A narrative review of hybrid ablation for persistent and longstanding persistent atrial fibrillation

Effectiveness of Maze IV procedure versus thoracoscopic ablation for atrial fibrillation: a propensity score-matched analysis

Background

Thoracoscopic ablation (TA) has emerged as a promising treatment for atrial fibrillation (AF), with the Cox-Maze IV Procedure (CMP-IV) as the current gold-standard intervention. This study aims to evaluate and compare the outcomes of TA and CMP-IV in treating AF.

Methods

Patients with AF underwent either CMP-IV or TA through a left-side chest approach. The CMP-IV entailed bi-atrium ablation, whereas the TA involved creating three circular plus three linear ablations in the left atrium. We analyzed baseline characteristics, perioperative outcomes and recurrence rates using propensity score matching (PSM) at a 1:1 ratio, to ensure comparability between the two treatment groups.

Results

A total of 459 patients underwent either CMP-IV (n=93) or TA via left chest (n=366) and 174 patients were deemed eligible for 1:1 PSM. The TA group experienced significantly shorter intensive care unit (ICU) and hospital stays. The mean follow-up period was 31.5±22.1 months. Pre- and post-matching analysis showed that CMP-IV had a higher rate of freedom from recurrence compared to TA, particularly in non-paroxysmal AF patients. Multivariable Cox regression analysis revealed that CMP-IV was associated with a reduced risk of recurrence, while an increased left atrial size emerged as an independent predictor of postoperative recurrence, regardless of the use of CMP-IV or TA.

Conclusions

Our study suggests that while the therapeutic efficacy of TA for "lone" AF may fall short of the classic CMP-IV, its less invasive nature results in significantly shorter ICU and hospital stays. To enhance patient outcomes following TA, it is essential to improve the quality of ablation, refine the ablation route, and focus on careful patient selection.

Atrial fibrillation: Primary prevention, secondary prevention, and prevention of thromboembolic complications: Part 2

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, once thought to be benign as long as the ventricular rate was controlled, is associated with significant cardiac morbidity and mortality. Increasing life expectancy driven by improved health care and decreased fertility rates has, in most of the world, resulted in the population aged ≥65 years growing more rapidly than the overall population. As the population ages, projections suggest that the burden of AF may increase more than 60% by 2050. Although considerable progress has been made in the treatment and management of AF, primary prevention, secondary prevention, and prevention of thromboembolic complications remain a work in progress. This narrative review was facilitated by a search of MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1950 and 2021. Atrial fibrillation was searched using the terms primary prevention, hyperthyroidism, Wolff-Parkinson-White syndrome, catheter ablation, surgical ablation, hybrid ablation, stroke prevention, anticoagulation, left atrial occlusion and atrial excision. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. In these two manuscripts, we discuss the current strategies available to prevent AF, then compare non-invasive and invasive treatment strategies to diminish AF recurrence. In addition, we examine the pharmacological, percutaneous device and surgical approaches to prevent stroke as well as other types of thromboembolic events.

Radiofrequency ablation for treatment of atrial fibrillation with the use of intracardiac echocardiography vs without intracardiac echocardiography: A meta-analysis of observational and randomized studies

AIMS

Intracardiac echocardiography (ICE) provides superior quality images and can monitor catheter location within the heart continuously. Given the limited evidence, we conducted the meta-analysis to evaluate outcomes with ICE in radiofrequency (RF) ablation of atrial fibrillation (AF).

METHODS AND RESULTS

PubMed/MEDLINE, Embase and Cochrane were searched for studies reporting RF ablation for treatment of AF with the use of ICE vs without ICE and 12 studies were included. Sensitivity analyses limiting studies to ablation with the use of contact force (CF) catheters were conducted and subgroup analyses were performed according to the published year. In main analyses, RF ablation with ICE for treatment of AF was associated with significant reduction in total X-ray time (MD, -9.80; 95% CI, -15.57 to -4.04; I² =99%; p <0.01), total procedure time (MD, -17.65; 95% CI, -30.22 to -5.09; I² =89%; p <0.01), and complications (RR, 0.90; 95% CI, 0.87 to 0.92; I² =20%; p<0.01) vs without ICE. The ICE-guided group tended to decrease total absorbed X-ray dose (SMD, -0.91; 95% CI, -1.86 to 0.04; I² =96%; p =0.06). Freedom from arrhythmia (RR, 1.06; 95% CI, 0.98 to 1.14; I² =0%; p =0.13) was comparable between the two groups.

CONCLUSION

In patients with AF, ICE-guided RF ablation is correlated with significant reductions in total X-ray time, total procedure time, and complications vs ablation without ICE. Total absorbed X-ray dose tends to reduce in the ICE group and freedom from arrhythmia is comparable between the two groups. This article is protected by copyright. All rights reserved.