Minimally Invasive Stand-Alone Cox Maze Procedure for Persistent and Long-Standing Persistent Atrial Fibrillation

Convergent ablation for persistent atrial fibrillation: A UK multicentre perspective

Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide and remains a major cause of morbidity and mortality. Unfortunately, a significant proportion of patients have persistent AF, for which conventional catheter ablation is less effective. However, convergent ablation has emerged in recent years as a hybrid treatment targeting both the epicardium and endocardium in a multidisciplinary joint cardiothoracic and electrophysiology procedure, with promising efficacy outcomes in recent studies. This treatment is increasingly being performed in the United Kingdom. This review article discusses the rationale and evidence behind convergent ablation, along with factors that need to be considered when setting up a successful ablation service.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

Long-term clinical outcomes and cost-effectiveness of catheter vs thoracoscopic surgical ablation in long-standing persistent atrial fibrillation using continuous cardiac monitoring: CASA-AF randomized controlled trial

BACKGROUND

Long-term clinical outcomes of catheter ablation (CA) compared to thoracoscopic surgical ablation (SA) to treat patients with long-standing persistent atrial fibrillation (LSPAF) are not known.

OBJECTIVE

The purpose of this study was to compare the long-term (36-month) clinical efficacy, quality of life, and cost-effectiveness of SA and CA in LSPAF.

METHODS

Participants were followed up for 3 years using implantable loop recorders and questionnaires to assess the change in quality of life. Intention-to-treat analyses were used to report the findings.

RESULTS

Of the 115 patients with LSPAF treated, 104 (90.4%) completed 36-month follow-up [CA: n = 57 (95%); SA: n = 47 (85%)]. After a single procedure without antiarrhythmic drugs, 7 patients (12%) in the CA arm and 5 (11%) in the SA arm [hazard ratio 1.22; 95% confidence interval (CI) 0.81-1.83; P = .41] were free from atrial fibrillation/tachycardia (AF/AT) ≥30 seconds at 36 months. Thirty-three patients (58%) in the CA arm and 26 (55%) in the SA arm (hazard ratio 1.04; 95% CI 0.57-1.88; P = .91) had their AF/AT burden reduced by ≥75%. The overall impact on health-related quality of life was similar, with mean quality-adjusted life year estimates of 2.45 (95% CI 2.31-2.59) for CA and 2.32 (95% CI 2.13-2.52) for SA. Estimated costs were higher for SA (mean £24,682; 95% CI £21,746-£27,618) than for CA (mean £18,002; 95% CI £15,422-£20,581).

CONCLUSION

In symptomatic LSPAF, CA and SA were equally effective at achieving arrhythmia outcomes (freedom from AF/AT ≥30 seconds and ≥75% burden reduction) after a single procedure without antiarrhythmic drugs. However, SA is significantly more costly than CA.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

Long-Term Results of the Mini Maze Standalone Bi-Atrial Surgical Ablation: A 10-Year Follow-Up

Background: One way to treat atrial fibrillation is through surgical ablation. However, the literature only provides information on patient follow-up results for up to 5 years. Methods: In order to assess long-term monitoring data over ten years, this retrospective study included 58 patients with paroxysmal or persistent atrial fibrillation who underwent Mini Maze surgical ablation at Santaros Clinics between 1 February 2009 and 1 June 2014. The follow-up time after surgery was 144 ± 48 months. We evaluated the absence of atrial fibrillation, echocardiographic and clinical parameters, and EHRA score. Results: Sinus rhythm remained in 69.4%, 75.5%, 55.6%, and 44.1% of patients with paroxysmal AF, and 68,2%, 59.1%, 50%, and 41.9% of patients with persistent AF (p = 0.681). In the post-operative period, one patient (1.7%) had a transient ischemic attack, and another patient (1.7%) had a thoracotomy for post-operative bleeding. A total of 20% of patients were diagnosed with a post-operative respiratory tract infection. EHRA scores showed that patients' quality of life improved after they underwent Mini Maze surgical ablation. Conclusions: Despite AF recurrences after surgery, quality of life remains better than before surgery, showing that Mini Maze surgery is an effective and safe second-line treatment method for atrial fibrillation.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

Concomitant ablation of atrial fibrillation: New pacemakers and early rhythm recovery

OBJECTIVE

New permanent pacemaker (PPM) implantation after concomitant atrial fibrillation (AF) ablation has been associated with surgical ablation (SA). We sought to determine factors for PPM use as well as early rhythm recovery.

METHODS

From 2004 through 2019, 6135 patients underwent valve surgery and were grouped: No AF (n = 4584), AF no SA (n = 346), and AF with SA (n = 1205) to evaluate predischarge PPM and 3-month rhythm recovery (intrinsic heart rate >40 beats per minute).

RESULTS

Overall, 282 (4.6%) patients required a predischarge PPM: atrioventricular node dysfunction in 75.3%, sick sinus syndrome in 19.1%, both (5%), and indeterminate (0.7%). Patients with AF had more PPMs: AF with SA (7.9%) versus AF no SA (6.9%) versus No AF (3.6%) (P < .001). For patients with AF, PPM rates were not significantly higher for ablation patients (7.6% SA vs 6.9% AF no SA; P = .56). There were differences in PPM by SA lesion set (biatrial 12.8%; left atrial only 6.1%; pulmonary vein isolation 3.0%; P < .001). Among patients with AF treated with 3-month PPM follow-up, rhythm recovery was common (35 out of 62 [56.5%]) and did not differ by lesion set. Rhythm recovery was seen in 63 out of 141 (44.7%) in the atrioventricular node dysfunction group versus 24 out of 35 (68.6%) in the sick sinus syndrome group (P = .011). In propensity score-matched groups, late survival was similar (P = .63) for new PPM patients.

CONCLUSIONS

Avoiding conduction system trauma and delaying implantation reduces the need for postoperative PPM. Rhythm recovery within 3 months is frequent, especially for patients with sick sinus syndrome. A conservative approach to the implantation of a new PPMs is warranted.

Outcomes and residual gap analysis after the modified cryomaze procedure performed via right minithoracotomy versus sternotomy

Objectives

Developments in both technique and technology have enabled surgeons to perform the maze procedure via right minithoracotomy (RMT) to treat atrial fibrillation (AF). This study aimed to clarify the outcomes of the modified cryomaze procedure via the RMT approach compared with the sternotomy approach.

Methods

The study cohort comprised 803 consecutive patients who underwent a modified cryomaze procedure (130 via RMT and 673 via sternotomy) for paroxysmal AF and persistent AF from January 2001 to March 2022. The Gray test was applied to compare the incidence of recurrent atrial tachyarrhythmias. Additionally, residual electrical gaps were investigated in the patients who underwent additional catheter ablation for recurrent atrial tachyarrhythmias.

Results

The respective 1-, 2-, and 3-year cumulative incidences of recurrent atrial tachyarrhythmias were 13.1%, 19.5%, and 23.1% in the RMT group, and 9.3%, 10.9%, and 12.8% in the sternotomy group (Gray test P = .036). All 31 patients with recurrent atrial tachyarrhythmias underwent additional catheter ablation, comprising 14 (10.8%) in the RMT group and 17 (2.5%) in the sternotomy group. There was a significant intergroup difference in the site of residual electrical gaps; the RMT group more frequently had residual gaps in the tricuspid annulus than the sternotomy group (6.2% vs 0.4%; P < .001).

Conclusions

In the modified cryomaze procedure via the RMT approach, ablation failure is more likely to occur at the tricuspid annulus, where the surgical field of view is relatively poor compared with the sternotomy approach. Therefore, surgical ablation should be performed with caution when the RMT approach is used.

Hybrid Totally Thoracoscopic Maze and Catheter Ablation for Persistent Atrial Fibrillation: Initial Experience

Atrial fibrillation is now a pandemic in our ageing community. Although James L. Cox devised a surgical procedure with near-universal curative success in 1987, catheter-based interventions have flourished. For persistent atrial fibrillation (AF), however, an isolated endocardial approach has limitations: procedural times are long, carry risk, and the outcomes are not durable. By combining left atrial endocardial and epicardial interventions with staged mapping, we optimise the benefits of both approaches. Our initial series of hybrid ablation for persistent atrial fibrillation reports excellent early outcomes, freedom from complications and excellent success at follow-up.

Non-Pharmacological Stroke Prevention in Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia worldwide. It is associated with increased mortality and morbidity, especially due to the increased risk of ischemic stroke and systemic embolism in these patients. For this reason, thromboembolism prevention is the cornerstone of managing AF, and oral anticoagulation is nowadays the first-line treatment. However, since most thrombi form in the left atrial appendage and anticoagulant therapy may have side effects and be contraindicated in some patients, surgical and percutaneous left atrial appendage occlusion (LAAO) have emerged as a non-pharmacological alternative. This review summarizes all existing evidence on surgical and percutaneous LAAO.

Dynamic electrophysiological mechanism in patients with long-standing persistent atrial fibrillation

Background

Improved understanding of the mechanisms that sustain persistent and long-standing persistent atrial fibrillation (LSpAF) is essential for providing better ablation solutions. The findings of traditional catheter-based electrophysiological studies can be impacted by the sedation required for these procedures. This is not required in non-invasive body-surface mapping (ECGI). ECGI allows for multiple mappings in the same patient at different times. This would expose potential electrophysiological changes over time, such as the location and stability of extra-pulmonary vein drivers and activation patterns in sustained AF.

Materials and methods

In this electrophysiological study, 10 open-heart surgery candidates with LSpAF, without previous ablation procedures (6 male, median age 73 years), were mapped on two occasions with a median interval of 11 days (IQR: 8–19) between mappings. Bi-atrial epicardial activation sequences were acquired using ECGI (CardioInsight™, Minneapolis, MN, United States).

Results

Bi-atrial electrophysiological abnormalities were documented in all 20 mappings. Interestingly, the anatomic location of focal and rotor activities changed between the mappings in all patients [100% showed changes, 95%CI (69.2–100%), p < 0.001]. Neither AF driver type nor their number varied significantly between the mappings in any patient (median total number of focal activities 8 (IQR: 1–16) versus 6 (IQR: 2–12), p = 0.68; median total number of rotor activities 48 (IQR: 44–67) versus 55 (IQR: 44–61), p = 0.30). However, individual zones showed a high number of quantitative changes (increase/decrease) of driver activity. Most changes of focal activity were found in the left atrial appendage, the region of the left lower pulmonary vein and the right atrial appendage. Most changes in rotor activity were found also at the left lower pulmonary vein region, the upper half of the right atrium and the right atrial appendage.

Conclusion

This clinical study documented that driver location and activation patterns in patients with LSpAF changes constantly. Furthermore, bi-atrial pathophysiology was demonstrated, which underscores the importance of treating both atria in LSpAF and the significant role that arrhythmogenic drivers outside the pulmonary veins seem to have in maintaining this complex arrhythmia.

A Chronicle of Hybrid Atrial Fibrillation Ablation Therapy: From Cox Maze to Convergent

The burden of AF is increasing in prevalence and healthcare resource usage in the UK and worldwide. It can result in impaired quality of life for affected patients, as well as increased risk of stroke, heart failure and mortality. A holistic, integrated approach to AF management is recommended, which may include a focus on reducing risk factors and on medical management with anticoagulation and anti-arrhythmic drugs. There are also various ablation strategies that may be considered when anti-arrhythmic drugs fail to alleviate symptoms and reduce AF burden. These ablation techniques range from standalone percutaneous endocardial catheter ablation to open surgical ablation procedures concomitant with cardiac surgery. More recently, hybrid ablation that combines aspects of both surgical and electrophysiologically targeted ablation has been described. This article reviews the evolution of ablation strategies, beginning with the origin of the Cox maze IV procedure and continuing to the recent hybrid convergent approach, and provides a summary of the associated outcomes.

Staged hybrid totally thoracoscopic maze and catheter ablation for atrial fibrillation

INTRODUCTION

Atrial fibrillation (AF) is a growing health problem and is associated with increased risk of stroke. The Cox-Maze surgical procedure has offered the highest success rate, but utilization of this technique is low due to procedure invasiveness and complexity. Advances in catheter ablation and minimally invasive surgical techniques offer new options for AF treatment.

METHODS

In this review, we describe current trends and outcomes of minimally invasive treatment of persistent and long-standing persistent AF.

RESULTS

Treatment of persistent and long-standing persistent AF can be successfully treated using a team approach combining cardiac surgery and electrophysiology procedures. With this approach, the 1-year freedom from AF off antiarrhythmic drugs was 85%.

DISCUSSION

There are a variety of techniques and approaches used around the world as technology evolves to help develop new treatment strategies for AF. Our report will focus on a hybrid treatment approach using surgical and electrophysiology approaches providing enhanced treatment options by replicating Cox-Maze IV lesions using skills from each specialty. Closure of the left atrial appendage as part of these procedures enhances protection from late stroke. A team approach provides a cohesive evaluation, treatment, and monitoring plan for patients. Development of successful, less invasive treatment options will help address the growing population of patients with AF.

Long-term follow-up of thoracoscopic ablation in long-standing persistent atrial fibrillation

OBJECTIVES

Catheter ablation of long-standing persistent atrial fibrillation (LSPAF) remains challenging, with suboptimal success rates obtained following multiple procedures. Thoracoscopic ablation has shown effective at creating transmural lesions around the pulmonary veins and box; however, long-term rhythm follow-up data are lacking. This study aims, for the first time, to assess the long-term outcomes of thoracoscopic pulmonary vein and box ablation in LSPAF.

METHODS

Rhythm follow-up consisted of continuous rhythm monitoring using implanted loop recorders or 24-h Holter recordings. Rhythm status and touch-up interventions were assessed up to 5 years.

RESULTS

Seventy-seven patients with symptomatic LSPAF underwent thoracoscopic ablation in 2 centres. Freedom from atrial arrhythmias at 5 years was 50% following a single thoracoscopic procedure and 68% allowing endocardial touch-up procedures (performed in 21% of patients). The mean atrial fibrillation burden in patients with continuous monitoring was reduced from 100% preoperatively to 0.1% at the end of the blanking period and 8.0% during the second year. Antiarrhythmic drug use decreased from 49.4% preoperative to 12.1% and 14.3% at 2 and 5 years, respectively (P < 0.001). Continuous rhythm monitoring resulted in higher recurrence detection rates compared to 24-h Holter monitoring at 2-year follow-up (hazard ratio: 6.5, P = 0.003), with comparable recurrence rates at 5-year follow-up.

CONCLUSIONS

Thoracoscopic pulmonary vein and box isolation are effective in long-term restoration of sinus rhythm in LSPAF, especially when complemented by endocardial touch-up procedures, as demonstrated by the 68% freedom rate at 5 years. Continuous rhythm monitoring revealed earlier, but not more numerous documentation of recurrences at 5-year follow-up.

Robotic-assisted Cryothermic Cox Maze for Persistent Atrial Fibrillation: Longitudinal Follow-up

OBJECTIVES

Surgical ablation of atrial fibrillation (AF) is recommended as a stand-alone therapy for patients refractory to medical or catheter-based treatment, or as a concomitant therapy when associated with structural disease. We report a single-therapy robotic approach to the Cox maze with longitudinal follow-up.

METHODS

Consecutive patients who underwent robotic biatrial cryothermic Cox maze for nonparoxysmal AF between November 2016 and January 2022 were examined at 1, 2, 3, 6, 9, 12, 18, 24, 36, 48, and 60 months. Freedom from atrial tachyarrhythmia was assessed with 24-hour continuous electrocardiogram or pacemaker interrogation in all patients after 6 months. Mean follow-up was 17 ± 14.5 months (range, 1-60 months). Time to event analysis with competing risks was used to determine risk-adjusted associations with late outcomes.

RESULTS

Patients (n = 135) had a median AF duration of 4.0 years (interquartile range, 0.8-7.0), with 29.6% in whom 1 or more catheter ablations had failed. Stand-alone maze was performed in 25.2%, whereas 61.4% underwent concomitant robotic mitral valve surgery, 7.4% tricuspid valve repair, and 4.4% aortic valve replacement. No patients were discharged in AF. There were 3 operative mortalities (2.2%), none in stand-alone patients. One patient required catheter ablation at 8 months postoperatively, and one had a nonembolic stroke at 18 months. There were 9 late deaths. Freedom from atrial tachyarrhythmia and antiarrhythmic drugs at 9, 12, 18, 24, 36, and 48 months was 97.0%, 96.7%, 98.1%, 97.1%, and 100%, respectively. Lower ejection fraction and need for concomitant mitral valve replacement and/or aortic valve replacement were independently associated with worse survival.

CONCLUSIONS

For persistent AF, robotic biatrial cryothermic Cox maze offered greater than 90% 1-year longitudinal freedom from stroke, oral anticoagulation, repeat ablation, and recurrent AF without the need for antiarrhythmic drugs.

Hybrid Ablation for Atrial Fibrillation: Safety & Efficacy of Unilateral Epicardial Access

Hybrid ablation combines thoracoscopic epicardial ablation with percutaneous catheter based endocardial ablation for the treatment of AF. The purpose of this study was to evaluate the safety and efficacy of hybrid ablation surgery for the treatment of atrial fibrillation (AF), and to compare outcomes of unilateral versus bilateral thoracoscopic epicardial ablation. Patients with documented AF who underwent hybrid ablation were followed post-operatively for major events. Major events were classified into two categories consisting of 1) safety, comprising all-cause mortality and major morbidities, and 2) efficacy, which included recurrence of atrial arrhythmia, cessation of antiarrhythmic drugs (AAD), and completeness of lesion set. A total of 84 consecutive patients were consented for hybrid ablation. Patients presented with an average AF duration of 85.9 months before hybrid ablation. 80 patients underwent successful thoracoscopic epicardial ablation. At one-year, 87% (60/69) of patients were free from AF and 73% (50/69) were free from AF and off AAD. 63 patients completed both epicardial and endocardial hybrid ablation with posterior wall isolation achieved in 89% (56/63) of patients. Unilateral epicardial ablation was associated with significantly shorter hospital length of stay compared to bilateral surgical approached (3.9 vs. 6.7 days, p = 0.002) with no difference in freedom from AF between groups at 1 year. Hybrid ablation for atrial fibrillation is effective for patients at high risk for recurrence after catheter ablation. The unilateral surgical approach may be associated with shorter hospital stay with no appreciable effect on procedure success rates. This study evaluates the safety and efficacy of unilateral epicardial access for hybrid ablation in patients with symptomatic atrial fibrillation refractory to antiarrhythmic treatment. Hybrid ablation for atrial fibrillation is effective for patients at high risk for recurrence after catheter ablation. The unilateral surgical approach may be associated with shorter hospital stay with no appreciable effect on procedure success rates.

Shone's complex and aortic dissection: case report and review of a rare, underdiagnosed congenital heart disease

BACKGROUND

Shone's complex is a rare congenital heart disease consisting of a variety of left ventricular inflow and outflow tract lesions. Patients typically present in childhood requiring early surgical intervention; however, with improved surgical techniques, these patients are surviving later into adulthood. This increased survival comes with a new set of medical complications that providers need to be aware of.

CASE PRESENTATION

A 27 year old man with a complex cardiac history including an incomplete Shone's complex and persistent symptomatic atrial flutter presented with sharp chest pain radiating to his back. He was found to have type A aortic dissection on imaging in the setting of severe patient-prosthesis mismatch. He had multiple valvular surgeries in childhood. The patient was being followed-up as an outpatient for an enlarging chronic aortic aneurysm and was non-compliant with his medications. He was taken emergently to the operating room for a skirted Bentall procedure, aortic valve replacement, and right sided MAZE.

CONCLUSIONS

Shone's complex is a rare congenital heart disease associated with significant morbidities including atrial flutter, patient-prosthesis mismatch, and aortic dissection. As patients continue to live longer into adulthood with this disease, it is important to raise awareness of this rare syndrome for providers and highlight its potential complications. Further research is needed to determine appropriate guidelines for when to intervene on aortopathy-associated CHD.

The long-term outcomes and durability of the Cox-Maze IV procedure for atrial fibrillation

OBJECTIVE

Surgical ablation of atrial fibrillation (AF) is indicated both in patients with AF undergoing concomitant cardiac surgery and in those who have not responded to medical and/or catheter-based ablation therapy. This study examined our long-term outcomes following the Cox-Maze IV procedure (CMP-IV).

METHODS

Between May 2003 and March 2018, 853 patients underwent either biatrial CMP-IV (n = 765) or a left-sided CMP-IV (n = 88) lesion set with complete isolation of the posterior left atrium. Freedom from atrial tachyarrhythmia (ATA) was assessed for up to 10 years. Rhythm outcomes were compared in multiple subgroups. Predictors of recurrence were determined using Fine-Gray regression, allowing for death as the competing risk.

RESULTS

The majority of patients (513/853, 60%) had nonparoxysmal AF. Twenty-four percent of patients (201/853) had not responded to at least 1 catheter-based ablation. Prolonged monitoring was used in 76% (647/853) of patients during their follow-up. Freedom from ATA was 92% (552/598), 84% (213/253), and 77% (67/87) at 1, 5, and 10 years, respectively. By competing risk analysis, incidence of first ATA recurrence was 11%, 23%, and 35% at 1, 5, and 10 years, respectively. On Fine-Gray regression, age, peripheral vascular disease, nonparoxysmal AF, left atrial size, early postoperative ATAs, and absence of sinus rhythm at discharge were the predictors of first ATA recurrence over 10 years of follow-up.

CONCLUSIONS

The CMP-IV had an excellent long-term efficacy at maintaining sinus rhythm. At late follow-up, the results of the CMP-IV remained superior to those reported for catheter ablation and other forms of surgical ablation for AF. Age, left atrial size, and nonparoxysmal AF were the most relevant predictors of late recurrence.

Surgery and Catheter Ablation for Atrial Fibrillation: History, Current Practice, and Future Directions

Atrial fibrillation (AF) is the most common of all cardiac arrhythmias, affecting roughly 1% of the general population in the Western world. The incidence of AF is predicted to double by 2050. Most patients with AF are treated with oral medications and only approximately 4% of AF patients are treated with interventional techniques, including catheter ablation and surgical ablation. The increasing prevalence and the morbidity/mortality associated with AF warrants a more aggressive approach to its treatment. It is the purpose of this invited editorial to describe the past, present, and anticipated future directions of the interventional therapy of AF, and to crystallize the problems that remain.

Launching minimally invasive stand-alone maze procedure for atrial fibrillation

BACKGROUND

Minimally invasive Maze procedure via right mini-thoracotomy approach is reportedly a promising option for paroxysmal and non-paroxysmal atrial fibrillation (AF), although it is not widely performed. This study aimed to validate feasibility and safety of minimally invasive stand-alone Maze procedure in an institutional first case series.

METHODS

This study enrolled an institutional consecutive series of 20 cases who underwent minimally invasive Maze procedure between November 2018 and January 2021. Concomitant tricuspid annuloplasty was performed in five cases who showed moderate tricuspid regurgitation preoperatively.

RESULTS

Minimally invasive Maze procedure using cryo-energy source was successfully accomplished with sinus rhythm being restored at the intensive care unit entry in all cases without conversion to the sternotomy approach. All cases were discharged home, while one case was complicated with stroke postoperatively. Nineteen cases (95%) showed sinus rhythm at the last follow-up, whereas one case, who had large left atrium, showed recurrent persistent AF despite optimum medical therapy. Catheter ablations were performed for residual conductions at box lesions and/or mitral/tricuspid isthmus in three cases, who showed medically refractory atrial tachycardia post-Maze procedure. Consequently, these three cases showed sinus rhythm restoration at the last follow-up Conclusions: Minimally invasive stand-alone Maze procedure with or without tricuspid annuloplasty was feasible and safe for AF in the institutional first case series. Catheter ablations for recurrent AF post-Maze procedure would be warranted.

Case Report: The Cox-Maze IV Procedure in the Mirror: The Use of Three-Dimensional Printing for Pre-operative Planning in a Patient With Situs Inversus Dextrocardia

The safety and efficacy of the Cox-Maze IV procedure (CMP-IV) for situs inversus dextrocardia patients with atrial fibrillation is yet to be determined. Herein, we present the case of a 39-year-old male patient admitted to our cardiac center following progressive exertional dyspnea. The patient was diagnosed with situs inversus dextrocardia, severe mitral regurgitation, and paroxysmal atrial fibrillation. A three-dimensional (3D) heart model printing device embedded with designated ablation lines was used for pre-operative planning. Mitral valvuloplasty, CMP-IV, and tricuspid annuloplasty were performed. The patient had an uneventful recovery and was in sinus rhythm during a 12-month follow-up period using a 24-h Holter monitoring device. The case herein is one of the first to report on adopting the CMP-IV procedure for situs inversus dextrocardia patients with complex valvuloplasty operation. In addition, the 3D printing technique enabled us to practice the Cox-maze IV procedure, given the patient's unique cardiac anatomy.

A heart-team hybrid approach for atrial fibrillation: a single-centre long-term clinical outcome cohort study

OBJECTIVES

The Cox-maze IV is the gold standard for surgical ablation of atrial fibrillation (AF). A heart-team hybrid approach using selected epicardial thoracoscopic surgical ablations and completion endocardial ablations to replicate the Cox-maze IV lesion set has gained popularity and early results have been promising. We herein report our single-centre long-term clinical outcomes using the heart-team hybrid approach with 455 patients.

METHODS

From 1 March 2013 to 1 July 2019, we prospectively collected data on all patients referred to our heart team for rhythm-control strategy for AF. Baseline characteristics, procedural complications and long-term freedom from AF (FFAF) both on and off anti-arrhythmic drug therapy were analysed. Ambulatory monitoring (>7 days) was obtained at 3 months and annually thereafter.

RESULTS

Four hundred and fifty-five patients completed the hybrid approach. Four hundred and forty-five (97.8%) patients had non-paroxysmal AF (long-standing persistent AF n = 249, 54.7%; persistent AF n = 196, 43.1%; paroxysmal AF n = 10, 2.2%). Average duration of AF was 5.9 ± 6.1 years. Average left atrial diameter was 4.8 ± 0.8 cm. FFAF at 3, 12, 24 and 36 months was 92%, 87%, 81% and 72%, respectively. FFAF without the use of anti-arrhythmic medications was 75%, 81%, 76% and 66%. Any surgical complications occurred in 28 (6.1%) patients.

CONCLUSIONS

A heart-team hybrid strategy for the treatment of AF is safe and effective. In a predominantly non-paroxysmal population with AF, at the 3-year follow-up, FFAF in patients on and off anti-arrhythmic drugs approaches that of patients who had the Cox-maze IV.

Shortened leukocyte telomere length as a potential biomarker for predicting the progression of atrial fibrillation from paroxysm to persistence in the short-term

This study aimed to assess the role of leukocyte telomere length (LTL) in the development of atrial fibrillation (AF) among Chinese patients.This is a cross-sectional study. A total of 350 patients from June 2016 to December 2017 were retrospectively analyzed. These included 219 AF patients and 131 with sinus rhythm in the control group. Quantitative real-time PCR was used to measure relative LTL.The relative LTLs of all subjects (n = 350) ranged from 0.4 to 2.41 (0.98 ± 0.29), showing a significant negative correlation (P < .001) with age. The AF-group had significantly shorter LTLs (0.93 ± 0.26 vs 1.07 ± 0.33, P < .001) and were older (61.50 ± 6.49 vs 59.95 ± 6.17, P = .028) than controls. LTLs among patients with persistent AF (PsAF), paroxysmal AF (PAF), and controls were significantly different (P < .001), with LTLs of PsAF patients being the shortest and controls being the longest. After adjusting for possible confounding factors, the PsAF group still showed significantly shorter LTLs than the PAF and control groups (P = .013 and P = .001, respectively). After an 18-month follow-up, 20 out of 119 PAF patients had progressed into PsAF and a relative LTL of ≤0.73 was an independent predictor for progression of PAF into PsAF.LTL was found to be shorter in patients with AF than in age-matched individuals with sinus rhythm and positively correlated with severity of AF. LTL shortening could be an independent risk factor for progression from paroxysmal AF to persistent AF in the short term.

Efficacy of the stand-alone Cox-Maze IV procedure in patients with longstanding persistent atrial fibrillation

INTRODUCTION

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and results in significant morbidity and mortality. The Cox-Maze IV procedure (CMP-IV) has been shown to have excellent efficacy in returning patients to sinus rhythm, but there have been few reports of late follow-up in sizable cohorts of patients with longstanding persistent AF, the most difficult type of AF to treat.

METHODS AND RESULTS

Between May 2003 and March 2020, 174 consecutive patients underwent a stand-alone CMP-IV for longstanding persistent AF. Rhythm outcome was assessed postoperatively for up to 10 years, primarily via prolonged monitoring (Holter monitor, pacemaker interrogation, or implantable loop recorder). Fine-Gray regression was used to investigate factors associated with atrial tachyarrhythmia (ATA) recurrence, with death as a competing risk. Median duration of preoperative AF was 7.8 years (interquartile range: 4.0-12.0 years), with 71% (124/174) having failed at least one prior catheter-based ablation. There were no 30-day mortalities. Freedom from ATAs was 94% (120/128), 83% (53/64), and 88% (35/40) at 1, 5, and 7 years, respectively. On regression analysis, preoperative AF duration and early postoperative ATAs were associated with late ATAs recurrence.

CONCLUSION

Despite the majority of patients having a long-duration of preoperative AF and having failed at least one catheter-based ablation, the stand-alone CMP-IV had excellent late efficacy in patients with longstanding persistent AF, with low morbidity and no mortality. We recommend consideration of stand-alone CMP-IV for patients with longstanding persistent AF who have failed or are poor candidates for catheter ablation.

Late results after stand-alone surgical ablation for atrial fibrillation

OBJECTIVES

Stand-alone surgical ablation of atrial fibrillation is indicated in patients with refractory atrial fibrillation who have failed medical or catheter-based ablation. Few reports of late outcomes after stand-alone surgical ablation exist using comprehensive follow-up with strict definitions of success. This study examined our late outcomes of the stand-alone Cox-Maze IV procedure.

METHODS

Between January 2003 and December 2019, 236 patients underwent a stand-alone Cox-Maze IV for refractory atrial fibrillation. Freedom from atrial tachyarrhythmias was assessed by electrocardiography, Holter, or pacemaker interrogation for up to 10 years, with a mean follow-up of 4.8 ± 3.5 years. Rhythm outcomes were compared in multiple subgroups. Factors associated with recurrence were determined using Fine-Gray regression, allowing for death as the competing risk.

RESULTS

The majority of patients (176/236, 75%) had nonparoxysmal atrial fibrillation. Median duration of preoperative atrial fibrillation was 6.2 years (interquartile range, 3-11). Fifty-nine percent of patients (140/236) failed 1 or more prior catheter-based ablation. Thirteen patients (6%) experienced a major complication. There was no 30-day mortality. Freedom from atrial tachyarrhythmias was 94% (187/199), 89% (81/91), and 77% (24/31) at 1, 5, and 10 years, respectively. There was no difference in freedom from atrial tachyarrhythmias between patients with paroxysmal atrial fibrillation versus nonparoxysmal atrial fibrillation (P > .05) or those undergoing sternotomy versus a minimally invasive approach (P > .05). Increased left atrial size and number of catheter ablations were associated with late atrial fibrillation recurrence. For patients who experienced any atrial tachyarrhythmia recurrence, the median number of recurrences was 1.5 (1.0-3.0).

CONCLUSIONS

The stand-alone Cox-Maze IV had excellent late efficacy at maintaining sinus rhythm in patients with symptomatic, refractory atrial fibrillation, with low morbidity and no mortality. The Cox-Maze IV, in contrast to catheter-based ablation, was equally effective in patients with paroxysmal and nonparoxysmal atrial fibrillation.

The Impact of the Cox-Maze Technique on Freedom From Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia observed with concomitant cardiac surgery. Surgical options include a cut-and-sew technique Maze (CAS) and a cryoablation/bipolar technique Maze (CB). There are limited data comparing the long-term outcomes of these 2 techniques.

METHODS

All patients who underwent either CAS or CB Maze between 2011 and 2018 were included in the study. Chi-square test and Fisher's exact test or Student's t test were used to compare differences between baseline characteristics. Kaplan-Meier survival curves were generated for each group. Cumulative incidence functions were generated for AF recurrence and Fine-Gray competing-risk regression was used to determine predictors for AF recurrence.

RESULTS

A total of 482 patients underwent open surgical ablation. Of those, 287 had CAS and 198 had CB. All procedures were concomitant with cardiac surgery. There was similar long-term mortality between the CAS and CB cohorts (22.3% vs 17.4%; log-rank P = .91). There was no difference in pacemaker implantation (11.1% vs 11.3%; P = .813) or long-term freedom from AF recurrence (73.3% vs 78.2%; P = .294). On Fine-Gray competing-risk regression, New York Heart Association functional class IV (hazard ratio [HR], 2.07; P = .03), concomitant aortic valve replacement (HR, 3.02; P = .01), and concomitant CABG + valve (HR, 2.36; P = .02) were significant independent predictors for AF recurrence; Maze type was not a predictor.

CONCLUSIONS

These data indicate no difference between the CAS vs CB with respect to freedom from long-term AF. Both techniques may be appropriate based on surgeon experience and patient characteristics.

Biatrial ablation vs. Pulmonary vein isolation in atrial fibrillation patients undergoing cardiac surgery: a retrospective study

OBJECTIVES

Surgical ablation is an established treatment for patients with atrial fibrillation undergoing cardiac surgery. This study aimed to compare postoperative rhythm outcomes and pacemaker implantation rates after biatrial ablation or pulmonary vein isolation (PVI) concomitantly with other cardiac surgery. Design: In a retrospective study, we included patients who underwent biatrial ablation or PVI. Postoperative rhythm status was assessed by Holter monitoring. All data on outcomes and patient characteristics were collected retrospectively. Results: In total 109 patients had a biatrial procedure whereas 337 had PVI performed. In patients with persistent/long-standing persistent atrial fibrillation, freedom from atrial fibrillation was more common after biatrial ablation than after PVI (63% and 45%, respectively; p = .039). Postoperative permanent pacemaker implantation was more common after biatrial ablation (12% and 6%, respectively; p = .039), compared to PVI. Age < 65 years (OR:2.0, 95% CI:1.1-3.6) was a predictor of freedom from atrial fibrillation in the biatrial group, whereas absence of left atrial dilatation (OR:1.8, 95% CI:1.1-3.2) and HAS-BLED score < 2 (OR:1.9, 95% CI:1.0-3.8) were significant predictors of freedom from atrial fibrillation in the PVI group. Conclusions: In patients with persistent/long-standing persistent atrial fibrillation, biatrial ablation is more effective than PVI in terms of obtaining freedom from postoperative atrial fibrillation. Although our groups were heterogenic in terms of concomitant surgery, our study also indicates that the risk of needing a permanent pacemaker is higher after biatrial ablation, compared to PVI. Therefore, our study highlights that the decision between biatrial ablation or PVI should be performed on an individual basis.

Sinoatrial nodal artery injury in thoracoscopic epicardial ablation for atrial fibrillation

OBJECTIVES

This study aimed to clarify the incidence of sinoatrial nodal artery (SANa) injury in thoracoscopic epicardial surgical ablation for atrial fibrillation (AF) and its impact on postoperative outcomes, which have not been previously elucidated.

METHODS

We enrolled 103 consecutively patients with AF who underwent thoracoscopic epicardial ablation at our institution. In these patients, we evaluated the postoperative incidence of SANa injury by using enhanced cardiac computed tomography. For patients with confirmed SANa injury, 3-day continuous electrocardiographic monitoring and exercise stress tests were performed to assess the sinus rhythm maintenance and sinus node function.

RESULTS

Thirteen patients (12.6%) had a confirmed SANa injury (left anterior type in 6 patients, left posterior type in 2 patients and double-branch type in 5 patients). After a median follow-up of 24 months, the patients with SANa injury were not found to be associated with lower sinus rhythm maintenance (hazard ratio 1.09, 95% confidential interval 0.36-3.31) as compared with those without SANa injury after adjustment for patient characteristics. Sinus node function was evaluated in 7 patients with SANa injury who remained in sinus rhythm after the procedure, and no sinus node dysfunction was confirmed in the 3-day electrocardiographic monitoring and exercise stress tests at a median follow-up of 12 months.

CONCLUSIONS

The prevalence of SANa injury in the patients who underwent thoracoscopic epicardial ablation for AF was relatively low, and the incidence of SANa injury was not associated with postoperative restoration of sinus rhythm and sinoatrial node dysfunction. More studies are required to better understand SANa injury.

Subxiphoid Hybrid Epicardial-Endocardial Atrial Fibrillation Ablation and LAA Ligation: Initial Sub-X Hybrid MAZE Registry Results

OBJECTIVES

The aim of this study was to assess the safety and efficacy of a new subxiphoid hybrid epicardial-endocardial atrial fibrillation (AF) ablation and left atrial appendage (LAA) ligation approach for the treatment of persistent AF.

BACKGROUND

Surgical hybrid ablation procedures have shown promise for maintaining sinus rhythm versus catheter ablation but are associated with increased periprocedural adverse events.

METHODS

Patients with symptomatic persistent AF (n = 33, mean age 64 ± 9 years, 25 men) who had antiarrhythmic drug therapy or prior catheter ablation was unsuccessful were referred for hybrid epicardial-endocardial AF ablation and LAA exclusion. LAA closure was confirmed by transesophageal echocardiographic Doppler flow and/or computed tomographic angiography 1 to 3 months post-ligation. The incidence of atrial tachycardia or AF recurrence, LAA closure, thromboembolic events, and post-operative complications were assessed.

RESULTS

All 33 patients underwent successful LAA ligation with epicardial ablation of the posterior left atrial wall, as well as endocardial pulmonary vein isolation and cavotricuspid isthmus ablation. Freedom from atrial tachycardia or AF was 91% (20 of 22 patients) at 6 months, 90% (18 of 20 patients) at 12 months, 92% (11 of 12 patients) at 18 months, and 92% (11 of 12) at 24 months. There were no acute periprocedural complications (<7 days). Thirty-day adverse events included 2 patients with pericardial effusion requiring pericardiocentesis and 1 incisional hernia repair. There were no long-term complications, strokes, or deaths. LAA ligation was complete in 27 of 33 subjects (82%), with 6 subjects having leaks of <5 mm.

CONCLUSIONS

Subxiphoid hybrid epicardial-endocardial ablation with LAA ligation is feasible, safe, and effective. Future prospective studies are needed to validate these initial findings.

Contemporary Surgical Management of Atrial Fibrillation

Atrial fibrillation is a common arrhythmia which may cause symptoms that significantly impact quality of life and is associated with increased risk of stroke, heart failure, and sudden death. Over the past three decades many surgical techniques as well as catheter-bases procedures have been developed to treat atrial fibrillation. In this review we describe the indications, treatments, outcomes, surgical techniques, and technical advances reported in the literature.

Atrial Fibrillation Ablation: Indications and Techniques

PURPOSE OF REVIEW

Atrial fibrillation (AF) predisposes to embolic strokes and reduced quality of life. Ablation (catheter-based or surgically performed) can be employed to promote the maintenance of sinus rhythm in a carefully selected subset of patients with AF. The goal of this review is to discuss the indications and techniques for AF ablation, as well as post-procedural outcomes.

RECENT FINDINGS

Atrial fibrillation ablation improves quality of life in patients with atrial fibrillation although no clear reduction in stroke or overall mortality has been shown. Familiarity with the indications for AF ablation is important for all cardiologists, as is having a sound understanding of the efficacy of the procedure and potential complications. Furthermore, acquiring a grasp of the different modalities of AF ablation (including percutaneous endocardial techniques and surgical ablation approaches) will help to facilitate effective and appropriate referrals.