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Baudo M, Rosati F, Lapenna E, Di Bacco L, Benussi S. Surgical options for atrial fibrillation treatment during concomitant cardiac procedures. Ann Cardiothorac Surg 2024; 13:135-145. [PMID: 38590994 PMCID: PMC10998971 DOI: 10.21037/acs-2023-afm-0208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/12/2024] [Indexed: 04/10/2024]
Abstract
Current guidelines recommend concomitant surgical ablation (SA) of atrial fibrillation (AF) in the context of mitral valve disease. A variety of energy sources have been tested for SA to perform effective transmural lesions reliably. To date, only radiofrequency and cryothermy energies are considered viable options. The gold standard for SA is the Cox-Maze ablation set, especially for non-paroxysmal AF (nPAF), with the aim of interrupting macro-reentrant drivers perpetuating AF, without hampering the sinus node activation of both atria, and to maintain the atrioventricular synchrony. Although the efficacy of SA in terms of early and late sinus rhythm restoration has been clearly demonstrated over the years, concomitant AF ablation is still underperformed in patients with AF undergoing cardiac surgery. From a surgical standpoint, concerns have been raised about whether a single (left) or double atriotomy would be justified in AF patients undergoing a "non-atriotomy" surgical procedure, such as aortic valve or revascularization surgery. Thus, an array of simplified lesion sets have been described in the last decade, which have unavoidably hampered procedural efficacy, somewhat jeopardizing the standardization process of ablation surgery. As a matter of fact, the term "Maze" has improperly become a generic term for SA. Surgical interventions that do not align with the principles of forming conduction-blocking lesions according to the Maze pattern, cannot be classified as Maze procedures. In this complex scenario, a tailored approach according to the different AF patterns has been proposed: for patients with concomitant nPAF, a biatrial Cox-Maze ablation is recommended. Conversely, it might be reasonable to limit lesions to the left atrium or the pulmonary veins in patients with paroxysmal AF (PAF) in some clinical scenarios. The aim of this review is to provide an overview of the current ablation strategies for patients with AF undergoing concomitant cardiac surgery.
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Affiliation(s)
- Massimo Baudo
- Department of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Fabrizio Rosati
- Department of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Lorenzo Di Bacco
- Department of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Stefano Benussi
- Department of Cardiac Surgery, Spedali Civili di Brescia, University of Brescia, Brescia, Italy
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Ye Q, Zhao Y, Liu K, Zhao C, Liu Y, Li Y, Wang J. Radiofrequency Ablation in Patients Undergoing Mitral Valve Surgery with or without Giant Left Atria. Ann Thorac Cardiovasc Surg 2022; 28:349-358. [PMID: 35793966 PMCID: PMC9585334 DOI: 10.5761/atcs.oa.22-00033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: We aimed to compare the efficacy of radiofrequency ablation (RFA) in patients undergoing mitral valve (MV) surgery with or without giant left atria. Methods: This retrospective, single-center, cohort study investigated patients who underwent MV surgery and concomitant RFA from 2009 to 2019. Patients were divided into non-giant left atria (diameter ≤65 mm, n = 1543) and giant left atria (diameter >65 mm, n = 241) groups. Five-year freedom from atrial tachyarrhythmia recurrence and thromboembolic event (TE) rates were assessed with death as the competing risk factor with and without propensity-score matching. Results: Patients with giant left atria had higher mortality (10.8% versus 6.2%, P = 0.008) and readmission rates for heart failure than those without (12.0% versus 6.8%, P = 0.004). Atrial tachyarrhythmia recurrence rates were higher in patients with giant left atria than in those without (49% versus 24% at 5 years, P <0.001), but the cumulative incidence of TEs before (P = 0.944) and after (P = 0.695) propensity-score matching was comparable. Conclusions: RFA effectively prevented TEs in patients with giant left atria, despite significant atrial tachyarrhythmia recurrence. Atrial tachyarrhythmia recurrence did not increase the risk of TEs. A lower success rate should be considered when deciding whether to perform surgical ablation in patients with giant left atria.
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Affiliation(s)
- Qing Ye
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yichen Zhao
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kemin Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Cheng Zhao
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Liu
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuqi Li
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiangang Wang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Kaba RA, Ahmed O, Behr E, Momin A. A Chronicle of Hybrid Atrial Fibrillation Ablation Therapy: From Cox Maze to Convergent. Arrhythm Electrophysiol Rev 2022; 11:e12. [PMID: 35846422 PMCID: PMC9277617 DOI: 10.15420/aer.2022.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/06/2022] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Riyaz A Kaba
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George’s, University of London and St George’s University Hospitals NHS Foundation Trust, London, UK; Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, Surrey, UK
| | - Omar Ahmed
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George’s, University of London and St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Elijah Behr
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George’s, University of London and St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Aziz Momin
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Institute, St George’s, University of London and St George’s University Hospitals NHS Foundation Trust, London, UK; Department of Cardiology, Ashford and St Peter’s NHS Foundation Trust, Chertsey, Surrey, UK
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Bogachev-Prokophiev A, Sharifulin R, Karadzha A, Zheleznev S, Afanasyev A, Ovcharov M, Pivkin A, Zalesov A, Budagaev S, Ivantsov S, Chernyavsky A. Results of concomitant cryoablation for atrial fibrillation during mitral valve surgery. Interact Cardiovasc Thorac Surg 2021; 34:540-547. [PMID: 34791269 PMCID: PMC8972332 DOI: 10.1093/icvts/ivab322] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/07/2021] [Accepted: 10/18/2021] [Indexed: 12/03/2022] Open
Affiliation(s)
| | - Ravil Sharifulin
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Anastasiia Karadzha
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Sergey Zheleznev
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Alexander Afanasyev
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Mikhail Ovcharov
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Alexey Pivkin
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Anton Zalesov
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Sergey Budagaev
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Sergey Ivantsov
- Department of Heart Valve Surgery, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation.,Department of Congenital Heart Disease, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
| | - Alexander Chernyavsky
- Department of Aortic and Coronary Artery Surgery, E. Meshalkin National Medical Research Centre, Novosibirsk, Russian Federation
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Gatti G, Fiorica I, Dell'Angela L, Morosin M, Faganello G, Cappelletto C, Pagura L, Ceschia A, Piazza R, Pappalardo A. Isolated left atrial cryoablation of atrial fibrillation in conventional mitral valve surgery. IJC HEART & VASCULATURE 2020; 31:100652. [PMID: 33102684 PMCID: PMC7575890 DOI: 10.1016/j.ijcha.2020.100652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/23/2020] [Accepted: 09/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recent trends of surgery for atrial fibrillation (AF) are towards more safe and effective energy sources, as well as to simplified sets of atrial lesions. METHODS One hundred eighteen (mean age, 67.4 ± 9.2 years) selected patients with paroxysmal/persistent AF and mitral valve (MV) disease underwent cryoablation of AF combined with conventional (not via mini-thoracotomy) MV surgery; the lesion set was limited to only the left atrium. Multivariable analyses identified predictors of cardiac rhythm at hospital discharge and follow-up. RESULTS There were 7 (5.9%) hospital deaths; 33 (28%) patients were discharged on AF. Higher values of preoperative left atrial volume index (odds ratio [OR] = 1.07, 95% confidence interval [95%CI]: 1.01-1.13) and mixed etiology of MV disease (OR = 4.19, 95%CI: 1.23-14.2) were predictors of hospital discharge on AF. Seventy-four (66.7%) patients were on stable sinus rhythm at follow-up (median period, 6.6 years); the 1, 5, and 10-year nonparametric estimates of adjusted freedom from AF were 98.1%, 89.2% and 45.6%, respectively. Higher values of preoperative systolic pulmonary artery pressure (hazard ratio [HR] = HR = 1.04, 95%CI: 1.01-1.08) and AF at hospital discharge (HR = 4.14, 95%CI: 1.50-11.4) were predictors of AF at follow-up. CONCLUSIONS During conventional MV surgery, a cryo-lesion set limited to only the left atrium may give good, immediate and long-term results. Left atrial dilation and mixed etiology of MV disease were predictors of hospital discharge on AF. Preoperative pulmonary hypertension and AF at discharge combined with an increased risk of AF at follow-up.
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Affiliation(s)
- Giuseppe Gatti
- Cardio-Thoracic & Vascular Department, Trieste University Hospital, Trieste, Italy
| | - Ilaria Fiorica
- Cardio-Thoracic & Vascular Department, Trieste University Hospital, Trieste, Italy
| | - Luca Dell'Angela
- Division of Cardiology, Gorizia & Monfalcone Hospital, Gorizia, Italy
| | - Marco Morosin
- Cardio-Thoracic & Vascular Department, Trieste University Hospital, Trieste, Italy
| | - Giorgio Faganello
- Cardio-Thoracic & Vascular Department, Trieste University Hospital, Trieste, Italy
| | - Chiara Cappelletto
- Department of Cardiology, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Linda Pagura
- Cardio-Thoracic & Vascular Department, Trieste University Hospital, Trieste, Italy
| | - Alessandro Ceschia
- Cardio-Thoracic & Vascular Department, Trieste University Hospital, Trieste, Italy
| | - Rita Piazza
- Department of Cardiology, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Aniello Pappalardo
- Cardio-Thoracic & Vascular Department, Trieste University Hospital, Trieste, Italy
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Türker FS, Erdogan MB, Dogan A. The Factors Affecting Rhythm Control for Cryoablation of Atrial Fibrillation in Mitral Valve Surgery. Braz J Cardiovasc Surg 2019; 34:525-534. [PMID: 31719006 PMCID: PMC6852447 DOI: 10.21470/1678-9741-2019-0064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate the factors impacting on the conversion to sinus rhythm and on the postoperative rhythm findings in the six-month follow-up period of a mitral valve surgery combined with cryoablation Cox-Maze III procedure, in patients with atrial fibrillation. METHODS In this study, we evaluated 80 patients who underwent structural valve disease surgery in combination with cryoablation. Indications for the surgical procedures were determined in the patients according to the presence of rheumatic or non-rheumatic structural disorders in the mitral valve as evaluated by echocardiography. Cox-Maze III procedure and left atrial appendix closure were applied. RESULTS The results of receiver operating characteristics analysis indicated that the rate of conversion to the sinus rhythm was significantly higher in patients with left atrial diameters ≥ 45.5 mm and with ejection fraction (EF) ≥ 48.5%. However, the statistical differences disappeared in the sixth month. Thromboembolic (TE) events were seen only in three patients in the early period and no more TE events occurred in the six-month follow-up period. CONCLUSION The EF and the preoperative left atrial diameter were determined to be the factors impacting on the conversion to sinus rhythm in patients who underwent mitral valve surgery in combination with cryoablation. Mitral valve surgery in combination with ablation for atrial fibrillation does not affect mortality and morbidity in the experienced health centers; however, it remains controversial whether it will provide additional health benefits to the patients compared to those who underwent only mitral valve surgery.
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Affiliation(s)
- Fevzi Sarper Türker
- University of Health Sciences Elazığ Training and Research Hospital Department of Cardiovascular Surgery Elazığ Turkey Department of Cardiovascular Surgery, University of Health Sciences, Elazığ Training and Research Hospital, Elazığ, Turkey
| | - Mustafa Bilge Erdogan
- Bahçeşehir University Medical School Department of Cardiovascular Surgery Istanbul Turkey Department of Cardiovascular Surgery, Bahçeşehir University Medical School, Istanbul, Turkey
| | - Ayşe Dogan
- Bitlis Eren University Health High School Department of Physiotherapy and Rehabilitation Bitlis Turkey Department of Physiotherapy and Rehabilitation, Bitlis Eren University Health High School, Bitlis, Turkey
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