Surgical techniques used for the treatment of atrial fibrillation.
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ABSTRACT:
SUBMITTER: Robertson JO
PROVIDER: S-EPMC4329768 | biostudies-literature | 2013
REPOSITORIES: biostudies-literature
Publications
Surgical techniques used for the treatment of atrial fibrillation.
Robertson Jason O JO Lawrance Christopher P CP Maniar Hersh S HS Damiano Ralph J RJ
Circulation journal : official journal of the Japanese Circulation Society 20130703 8
The use of surgical lesion sets for the treatment of atrial fibrillation has been increasing, particularly in patients with complicated anatomical substrates and those undergoing concomitant surgery. Preferences in terms of lesion set, surgical approach and ablation technology vary by center. This review discusses both the surgical techniques and the outcomes for the most commonly performed procedures in the context of recent consensus guidelines. The Cox-Maze IV, pulmonary vein isolation, exten ...[more]
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Project description:To assess heart rhythm and predictive factors associated with sinus rhythm after one year in patients with rheumatic valve disease undergoing concomitant surgical treatment of atrial fibrillation. Operative mortality, survival and occurrence of stroke after one year were also evaluated.Retrospective longitudinal observational study of 103 patients undergoing rheumatic mitral valve surgery and ablation of atrial fibrillation using uni- or bipolar radiofrequency between January 2013 and December 2014. Age, gender, functional class (NYHA), type of atrial fibrillation, EuroSCORE, duration of atrial fibrillation, stroke, left atrial size, left ventricular ejection fraction, cardiopulmonary bypass time, myocardial ischemia time and type of radiofrequency were investigated.After one year, 66.3% of patients were in sinus rhythm. Sinus rhythm at hospital discharge, lower left atrial size in the preoperative period and bipolar radiofrequency were associated with a greater chance of sinus rhythm after one year. Operative mortality was 7.7%. Survival rate after one year was 92.3% and occurrence of stroke was 1%.Atrial fibrillation ablation surgery with surgical approach of rheumatic mitral valve resulted in 63.1% patients in sinus rhythm after one year. Discharge from hospital in sinus rhythm was a predictor of maintenance of this rhythm. Increased left atrium and use of unipolar radiofrequency were associated with lower chance of sinus rhythm. Operative mortality rate of 7.7% and survival and stroke-free survival contribute to excellent care results for this approach.
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Project description:The mouse is a useful preclinical species for evaluating disease etiology due to the availability of a wide variety of genetically modified strains and the ability to perform disease-modifying manipulations. In order to establish an atrial filtration (AF) model in our laboratory, we profiled several commonly used murine AF models. We initially evaluated a pharmacological model of acute carbachol (CCh) treatment plus atrial burst pacing in C57BL/6 mice. In an effort to observe micro-reentrant circuits indicative of authentic AF, we employed optical mapping imaging in isolated mouse hearts. While CCh reduced atrial refractoriness and increased atrial tachyarrhythmia vulnerability, the left atrial (LA) excitation patterns were rather regular without reentrant circuits or wavelets. Therefore, the atrial tachyarrhythmia resembled high frequency atrial flutter, not typical AF per se. We next examined both a chronic angiotensin II (Ang II) infusion model and the surgical model of transverse aortic constriction (TAC), which have both been reported to induce atrial and ventricular structural changes that serve as a substrates for micro-reentrant AF. Although we observed some extent of atrial remodeling such as fibrosis or enlarged LA diameter, burst pacing-induced atrial tachyarrhythmia vulnerability did not differ from control mice in either model. This again suggested that an AF-like pathophysiology is difficult to demonstrate in the mouse. To continue searching for a valid murine AF model, we studied mice with a cardiac-specific deficiency (KO) in liver kinase B1 (Cardiac-LKB1), which has been reported to exhibit spontaneous AF. Indeed, the electrocardiograms (ECG) of conscious Cardiac-LKB1 KO mice exhibited no P waves and had irregular RR intervals, which are characteristics of AF. Histological evaluation of Cardiac-LKB1 KO mice revealed dilated and fibrotic atria, again consistent with AF. However, atrial electrograms and optical mapping revealed that electrical activity was limited to the sino-atrial node area with no electrical conduction into the atrial myocardium beyond. Thus, Cardiac-LKB1 KO mice have severe atrial myopathy or atrial standstill, but not AF. In summary, the atrial tachyarrhythmias we observed in the four murine models were distinct from typical human AF, which often exhibits micro- or macro-reentrant atrial circuits. Our results suggest that the four murine AF models we examined may not reflect human AF well, and raise a cautionary note for use of those murine models to study AF.
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Project description:Atrial fibrillation (AF) is the most common sustained arrhythmia, that substantially increases morbidity and mortality. AF is gaining in clinical and economic importance, with stroke and thromboembolism being major complications. In this article, the evidence for AF treatment trial of antithrombotic therapy is reviewed. Stroke risk stratification of patients with AF is discussed, and practical recommendations for thromboprophylaxis are presented.
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| S-EPMC5520636 | biostudies-literature
Project description:BackgroundAmong patients undergoing mitral-valve surgery, 30 to 50% present with atrial fibrillation, which is associated with reduced survival and increased risk of stroke. Surgical ablation of atrial fibrillation has been widely adopted, but evidence regarding its safety and effectiveness is limited.MethodsWe randomly assigned 260 patients with persistent or long-standing persistent atrial fibrillation who required mitral-valve surgery to undergo either surgical ablation (ablation group) or no ablation (control group) during the mitral-valve operation. Patients in the ablation group underwent further randomization to pulmonary-vein isolation or a biatrial maze procedure. All patients underwent closure of the left atrial appendage. The primary end point was freedom from atrial fibrillation at both 6 months and 12 months (as assessed by means of 3-day Holter monitoring).ResultsMore patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months (63.2% vs. 29.4%, P<0.001). There was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrial maze procedure (61.0% and 66.0%, respectively; P=0.60). One-year mortality was 6.8% in the ablation group and 8.7% in the control group (hazard ratio with ablation, 0.76; 95% confidence interval, 0.32 to 1.84; P=0.55). Ablation was associated with more implantations of a permanent pacemaker than was no ablation (21.5 vs. 8.1 per 100 patient-years, P=0.01). There were no significant between-group differences in major cardiac or cerebrovascular adverse events, overall serious adverse events, or hospital readmissions.ConclusionsThe addition of atrial fibrillation ablation to mitral-valve surgery significantly increased the rate of freedom from atrial fibrillation at 1 year among patients with persistent or long-standing persistent atrial fibrillation, but the risk of implantation of a permanent pacemaker was also increased. (Funded by the National Institutes of Health and the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00903370.).
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Project description:Atrial fibrillation (AF) is the most common arrhythmia in the adult population and catheter ablation has emerged as an important rhythm-control strategy and is the most common cardiac ablation procedure performed worldwide. The antiarrhythmic drugs have demonstrated moderate efficacy in long-term maintenance of sinus rhythm; moreover, they are often not tolerated and are associated with adverse events. Catheter ablation has proven to be effective in treating AF, although long-term outcomes have been significantly less favorable in persistent AF than in paroxysmal. The current guidelines recommend catheter ablation as class I indication for patients whom antiarrhythmic drugs have failed or are not tolerated, and as first-line rhythm-control therapy in selected patients with symptomatic AF. Advances in technology and innovative ablation protocols resulted in a remarkable improvement of the efficacy outcomes after pulmonary vein isolation. This review seeks to provide an updated report of the current practices and approaches, and to describe the latest advances in technology that aim to improve procedural safety, efficacy and to reduce procedural requirements in terms of duration and fluoroscopy exposure.
| S-EPMC10875204 | biostudies-literature
Project description:IntroductionSurgical 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.MethodsA 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.ResultsEleven 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.ConclusionsThe 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.
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Project description:The inverse problem of electrocardiography is usually analyzed during stationary rhythms. However, the performance of the regularization methods under fibrillatory conditions has not been fully studied. In this work, we assessed different regularization techniques during atrial fibrillation (AF) for estimating four target parameters, namely, epicardial potentials, dominant frequency (DF), phase maps, and singularity point (SP) location. We use a realistic mathematical model of atria and torso anatomy with three different electrical activity patterns (i.e., sinus rhythm, simple AF, and complex AF). Body surface potentials (BSP) were simulated using Boundary Element Method and corrupted with white Gaussian noise of different powers. Noisy BSPs were used to obtain the epicardial potentials on the atrial surface, using 14 different regularization techniques. DF, phase maps, and SP location were computed from estimated epicardial potentials. Inverse solutions were evaluated using a set of performance metrics adapted to each clinical target. For the case of SP location, an assessment methodology based on the spatial mass function of the SP location, and four spatial error metrics was proposed. The role of the regularization parameter for Tikhonov-based methods, and the effect of noise level and imperfections in the knowledge of the transfer matrix were also addressed. Results showed that the Bayes maximum-a-posteriori method clearly outperforms the rest of the techniques but requires a priori information about the epicardial potentials. Among the purely non-invasive techniques, Tikhonov-based methods performed as well as more complex techniques in realistic fibrillatory conditions, with a slight gain between 0.02 and 0.2 in terms of the correlation coefficient. Also, the use of a constant regularization parameter may be advisable since the performance was similar to that obtained with a variable parameter (indeed there was no difference for the zero-order Tikhonov method in complex fibrillatory conditions). Regarding the different targets, DF and SP location estimation were more robust with respect to pattern complexity and noise, and most algorithms provided a reasonable estimation of these parameters, even when the epicardial potentials estimation was inaccurate. Finally, the proposed evaluation procedure and metrics represent a suitable framework for techniques benchmarking and provide useful insights for the clinical practice.
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Project description:ObjectivesThe CArdioSurgEry Atrial Fibrillation (CASE-AF) registry is a prospective, multicentre study for collecting and analysing real-world data of surgical atrial fibrillation (AF) treatment. This study aimed to evaluate outcomes of surgery for long-standing persistent AF at 1 year.MethodsIn total, 17 centres consecutively include all eligible patients with continuous AF lasting for ≥1 year. Exclusion criteria are missing informed consent or age <18 years. For patient-reported outcomes measures, the European Heart Rhythm Association score was used. No presence of AF (based on ECG findings including Holter ECG and/or implanted devices), no re-ablation, no further cardioversion and no rehospitalization due to AF after a 3-month blanking period defined no AF recurrence at 1 year.ResultsFrom January 2017 to January 2020, a total of 1115 patients were enrolled in CASE-AF. Of them, 202 patients (mean age 69.7 ± 7.8 years, 27.2% female) underwent surgical ablation of long-standing persistent AF (study cohort), mostly accompanied by left atrial appendage closure (n = 180 [89%], resection n = 75 [42%]) and predominantly performed as concomitant (n = 174 [86%]) and left atrial only procedure (n = 144 [71%]). Early mortality (30 days) was 2.0% and morbidity was low. At follow-up (median 14.4 months, interquartile range, 12.7-17.6 months, 100% complete), 106 patients (56%) had no AF recurrence and 93% of them were asymptomatic. AF recurrence was accompanied by AF-related rehospitalization (n = 12, P = 0.003), direct current shock cardioversion (n = 23, P < 0.001), AF ablation (n = 7, P = 0.003) and stroke (n = 3, P = 0.059). Multivariable analysis identified cryoablation, predominantly performed endocardially including additional left atrial (74%) and biatrial (42%) lesions, as a significant factor for freedom from AF recurrence (odds ratio 2.7, 95% confidence interval 1.07-6.79, P = 0.035).ConclusionsAccording to CASE-AF, surgical ablation of long-standing persistent AF is most effective when concomitantly performed using endocardial cryoablation. Ongoing follow-up allows further elucidation of efficacious treatment strategies.
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