR at 2 years, overall and stroke-free survival, drug use, quality of life (QoL), cost-effectiveness and safety.

RESULTS

Between 25 February 2009 and 6 March 2014, 352 patients were randomised to the control (n = 176) or experimental (n = 176) arms. The odds ratio (OR) for return to SR at 12 months was 2.06 [95% confidence interval (CI) 1.20 to 3.54; p = 0.0091]. The mean difference (95% CI) in QALYs at 2 years between the two trial arms (maze/control) was -0.025 (95% CI 0.129 to 0.078; p = 0.6319). The OR for SR at 2 years was 3.24 (95% CI 1.76 to 5.96). The number of patients requiring anticoagulant drug use was significantly lower in the maze arm from 6 months after the procedure. There were no significant differences between the two arms in operative or overall survival, stroke-free survival, need for cardioversion or permanent pacemaker implants, New York Heart Association Functional Classification (for heart failure), EuroQol-5 Dimensions, three-level version score and Short Form questionnaire-36 items score at any time point. Sixty per cent of patients in each trial arm had a serious adverse event (p = 1.000); most events were mild, but 71 patients (42.5%) in the maze arm and 84 patients (45.5%) in the control arm had moderately severe events; 31 patients (18.6%) in the maze arm and 38 patients (20.5%) in the control arm had severe events. The mean additional cost of the maze procedure was £3533 (95% CI £1321 to £5746); the mean difference in QALYs was -0.022 (95% CI -0.1231 to 0.0791). The maze procedure was not cost-effective at £30,000 per QALY over 2 years in any analysis. In a small substudy, the active left atrial ejection fraction was smaller than that of the control patients (mean difference of -8.03, 95% CI -12.43 to -3.62), but within the predefined clinically equivalent range.

LIMITATIONS

Low recruitment, early release of trial summaries and intermittent resource-use collection may have introduced bias and imprecise estimates.

CONCLUSIONS

Ablation can be practised safely in routine NHS cardiac surgical settings and increases return to SR rates, but not survival or QoL up to 2 years after surgery. Lower anticoagulant drug use and recovery of left atrial function support anticoagulant drug withdrawal provided that good atrial function is confirmed.

FURTHER WORK

Continued follow-up and long-term clinical effectiveness and cost-effectiveness analysis. Comparison of ablation methods.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN82731440.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 19. See the NIHR Journals Library website for further project information.

Remote ischaemic preconditioning ameliorates sinus rhythm restoration rate through Cox maze radiofrequency procedure associated with inflammation reaction reduction

Remote ischaemic preconditioning (RIPC) as adjuvant to selective heart surgery attenuates cardiac injury and atrial fibrillation (AF) occurrence. We investigated its effect on sinus rhythm (SR) restoration rate in permanent AF patients undergoing Cox maze (CM) radiofrequency ablation with concomitant mitral valve surgery. From May 2013 to May 2017, 206 patients with rheumatic valve disease concomitant with permanent AF were randomized to receive prosthesis valve replacement and CM radiofrequency ablation procedure with (n = 104) or without (n = 102) RIPC (intermittent arm ischaemia through three cycles of 5-min inflation, followed by 5-min deflation of a blood pressure cuff). The primary end point of the study was freedom from cumulative AF without using antiarrhythmic drugs 1 year after operation; the secondary end points included inflammation reaction index over 48 h postoperatively and clinical outcomes. Baseline characteristics and preoperative data did not differ between groups. The SR restoration rates were significantly higher in the RIPC group, 85.6%, 83.7%, and 82.7%, than those in the control group, 72.5%, 70.6%, and 69.6%, at discharge, 6 months and 12 months, respectively, after the radiofrequency ablation procedure (P < 0.05). The serum concentration of high sensitivity C-reactive protein and neutrophil-lymphocyte ratio were significantly decreased at 12 h, 24 h, and 48 h postoperatively in the RIPC group compared to those in the control group (P < 0.05). RIPC induced by brief ischaemia and reperfusion of the arm ameliorated SR restoration rate in patients with permanent AF through CM radiofrequency ablation procedure and was associated with reduction of postoperative systemic inflammation reaction index.

Left atrial concomitant surgical ablation for treatment of atrial fibrillation in cardiac surgery: A meta-analysis of randomized controlled trials

INTRODUCTION

Surgical ablation is a generally established treatment for patients with atrial fibrillation undergoing concomitant cardiac surgery. Left atrial (LA) lesion set for ablation is a simplified procedure suggested to reduce the surgery time and morbidity after procedure. The present meta-analysis aims to explore the outcomes of left atrial lesion set versus no ablative treatment in patients with AF undergoing cardiac surgery.

METHODS

A literature research was performed in six database from their inception to July 2017, identifying all relevant randomized controlled trials (RCTs) comparing left atrial lesion set versus no ablative treatment in AF patient undergoing cardiac surgery. Data were extracted and analyzed according to predefined clinical endpoints.

RESULTS

Eleven relevant RCTs were included for analysis in the present study. The prevalence of sinus rhythm in ablation group was significantly higher at discharge, 6-month and 1-year follow-up period. The morbidity including 30 day mortality, late all-cause mortality, reoperation for bleeding, permanent pacemaker implantation and neurological events were of no significant difference between two groups.

CONCLUSIONS

The result of our meta-analysis demonstrates that left atrial lesion set is an effective and safe surgical ablation strategy for AF patients undergoing concomitant cardiac surgery.

Chronic Atrial Fibrillation Ablation with Harmonic Scalpel during Mitral Valve Surgery

Objective

To evaluate surgical treatment of chronic atrial fibrillation with ultrasound in patients with mitral valve disease, considering preoperative clinical characteristics of patients undergoing surgical procedure and follow-up in the immediate postoperative period, in hospital and up to 60 months after discharge.

Methods

We studied 100 patients with chronic atrial fibrillation and mitral valve disease who underwent surgical treatment using ultrasound ablation. Patient data were reviewed by consulting the control reports, including signs and symptoms, underlying disease, functional class, hospital stay, surgical procedure time, ablation time, immediate complications, and complications at discharged and up to 60 months later. Actuarial curve (Kaplan-Meier) was used for the study of permanence without recurrence after 12, 24, 36, 48 and 60 months.

Results

86% of the patients had rheumatic mitral valve disease, 14% had degeneration of the mitral valve, 40% had mitral regurgitation, and 36% had mitral stenosis. Main symptoms included palpitations related to tachycardia by chronic atrial fibrillation (70%), congestive heart failure (70%), and previous episodes of acute pulmonary edema (27%). Early results showed that 94% of the patients undergoing ultrasound ablation reversed the rate of chronic atrial fibrillation, 86% being in sinus rhythm and 8% in atrioventricular block. At hospital discharge, maintenance of sinus rhythm was observed in 86% of patients and there was recurrence of chronic atrial fibrillation in 8% of patients. At follow-up after 60 months, 83.8% of patients maintained the sinus rhythm.

Conclusion

Surgical treatment of chronic atrial fibrillation with ultrasound concomitant with mitral valve surgery is feasible and satisfactory, with maintenance of sinus rhythm in most patients (83.8%) after 60 months of follow-up.

Concomitant atrial fibrillation surgery for people undergoing cardiac surgery

BACKGROUND

People with atrial fibrillation (AF) often undergo cardiac surgery for other underlying reasons and are frequently offered concomitant AF surgery to reduce the frequency of short- and long-term AF and improve short- and long-term outcomes.

OBJECTIVES

To assess the effects of concomitant AF surgery among people with AF who are undergoing cardiac surgery on short-term and long-term (12 months or greater) health-related outcomes, health-related quality of life, and costs.

SEARCH METHODS

Starting from the year when the first "maze" AF surgery was reported (1987), we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (March 2016), MEDLINE Ovid (March 2016), Embase Ovid (March 2016), Web of Science (March 2016), the Database of Abstracts of Reviews of Effects (DARE, April 2015), and Health Technology Assessment Database (HTA, March 2016). We searched trial registers in April 2016. We used no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials evaluating the effect of any concomitant AF surgery compared with no AF surgery among adults with preoperative AF, regardless of symptoms, who were undergoing cardiac surgery for another indication.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and extracted data. We evaluated the risk of bias using the Cochrane 'Risk of bias' tool. We included outcome data on all-cause and cardiovascular-specific mortality, freedom from atrial fibrillation, flutter, or tachycardia off antiarrhythmic medications, as measured by patient electrocardiographic monitoring greater than three months after the procedure, procedural safety, 30-day rehospitalisation, need for post-discharge direct current cardioversion, health-related quality of life, and direct costs. We calculated risk ratios (RR) for dichotomous data with 95% confidence intervals (CI) using a fixed-effect model when heterogeneity was low (I² ≤ 50%) and random-effects model when heterogeneity was high (I² > 50%). We evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework to create a 'Summary of findings' table.

MAIN RESULTS

We found 34 reports of 22 trials (1899 participants) with five additional ongoing studies and three studies awaiting classification. All included studies were assessed as having high risk of bias across at least one domain. The effect of concomitant AF surgery on all-cause mortality was uncertain when compared with no concomitant AF surgery (7.0% versus 6.6%, RR 1.14, 95% CI 0.81 to 1.59, I² = 0%, 20 trials, 1829 participants, low-quality evidence), but the intervention increased freedom from atrial fibrillation, atrial flutter, or atrial tachycardia off antiarrhythmic medications > three months (51.0% versus 24.1%, RR 2.04, 95% CI 1.63 to 2.55, I² = 0%, eight trials, 649 participants, moderate-quality evidence). The effect of concomitant AF surgery on 30-day mortality was uncertain (2.3% versus 3.1%, RR 1.25 95% CI 0.71 to 2.20, I² = 0%, 18 trials, 1566 participants, low-quality evidence), but the intervention increased the risk of permanent pacemaker implantation (6.0% versus 4.1%, RR 1.69, 95% CI 1.12 to 2.54, I² = 0%, 18 trials, 1726 participants, moderate-quality evidence). Investigator-defined adverse events, including but limited to, need for surgical re-exploration or mediastinitis, were not routinely reported but were not different between the two groups (other adverse events: 24.8% versus 23.6%, RR 1.07, 95% CI 0.85 to 1.34, I² = 45%, nine trials, 858 participants), but the quality of this evidence was very low.

AUTHORS' CONCLUSIONS

For patients with AF undergoing cardiac surgery, there is moderate-quality evidence that concomitant AF surgery approximately doubles the risk of freedom from atrial fibrillation, atrial flutter, or atrial tachycardia off anti-arrhythmic drugs while increasing the risk of permanent pacemaker implantation. The effects on mortality are uncertain. Future, high-quality and adequately powered trials will likely affect the confidence on the effect estimates of AF surgery on clinical outcomes.

Radiofrequency Ablation of Left Atrial Reentrant Tachycardias in Rheumatic Mitral Valve Disease: A Case Series

BACKGROUND

Left atrial (LA) reentrant tachycardias are not uncommon in regions where rheumatic heart disease is prevalent. Some of these arrhythmias may be curable by radiofrequency ablation (RFA). However, there are limited data pertaining to this in existing literature.

CASE REPORT

Three patients who had rheumatic mitral valve disease with past history of surgical-/catheter-based intervention and having no significant residual disease had symptomatic atrial flutter despite optimal medical management. An electrophysiological study confirmed an LA focal/micro-reentrant mechanism in all. There was patchy scarring of the LA, and successful RFA of these arrhythmias could be achieved.

CONCLUSION

The focal nature of the scar in these patients may suggest that the rheumatic involvement of the atrium or the hemodynamic consequence of the vulvar lesion causes nonuniform insult to the atrial tissue and limited scar. At least in some patients with limited scarring, early RFA may help in the maintenance of sinus rhythm.

Valvular aspects of rheumatic heart disease

Acute rheumatic fever and rheumatic heart disease remain major global health problems. Although strategies for primary and secondary prevention are well established, their worldwide implementation is suboptimum. In patients with advanced valvular heart disease, mechanical approaches (both percutaneous and surgical) are well described and can, for selected patients, greatly improve outcomes; however, access to centres with experienced staff is very restricted in regions that have the highest prevalence of disease. Development of diagnostic strategies that can be locally and regionally provided and improve access to expert centres for more advanced disease are urgent and, as yet, unmet clinical needs. We outline current management strategies for valvular rheumatic heart disease on the basis of either strong evidence or expert consensus, and highlight areas needing future research and development.