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Ajoolabady A, Pratico D, Mazidi M, Davies IG, Lip GYH, Seidah N, Libby P, Kroemer G, Ren J. PCSK9 in metabolism and diseases. Metabolism 2025; 163:156064. [PMID: 39547595 DOI: 10.1016/j.metabol.2024.156064] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Revised: 10/02/2024] [Accepted: 11/05/2024] [Indexed: 11/17/2024]
Abstract
PCSK9 is a serine protease that regulates plasma levels of low-density lipoprotein (LDL) and cholesterol by mediating the endolysosomal degradation of LDL receptor (LDLR) in the liver. When PCSK9 functions unchecked, it leads to increased degradation of LDLR, resulting in elevated circulatory levels of LDL and cholesterol. This dysregulation contributes to lipid and cholesterol metabolism abnormalities, foam cell formation, and the development of various diseases, including cardiovascular disease (CVD), viral infections, cancer, and sepsis. Emerging clinical and experimental evidence highlights an imperative role for PCSK9 in metabolic anomalies such as hypercholesterolemia and hyperlipidemia, as well as inflammation, and disturbances in mitochondrial homeostasis. Moreover, metabolic hormones - including insulin, glucagon, adipokines, natriuretic peptides, and sex steroids - regulate the expression and circulatory levels of PCSK9, thus influencing cardiovascular and metabolic functions. In this comprehensive review, we aim to elucidate the regulatory role of PCSK9 in lipid and cholesterol metabolism, pathophysiology of diseases such as CVD, infections, cancer, and sepsis, as well as its pharmaceutical and non-pharmaceutical targeting for therapeutic management of these conditions.
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Affiliation(s)
- Amir Ajoolabady
- Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Domenico Pratico
- Alzheimer's Center at Temple, Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, USA
| | - Mohsen Mazidi
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK; King's College London, Department of Twin Research & Genetic Epidemiology, South Wing St Thomas', London, UK; Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ian G Davies
- School of Sport and Exercise Sciences, Faculty of Science, Liverpool John Moores University, Copperas Hill, Liverpool L3 5AJ, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nabil Seidah
- Laboratory of Biochemical Neuroendocrinology, Montreal Clinical Research Institute (IRCM, affiliated to the University of Montreal), Montreal, QC H2W 1R7, Canada.
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Guido Kroemer
- Centre de Recherche des Cordeliers, Equipe labellisée par la Ligue contre le cancer, Université de Paris Cité, Sorbonne Université, Inserm U1138, Institut Universitaire de France, Paris, France; Metabolomics and Cell Biology Platforms, Institut Gustave Roussy, Villejuif, France; Institut du Cancer Paris CARPEM, Department of Biology, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.
| | - Jun Ren
- Shanghai Institute of Cardiovascular Diseases, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China; National Clinical Research Center for Interventional Medicine, Shanghai 200032, China.
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Mitrovic I, Eszlari E, Cvorak A, Liebold A, Rastan A, Grubitzsch H, Knaut M, Fischlein T, Ouarrak T, Senges J, Hanke T, Doll N, Eichinger W. Epicardial and endocardial surgical ablation of atrial fibrillation: outcomes from CASE-AF Registry. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 39:ivae123. [PMID: 38937269 PMCID: PMC11246162 DOI: 10.1093/icvts/ivae123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 06/07/2024] [Accepted: 06/26/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVES The German CArdioSurgEry Atrial Fibrillation Registry is a prospective, multicentric registry analysing outcomes of patients undergoing surgical ablation for atrial fibrillation as concomitant or stand-alone procedures. This data sub-analysis of the German CArdioSurgEry Atrial Fibrillation Registry aims to describe the in-hospital and 1-year outcomes after concomitant surgical ablation, based on 2 different ablation approaches, epicardial and endocardial surgical ablation. METHODS Between January 2017 and April 2020, 17 German cardiosurgical units enrolled 763 consecutive patients after concomitant surgical ablation. In the epicardial group, 413 patients (54.1%), 95.6% underwent radiofrequency ablation. In the endocardial group, 350 patients (45.9%), 97.7% underwent cryoablation. 61.5% of patients in the epicardial group and 49.4% of patients in the endocardial group presenting with paroxysmal atrial fibrillation. Pre-, intra- and post-operative data were gathered. RESULTS Upon discharge, 32.3% (n = 109) of patients after epicardial surgical ablation and 24.0% (n = 72) of patients after endocardial surgical ablation showed recurrence of atrial fibrillation. The in-hospital mortality rate was low, 2.2% (n = 9) in the epicardial and 2.9% (n = 10) in the endocardial group. The overall 1-year procedural success rate was 58.4% in the epicardial and 62.2% in the endocardial group, with significant symptom improvement in both groups. The 1-year mortality rate was 7.7% (n = 30) in epicardial and 5.0% (n = 17) in the endocardial group. CONCLUSIONS Concomitant surgical ablation is safe and effective with significant improvement in patient symptoms and freedom from atrial fibrillation. Adequate cardiac rhythm monitoring should be prioritized for higher quality data acquisition.
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Affiliation(s)
- Ivana Mitrovic
- Department of Cardiac Surgery, Munich Clinic Bogenhausen, Munich, Germany
| | - Edgar Eszlari
- Department of Cardiac Surgery, Munich Clinic Bogenhausen, Munich, Germany
| | - Adi Cvorak
- Department of Cardiac Surgery, Munich Clinic Bogenhausen, Munich, Germany
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University Hospital, Ulm, Germany
| | - Ardawan Rastan
- Department of Cardiothoracic and Vascular Surgery, Philipps-University Hospital, Marburg, Germany
| | - Herko Grubitzsch
- Department of Cardiothoracic and Vascular Surgery, Charite University Hospital, Berlin, Germany
| | - Michael Knaut
- Department of Cardiac Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Theodor Fischlein
- Department of Cardiac Surgery, Nuremberg Clinic, Paracelsus Medical University, Nuremberg, Germany
| | | | - Jochen Senges
- Institute for Heart Attack Research, Ludwigshafen, Germany
| | - Thorsten Hanke
- Department of Cardiac Surgery, Asklepios Clinic Harburg, Hamburg, Germany
| | - Nicolas Doll
- Department of Cardiac Surgery, Schuechtermann-Clinic, Bad Rothenfelde, Germany
| | - Walter Eichinger
- Department of Cardiac Surgery, Munich Clinic Bogenhausen, Munich, Germany
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Gao Y, Luo H, Yang R, Xie W, Jiang Y, Wang D, Cao H. Safety and efficacy of Cox-Maze procedure for atrial fibrillation during mitral valve surgery: a meta-analysis of randomized controlled trials. J Cardiothorac Surg 2024; 19:140. [PMID: 38504314 PMCID: PMC10949564 DOI: 10.1186/s13019-024-02622-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 03/09/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Cox-Maze procedure is currently the gold standard treatment for atrial fibrillation (AF). However, data on the effectiveness of the Cox-Maze procedure after concomitant mitral valve surgery (MVS) are not well established. The aim of this study was to assess the safety and efficacy of Cox-Maze procedure versus no-maze procedure n in AF patients undergoing mitral valve surgery through a systematic review of the literature and meta-analysis. METHODS A systematic search on PubMed/MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials (Cochrane Library, Issue 02, 2017) databases were performed using three databases from their inception to March 2023, identifying all relevant randomized controlled trials (RCTs) comparing Cox-Maze procedure versus no procedure in AF patients undergoing mitral valve surgery. Data were extracted and analyzed according to predefined clinical endpoints. RESULTS Nine RCTs meeting the inclusion criteria were included in this systematic review with 663 patients in total (341 concomitant Cox-Maze with MVS and 322 MVS alone). Across all studies with included AF patients undergoing MV surgery, the concomitant Cox-Maze procedure was associated with significantly higher sinus rhythm rate at discharge, 6 months, and 12 months follow-up when compared with the no-Maze group. Results indicated that there was no significant difference between the Cox-Maze and no-Maze groups in terms of 1 year all-cause mortality, pacemaker implantation, stroke, and thromboembolism. CONCLUSIONS Our systematic review suggested that RCTs have demonstrated the addition of the Cox-Maze procedure for AF leads to a significantly higher rate of sinus rhythm in mitral valve surgical patients, with no increase in the rates of mortality, pacemaker implantation, stroke, and thromboembolism.
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Affiliation(s)
- Yaxuan Gao
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, Jiangsu, China
| | - Hanqing Luo
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, Jiangsu, China
| | - Rong Yang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
- Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Wei Xie
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, Jiangsu, China
| | - Yi Jiang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
- Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China
| | - Dongjin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, Jiangsu, China.
| | - Hailong Cao
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
- Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China.
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Je HG, Choi JW, Hwang HY, Kim HJ, Kim JB, Kim HJ, Choi JS, Jeong DS, Kwak JG, Park HK, Lee SH, Lim C, Lee JW. 2023 KASNet Guidelines on Atrial Fibrillation Surgery. J Chest Surg 2024; 57:1-24. [PMID: 37994091 DOI: 10.5090/jcs.23.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 11/24/2023] Open
Affiliation(s)
- Hyung Gon Je
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University College of Medicine, Yangsan, Korea
| | - Jae Woong Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ho Jin Kim
- Departments of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Bum Kim
- Departments of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee-Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jae-Sung Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Han Ki Park
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyun Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Cheong Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Won Lee
- Department of Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
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Gemelli M, Gallo M, Addonizio M, Van den Eynde J, Pradegan N, Danesi TH, Pahwa S, Dixon LK, Slaughter MS, Gerosa G. Surgical Ablation for Atrial Fibrillation During Mitral Valve Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Am J Cardiol 2023; 209:104-113. [PMID: 37848175 DOI: 10.1016/j.amjcard.2023.09.088] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/15/2023] [Accepted: 09/24/2023] [Indexed: 10/19/2023]
Abstract
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.
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Affiliation(s)
- Marco Gemelli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Cardiac Surgery Unit, University of Padua, Padua, Italy
| | - Michele Gallo
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky.
| | - Mariangela Addonizio
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Cardiac Surgery Unit, University of Padua, Padua, Italy
| | | | - Nicola Pradegan
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Cardiac Surgery Unit, University of Padua, Padua, Italy
| | - Tommaso Hinna Danesi
- Cardiac Surgery Unit, San Bortolo Hospital, Vicenza, Italy; Division of Cardiac Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Siddharth Pahwa
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Lauren K Dixon
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Mark S Slaughter
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Gino Gerosa
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Cardiac Surgery Unit, University of Padua, Padua, Italy
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Al-Zubaidi F, Pufulete M, Sinha S, Kendall S, Moorjani N, Caputo M, Angelini GD, Vohra HA. Mitral repair versus replacement: 20-year outcome trends in the UK (2000-2019). INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 36:ivad086. [PMID: 37208195 PMCID: PMC10250075 DOI: 10.1093/icvts/ivad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/10/2023] [Accepted: 05/18/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVES Using a large national database, we sought to describe outcome trends in mitral valve surgery between 2000 and 2019. METHODS The study cohort was split into mitral valve repair (MVr) or replacement, including all patients regardless of concomitant procedures. Patients were grouped by four-year admission periods into groups (A to E). The primary outcome was in hospital mortality and secondary outcomes were return to theatre, postoperative stroke and postoperative length of stay. We investigated trends over time in patient demographics, comorbidities, intraoperative characteristics and postoperative outcomes. We used a multivariable binary logistic regression model to assess the relationship between mortality and time. Cohorts were further stratified by sex and aetiology. RESULTS Of the 63 000 patients in the study cohort, 31 644 had an MVr and 31 356 had a replacement. Significant demographic shifts were observed. Aetiology has shifted towards degenerative disease; endocarditis rates in MVr dropped initially but are now rising (period A = 6%, period C = 4%, period E = 6%; P < 0.001). The burden of comorbidities has increased over time. In the latest time period, women had lower repair rates (49% vs 67%, P < 0.001) and higher mortality rates when undergoing repair (3% vs 2%, P = 0.001) than men. Unadjusted postoperative mortality dropped in MVr (5% vs 2%, P < 0.001) and replacement (9% vs 7%, P = 0.015). Secondary outcomes have improved. Time period was an independent predictor for reduced mortality in both repair (odds ratio: 0.41, 95% confidence interval: 0.28-0.61, P < 0.001) and replacement (odds ratio: 0.50, 95% confidence interval: 0.41-0.61, P < 0.001). CONCLUSIONS In-hospital mortality has dropped significantly over time for mitral valve surgery in the UK. MVr has become the more common procedure. Sex-based discrepancies in repair rates and mortality require further investigation. Endocarditis rates in MVS are rising.
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Affiliation(s)
- Fadi Al-Zubaidi
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
| | - Maria Pufulete
- Faculty of Health Sciences, University of Bristol, Bristol Heart Institute, Bristol, UK
| | - Shubhra Sinha
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
| | - Simon Kendall
- Department of Cardiac Surgery, South Tees Hospital, Newcastle, UK
| | - Narain Moorjani
- Department of Cardiac Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Massimo Caputo
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
| | | | - Hunaid A Vohra
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
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Zhang T, Wu X, Zhang Y, Zeng L, Liu B. Efficiency and safety of ablation procedure for the treatment of atrial fibrillation in valve surgery: A PRISMA-compliant cumulative systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e28180. [PMID: 34918672 PMCID: PMC8677930 DOI: 10.1097/md.0000000000028180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 11/19/2021] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Tianyao Zhang
- Department of Anesthesiology, the First Affiliated Hospital of Chengdu Medical College, Sichuan, China
| | - Xiaochu Wu
- National Clinical Research Center for Geriatrics and Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yu Zhang
- Department of Anesthesiology, the First Affiliated Hospital of Chengdu Medical College, Sichuan, China
| | - Lin Zeng
- Department of Anesthesiology, the First Affiliated Hospital of Chengdu Medical College, Sichuan, China
| | - Bin Liu
- National Clinical Research Center for Geriatrics and Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Maesen B, van der Heijden CAJ, Bidar E, Vos R, Athanasiou T, Maessen JG. Patient-reported quality of life after stand-alone and concomitant arrhythmia surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2021; 34:339-348. [PMID: 34632489 PMCID: PMC8860412 DOI: 10.1093/icvts/ivab282] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 09/01/2021] [Accepted: 09/14/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Patient-reported quality of life (QOL) has become an important endpoint for arrhythmia surgery for atrial fibrillation (AF). While studies specifically evaluating the effect of arrhythmia surgery on QOL are scarce, we aimed to summarize current evidence of QOL following concomitant and stand-alone arrhythmia surgery for AF. METHODS All studies reporting on QOL using questionnaires from patients undergoing arrhythmia surgery for AF, both stand-alone and concomitant, were included in this systematic review. A meta-analysis was performed on inter-study heterogeneity of changes in QOL on 9 of 12 included studies that used the Short-Form 36 tool and meta-regression based on rhythm outcome after 1 year was executed. Finally, differences in QOL following stand-alone arrhythmia surgery and concomitant procedures were evaluated. RESULTS Overall, QOL scores improved 1 year after surgical ablation for AF evaluated by several questionnaires. In stand-alone arrhythmia procedures, meta-regression showed significant improvements in those who were in sinus rhythm compared to those in AF after 1 year. This association between an improved QOL and the procedural effectiveness was also suggested in concomitant procedures. However, when comparing QOL of patients undergoing cardiac surgery with and without add-on surgical ablation for AF, only the variable ‘physical role’ demonstrated a significant improvement. CONCLUSIONS In patients with AF, QOL improves after both stand-alone and concomitant arrhythmia surgery. In the concomitant group, this improvement can be attributed to both the cardiac procedure itself as well as the add-on arrhythmia surgery. However, both in stand-alone and concomitant procedures, the improvement in QOL seems to be related to the effectiveness of the procedure to maintain sinus rhythm after 12 months.
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Affiliation(s)
- Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | | | - Elham Bidar
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Rein Vos
- Department of Methodology and Statistics, Maastricht University, Maastricht, Netherlands
| | - Thanos Athanasiou
- Department of Cardiothoracic Surgery, Imperial College London, St Mary's Hospital, London, UK
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
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Guo Q, Yan F, Ouyang P, Xie Z, Wang H, Yang W, Pan X. Bi-atrial or left atrial ablation of atrial fibrillation during concomitant cardiac surgery: A Bayesian network meta-analysis of randomized controlled trials. J Cardiovasc Electrophysiol 2021; 32:2316-2328. [PMID: 34164872 DOI: 10.1111/jce.15127] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/11/2021] [Accepted: 05/31/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Qiuzhe Guo
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming Medical University, Kunming, China
- Department of Cardiovascular Surgery, First Affiliated Hospital of Kunming Medical University, Kunming, China
- School of Pharmaceutical Science and Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming, China
| | - Fangbing Yan
- School of Pharmaceutical Science and Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming, China
- Department of Ophthalmology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Peigang Ouyang
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming Medical University, Kunming, China
| | - Zhuxinyue Xie
- School of Pharmaceutical Science and Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming, China
- Department of Cardiology, Yunnan Fuwai Cardiovascular Hospital, Kunming Medical University, Kunming, China
| | - Haonan Wang
- Department of Cardiovascular Surgery, First Affiliated Hospital of Kunming Medical University, Kunming, China
- School of Pharmaceutical Science and Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming, China
| | - Weimin Yang
- School of Pharmaceutical Science and Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming, China
| | - Xiangbin Pan
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming Medical University, Kunming, China
- Department of Structural Heart Disease, National Center for Cardiovascular Disease, China & Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Kunming, China
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Shenthar J, Banavalikar B, Valappil SP, Deshpande S, Nireshwalia A, Padmanabhan D, Reddy SS. Safety and Efficacy of Ibutilide for Acute Pharmacological Cardioversion of Rheumatic Atrial Fibrillation. Cardiology 2021; 146:624-632. [PMID: 34265762 DOI: 10.1159/000516590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 04/16/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Ibutilide is indicated for acute cardioversion of nonvalvular atrial fibrillation (AF). However, its efficacy and safety in the pharmacological cardioversion of rheumatic AF are unknown. METHODS Patients with mild-to-moderate rheumatic mitral valve (MV) disease with symptomatic, paroxysmal, or persistent AF were included in the analysis. Intravenous ibutilide was administered at doses tailored to body weight (0.5-2.0 mg) for over 10 min. The primary end point was efficacy, assessed as the rate of conversion of AF to sinus rhythm. The secondary end point was safety, including arrhythmic events and death within 24 h of drug initiation. RESULTS From June 2016 to October 2018, 165 patients (94 with mitral stenosis, 23 with mitral regurgitation, 11 with mixed MV disease, and 37 with MV replacement) received ibutilide (mean dose 0.90 ± 0.54 mg). Ibutilide successfully converted AF to sinus rhythm in 127/165 (76.9%) patients, with a conversion time of 7.9 ± 4.1 min. The QTc increased from 419.9 ± 15.8 to 487.5 ± 34 ms after ibutilide administration (p < 0.001). The mean change in QTc after ibutilide administration (∆QTc) was 72.01 ± 36.03. There were no deaths, but 3 patients (1.8%) developed torsades de pointes (TdP) requiring defibrillation 55 ± 37 min after infusion. CONCLUSION Ibutilide cardioverted 77% of rheumatic AF to sinus rhythm, indicating its potential as a clinically useful option for pharmacological cardioversion of rheumatic AF. TdP is a potentially serious adverse event that requires careful monitoring.
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Affiliation(s)
- Jayaprakash Shenthar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Bharatraj Banavalikar
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Sanjai Pattu Valappil
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Saurabh Deshpande
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Aparna Nireshwalia
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Deepak Padmanabhan
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
| | - Sathish S Reddy
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, India
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11
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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: 0.2] [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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12
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 387] [Impact Index Per Article: 77.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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McCarthy PM, Gerdisch M, Philpott J, Barnhart GR, Waldo AL, Shemin R, Andrei AC, Gaynor S, Ndikintum N, Calkins H. Three-year outcomes of the postapproval study of the AtriCure Bipolar Radiofrequency Ablation of Permanent Atrial Fibrillation Trial. J Thorac Cardiovasc Surg 2020; 164:519-527.e4. [PMID: 33129501 DOI: 10.1016/j.jtcvs.2020.09.099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 09/08/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The Cox Maze IV operation is commonly performed concomitant with other cardiac operations and effectively reduces the burden of atrial fibrillation. Prospective randomized trials have reported outcomes early and at 12 months, but only single-center late durability results are available. As part of the postapproval process for a bipolar radiofrequency ablation system, we sought to determine early and midterm outcomes of patients undergoing the Cox Maze IV operation. METHODS A prospective, multicenter, single-arm study of 363 patients (mean age, 70 years, 82% valve surgery) with nonparoxysmal atrial fibrillation (mean duration, 60 months, 94% Congestive heart failure, Hypertension, Age ≥ 75, Diabetes, Stroke, VAScular disease, Age 65-74, Sex category ≥2) undergoing concomitant Maze IV atrial fibrillation ablation at 40 sites with 70 surgeons was performed between June 2010 and October 2014. Compliance with the study lesion set was 94.5%, and 99% had left atrial appendage closure. Freedom from atrial fibrillation was determined by extended monitoring, with a 48-hour Holter monitor minimum. RESULTS There were no device-related complications. Freedom from atrial fibrillation off antiarrhythmic medications at 1, 2, and 3 years was 66%, 65%, and 64%, respectively, and including those using antiarrhythmics was 80%, 78%, and 76%, respectively. Warfarin was used in 49%, 44%, and 40%, respectively. CONCLUSIONS In patients with nonparoxysmal atrial fibrillation, compliance with the protocol was high, and freedom from atrial fibrillation off antiarrhythmics was high and sustained to 3 years. The safety and effectiveness of the system and Cox Maze IV procedure support the Class I guideline recommendation for concomitant atrial fibrillation ablation in patients undergoing cardiac surgery.
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Affiliation(s)
- Patrick M McCarthy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill.
| | - Marc Gerdisch
- Department of Cardiovascular and Thoracic Surgery, Franciscan St Francis Heart Center, Indianapolis, Ind
| | | | - Glenn R Barnhart
- Swedish Heart and Vascular Institute, Swedish Medical Center, Seattle, Wash
| | - Albert L Waldo
- Division of Cardiovascular Medicine, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Richard Shemin
- Division of Cardiac Surgery, Department of Surgery, School of Medicine at UCLA, Los Angeles, Calif
| | | | | | | | - Hugh Calkins
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, Md
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Patel NJ, Maradey JA, Bhave PD. Atrial Fibrillation Ablation: Indications and Techniques. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:43. [PMID: 31342171 DOI: 10.1007/s11936-019-0747-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Neel J Patel
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Joan A Maradey
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Prashant D Bhave
- Department of Internal Medicine, Section on Cardiovascular Medicine, Wake Forest University Baptist Medical Center, 1 Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
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Sharples L, Everett C, Singh J, Mills C, Spyt T, Abu-Omar Y, Fynn S, Thorpe B, Stoneman V, Goddard H, Fox-Rushby J, Nashef S. 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. Health Technol Assess 2019; 22:1-132. [PMID: 29701167 DOI: 10.3310/hta22190] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Linda Sharples
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Colin Everett
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Jeshika Singh
- Health Economics Research Group (HERG), Brunel University London, London, UK
| | - Christine Mills
- Papworth Trials Unit Collaboration, Papworth Hospital, Cambridge, UK
| | - Tom Spyt
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, UK
| | - Yasir Abu-Omar
- Department of Cardiology and Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Simon Fynn
- Department of Cardiology and Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Benjamin Thorpe
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Victoria Stoneman
- Papworth Trials Unit Collaboration, Papworth Hospital, Cambridge, UK
| | - Hester Goddard
- Papworth Trials Unit Collaboration, Papworth Hospital, Cambridge, UK
| | - Julia Fox-Rushby
- Department of Population Science, King's College London, London, UK
| | - Samer Nashef
- Department of Cardiology and Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
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16
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Blackstone EH, Chang HL, Rajeswaran J, Parides MK, Ishwaran H, Li L, Ehrlinger J, Gelijns AC, Moskowitz AJ, Argenziano M, DeRose JJ, Couderc JP, Balda D, Dagenais F, Mack MJ, Ailawadi G, Smith PK, Acker MA, O'Gara PT, Gillinov AM. Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery: New analytical approaches and end points. J Thorac Cardiovasc Surg 2018; 157:234-243.e9. [PMID: 30557941 DOI: 10.1016/j.jtcvs.2018.06.093] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/07/2018] [Accepted: 06/27/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation during mitral valve surgery (MVS). METHODS Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P < .001) by 72-hour Holter monitoring, without evident difference between lesion sets (for which the trial was underpowered). RESULTS Estimated freedom from AF/AFL/AT on any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95-5.65; P = .07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57-1.43; P = .6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P < .02). CONCLUSIONS Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.
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Affiliation(s)
- Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.
| | - Helena L Chang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Michael K Parides
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Hemant Ishwaran
- Department of Public Health Sciences, Division of Biostatistics, University of Miami, Miami, Fla
| | - Liang Li
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Tex
| | - John Ehrlinger
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alan J Moskowitz
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Argenziano
- Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Joseph J DeRose
- Department of Cardiovascular and Thoracic Surgery, Montefiore-Einstein Heart Center, Bronx, NY
| | - Jean-Phillipe Couderc
- Heart Research Follow-Up Program, Cardiology Department, University of Rochester Medical Center, Rochester, NY
| | | | - François Dagenais
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie de Québec, Hôpital Laval, Québec City, Québec, Canada
| | - Michael J Mack
- Department of Cardiothoracic Surgery, Baylor Research Institute, Baylor Health Care System, Plano, Tex
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, Va
| | - Peter K Smith
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Michael A Acker
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Patrick T O'Gara
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Boston, Mass
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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Right minithoracotomy versus conventional median sternotomy for patients undergoing mitral valve surgery and Cox-maze IV ablation with entirely bipolar radiofrequency clamp. Heart Vessels 2018; 33:901-907. [PMID: 29396769 DOI: 10.1007/s00380-018-1126-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 01/24/2018] [Indexed: 10/18/2022]
Abstract
Cox-maze IV ablation by bipolar radiofrequency clamp was considered to be only performed through median sternotomy (MS), but impossible through right minithoracotomy (RM). Now, we developed a novel technique of performing Cox-maze IV ablation entirely by bipolar clamp through RM. To compare the outcomes of RM or MS for patients undergoing mitral valve surgery and concomitant Cox-maze IV ablation with entirely bipolar clamp. All 152 patients underwent mitral valve surgery and concomitant Cox-maze IV ablation with bipolar clamp through RM (n = 69) or MS (n = 83) were analyzed for outcome differences. The etiology of mitral valve disease was rheumatic (n = 97) and degenerative (n = 55). All patients had long-standing persistent atrial fibrillation (AF). Diameter of left atrium ranged from 42 to 60 mm. All patients successfully underwent Cox-maze IV ablation by bipolar clamp. RM group had longer cardiopulmonary bypass time (130.3 ± 17.7 vs 115.3 ± 14.4 min; P < 0.001) and aortic cross-clamp time (91.8 ± 12.7 vs 74.6 ± 9.3 min; P < 0.001). But mechanical ventilation time (14.2 ± 6.6 vs 21.3 ± 9.0 h; P < 0.001) and hospital length of stay (9.3 ± 2.6 vs 11.7 ± 3.0 days; P < 0.001) were shorter in RM group. At discharge, the maintenance of normal sinus rhythm (NSR) was 94.2% in RM group and 95.1% in MS group (P = 1.000). Cumulative maintenance of NSR at 2 years postoperatively was 85.1 ± 5.8% in RM group and 88.6 ± 3.6% in MS group (P = 0.767). RM can achieve similar therapeutic effect to MS for patients undergoing mitral valve surgery and concomitant Cox-maze IV ablation with entirely bipolar clamp. In addition, patients through RM had faster recovery.
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McClure GR, Belley-Cote EP, Jaffer IH, Dvirnik N, An KR, Fortin G, Spence J, Healey J, Singal RK, Whitlock RP. Surgical ablation of atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials. Europace 2017; 20:1442-1450. [DOI: 10.1093/europace/eux336] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 10/17/2017] [Indexed: 01/18/2023] Open
Affiliation(s)
- Graham R McClure
- Michael G. DeGroote School of Medicine, McMaster University, 1280 Main St W, Hamilton, ON, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St W, Hamilton, ON, Canada
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton, ON, Canada
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada
- Department of Medicine, Université de Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, Canada
| | - Iqbal H Jaffer
- Thrombosis & Atherosclerosis Research Institute (TaARI), McMaster University, 20 Copeland Ave, Hamilton, ON, Canada
- Department of Cardiac Surgery, McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Nazari Dvirnik
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St W, Hamilton, ON, Canada
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada
- Department of Cardiac Surgery, McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Kevin R An
- Michael G. DeGroote School of Medicine, McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Gabriel Fortin
- Department of Medicine, Université de Sherbrooke, 2500 Boulevard de l'Université, Sherbrooke, QC, Canada
| | - Jessica Spence
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St W, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, 1280 Main St W, Hamilton, ON, Canada
| | - Jeff Healey
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton, ON, Canada
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada
| | - Rohit K Singal
- Department of Surgery, University of Manitoba, 66 Chancellors Cir, Winnipeg, MB, Canada
- I.H. Asper Clinical Research Institute, St. Boniface General Hospital, 69 Taché Avenue, Winnipeg, MB, Canada
| | - Richard P Whitlock
- Department of Clinical Epidemiology and Biostatistics, McMaster University, 1280 Main St W, Hamilton, ON, Canada
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON, Canada
- Department of Cardiac Surgery, McMaster University, 1280 Main St W, Hamilton, ON, Canada
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Bagge L, Probst J, Jensen SM, Blomström P, Thelin S, Holmgren A, Blomström-Lundqvist C. Quality of life is not improved after mitral valve surgery combined with epicardial left atrial cryoablation as compared with mitral valve surgery alone: a substudy of the double blind randomized SWEDish Multicentre Atrial Fibrillation study (SWEDMAF). Europace 2017; 20:f343-f350. [DOI: 10.1093/europace/eux253] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/08/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Louise Bagge
- Departments of Cardiology and Medical Science, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Johan Probst
- Departments of Cardiology and Medical Science, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Steen M Jensen
- Faculty of Medicine, Department of Public Health and Clinical Medicine (Heart centre) Umeå University, SE-901 87 Umeå, Sweden
| | - Per Blomström
- Departments of Cardiology and Medical Science, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Stefan Thelin
- Department of Cardiothoracic Surgery, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Anders Holmgren
- Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Cardiology, Umeå University, SE-901 87 Umeå, Sweden
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Ad N, Damiano RJ, Badhwar V, Calkins H, La Meir M, Nitta T, Doll N, Holmes SD, Weinstein AA, Gillinov M. Expert consensus guidelines: Examining surgical ablation for atrial fibrillation. J Thorac Cardiovasc Surg 2017; 153:1330-1354.e1. [PMID: 28390766 DOI: 10.1016/j.jtcvs.2017.02.027] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 01/27/2017] [Accepted: 02/01/2017] [Indexed: 01/15/2023]
Affiliation(s)
- Niv Ad
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa; Washington Adventist Hospital, Adventist HealthCare, Takoma Park, Md.
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, Mo
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University Morgantown, WVa
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Mark La Meir
- Department of Cardiothoracic Surgery, Academic Hospital Maastricht, Maastricht, The Netherlands
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Nicolas Doll
- Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany
| | - Sari D Holmes
- WVU Heart and Vascular Institute, West Virginia University, Morgantown, WVa
| | - Ali A Weinstein
- Center for the Study of Chronic Illness and Disability, George Mason University, Fairfax, Va
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio
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21
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Churyla A, Iddriss A, Andrei AC, Kruse J, Malaisrie SC, Passman R, Li Z, Lee R, McCarthy PM. Biatrial or Left Atrial Lesion Set for Ablation During Mitral Surgery: Risks and Benefits. Ann Thorac Surg 2017; 103:1858-1865. [DOI: 10.1016/j.athoracsur.2016.10.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 09/03/2016] [Accepted: 10/07/2016] [Indexed: 11/28/2022]
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Compier MG, Tops LF, Braun J, Zeppenfeld K, Klautz RJ, Schalij MJ, Trines SA. Limited left atrial surgical ablation effectively treats atrial fibrillation but decreases left atrial function. Europace 2017; 19:560-567. [PMID: 28431066 DOI: 10.1093/europace/euw106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/19/2016] [Indexed: 11/15/2022] Open
Abstract
AIMS Limited left atrial (LA) surgical ablation with bipolar radiofrequency is considered to be an effective procedure for treatment of atrial fibrillation (AF). We studied whether limited LA surgical ablation concomitant to cardiac surgery is able to maintain LA function. METHODS AND RESULTS Thirty-six consecutive patients (age 66 ± 12 years, 53% male, 78% persistent AF) scheduled for valve surgery and/or coronary revascularization and concomitant LA surgical ablation were included. Epicardial pulmonary vein isolation (PVI) and additional endo-epicardial lines were performed using bipolar radiofrequency. An age- and gender-matched control group (n = 36, age 66 ± 9 years, 69% male, 81% paroxysmal AF) was selected from patients undergoing concomitant epicardial PVI only. Left atrial dimensions and function were assessed on two-dimensional echocardiography preoperatively and at 3- and 12-month follow-up. Sinus rhythm (SR) maintenance was 67% for limited LA ablation and 81% for PVI at 1-year follow-up (P = 0.18). Left atrial volume decreased from 72 ± 21 to 50 ± 14 mL (31%, P < 0.01) after limited LA ablation and from 65 ± 23 to 56 ± 20 mL (14%, P < 0.01) after PVI. Atrial transport function was restored in 54% of patients in SR after limited LA ablation compared with 100% of patients in SR after PVI. Atrial strain and contraction parameters (LA ejection fraction, A-wave velocity, reservoir function, and strain rate) significantly decreased after limited LA ablation. After PVI, strain and contraction parameters remained unchanged. CONCLUSION Even limited LA ablation decreased LA volume, contraction, transport function, and compliance, indicating both reverse remodelling combined with significant functional deterioration. In contrast, surgical PVI decreased LA volume while function remained unchanged.
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Affiliation(s)
- Marieke G Compier
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Laurens F Tops
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Robert J Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin J Schalij
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Serge A Trines
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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Abstract
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia in modern clinical practice, with an estimated prevalence of 1.5-2%. The prevalence of AF is expected to double in the next decades, progressing with age and increasingly becoming a global medical challenge. The first-line treatment for AF is often medical treatment with either rate control or anti-arrhythmic agents for rhythm control, in addition to anti-coagulants such as warfarin for stroke prevention in patient at risk. Catheter ablation has emerged as an alternative for AF treatment, which involves myocardial tissue lesions to disrupt the underlying triggers and substrates for AF. Surgical approaches have also been developed for treatment of AF, particularly for patients requiring concomitant cardiac surgery or those refractory to medical and catheter ablation treatments. Since the introduction of the Cox-Maze III, this procedure has evolved into several modern variations, including the use of alternative energy sources (Cox-Maze IV) such as radiofrequency, cryo-energy and microwave, as well as minimally invasive thoracoscopic epicardial approaches. Another recently introduced technique is the hybrid ablation approach, where in a single setting both epicardial thoracoscopic ablation lesions and endocardial catheter ablation lesions are performed by the cardiothoracic surgeon and cardiologist. There remains controversy surrounding the optimal approach for AF ablation, energy sources, and lesion sets employed. The goal of this article is review the history, classifications, pathophysiology and current treatment options for AF.
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Affiliation(s)
- Joshua Xu
- Sydney Medical School, University of Sydney, Sydney, Australia;; The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Jessica G Y Luc
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Kevin Phan
- Sydney Medical School, University of Sydney, Sydney, Australia;; The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia;; Faculty of Medicine, University of New South Wales, Sydney, Australia
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Huffman MD, Karmali KN, Berendsen MA, Andrei A, Kruse J, McCarthy PM, Malaisrie SC, Cochrane Heart Group. Concomitant atrial fibrillation surgery for people undergoing cardiac surgery. Cochrane Database Syst Rev 2016; 2016:CD011814. [PMID: 27551927 PMCID: PMC5046840 DOI: 10.1002/14651858.cd011814.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Mark D Huffman
- Northwestern University Feinberg School of MedicineDepartments of Preventive Medicine and Medicine (Cardiology)680 N. Lake Shore Drive, Suite 1400ChicagoILUSA60611
| | - Kunal N Karmali
- Northwestern University Feinberg School of MedicineDepartments of Medicine (Cardiology)ChicagoILUSA60611
| | - Mark A Berendsen
- Northwestern UniversityGalter Health Sciences Library303 E. Chicago AvenueChicagoILUSA60611
| | - Adin‐Cristian Andrei
- Northwestern UniversityDepartment of Surgery676 N.Saint Clair St.Suite 1700ChicagoILUSA60611
| | - Jane Kruse
- Northwestern MedicineBluhm Cardiovascular Institute201 East Huron, Galter 11‐140ChicagoILUSA60611
| | - Patrick M McCarthy
- Northwestern UniversityDivision of Cardiac Surgery201 E. Huron StreetGalter 11‐140ChicagoILUSA60611
| | - S. Chris Malaisrie
- Northwestern UniversityDivision of Cardiac Surgery201 E. Huron StreetGalter 11‐140Chicago, ILUSA60611
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Early and long-term outcomes and quality of life after concomitant mitral valve surgery, left atrial size reduction, and radiofrequency surgical ablation of atrial fibrillation. Anatol J Cardiol 2016; 16:797-803. [PMID: 27025202 PMCID: PMC5324943 DOI: 10.14744/anatoljcardiol.2015.6960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Objective: Atrial fibrillation (AF) is the most formidable supraventricular tachyarrhythmia, which worsens the natural course of mitral valve disease. In this study, we evaluated early and long-term results and quality of life (QOL) after simultaneous surgical radiofrequency ablation (RFA) of AF, left atrial reduction and mitral valve repair or replacement. Methods: Overall, 147 patients with mitral valve diseases who underwent mitral valve surgery were included in this prospective cohort study. Patients were divided into two groups according to the type of operation: the study group—patients after mitral valve surgery with concomitant radiofrequency surgical ablation and left atrial reduction procedure (54 patients), and the control group—patients undergoing only mitral valve surgery (93 cases). We assessed AF recurrence and sinus rhythm restoration rates and mortality rates, QOL measures, postoperative complications rates, and left atrial size during follow-up. Results: In the study group, sinus rhythm restoration rate in the early postoperative period was 63%, but at the time of discharge it reduced to 29%; after 6 months, it significantly increased to 72% and after 3 years, to 81% (p=0.02). In the control group, the sinus rhythm restored only in 14% after 1 year, and at 3 years, it was 22%, although in the early postoperative period it, was 43%. Analysis of left atrial size before and after surgery showed that dimension significantly reduced in both groups (study group, p=0.013; control group, p=0.024). In addition, in patients undergoing surgical RFA procedure, there was a significant association between shorter heart disease history (p=0.02) and shorter AF history (p=0.074) with maintenance of sinus rhythm. The mortality rate in the study group was 4% (two patients) and in the control group 5% (five patients). Comparison of QOL measures between study and control groups after 1 year showed that patients undergoing concomitant atrial reduction surgery and RFA had significant improvement of QOL physical (p=0.03) and role (p=0.03) functioning, heartbeat (p=0.01), general (p=0.03) and mental health (p=0.01), vitality (p=0.007), and social role (p=0.02) functioning measures as compared to preoperative state, being higher than in patients who underwent only mitral valve surgery. Conclusion: Application of surgical RFA using irrigated cooling electrode and atrial reduction during mitral valve surgery is associated with higher restoration and maintenance of SR as compared to patients undergoing only mitral valve surgery. We did not observe complications related to AF surgery that required permanent pacemaker implantation. Performing concomitant surgery as surgical RFA, atrial reduction along with mitral valve surgery, improves QOL in the short- and long-term and reduces the feeling of heartbeat and discomfort. (Anatol J Cardiol 2016; 16: 797-803)
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Holmes SD, Fornaresio LM, Shuman DJ, Pritchard G, Ad N. Health-Related Quality of Life after Minimally Invasive Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:128-33. [DOI: 10.1097/imi.0000000000000255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective Factors influencing health-related quality of life (HRQL) after minimally invasive cardiac surgery have not been well described. We examined the trajectory of HRQL after minimally invasive cardiac surgery and the role of perioperative factors and rhythm on HRQL changes. Methods Patients underwent minimally invasive surgical ablation for atrial fibrillation and/or valve surgery (n = 235). Health-related quality of life (SF-12) and clinical status were assessed preoperatively and postoperatively. Results Physical summary HRQL (F = 36.2, P < 0.001) and mental summary HRQL (F = 3.2, P = 0.047) improved significantly by 12 months after surgery. Improvement on HRQL peaked at 6 months and plateaued between 6 and 12 months. Physical HRQL was similar to age-based normal values before surgery (P = 0.66) and surpassed norms by 6 months after surgery (P < 0.001). Younger age (r = −0.15, P = 0.02) and lower EuroSCORE II (r = −0.19, P = 0.003) correlated with greater HRQL improvements by 6 months. Only lower EuroSCORE II (r = −0.14, P = 0.04) correlated with greater HRQL improvement by 12 months. Length of stay and major morbidity were not related to HRQL improvement. In surgical ablation patients, restoration of stable sinus rhythm throughout the first 12 months was associated with greater physical HRQL improvement by 6 months compared with patients who had atrial arrhythmia recurrences (change, 5.0 vs. −1.0, P = 0.02). Conclusions Health-related quality of life improved significantly after minimally invasive cardiac surgery. These improvements were influenced by age, operative risk, symptoms, and rhythm status. Even patients with HRQL in a normal range before surgery can experience improved HRQL after surgery. Minimally invasive cardiac surgery can offer decreased postoperative complications and also improved HRQL.
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Affiliation(s)
- Sari D. Holmes
- Inova Heart and Vascular Institute, Falls Church, VA USA
| | | | | | | | - Niv Ad
- Inova Heart and Vascular Institute, Falls Church, VA USA
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27
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Holmes SD, Fornaresio LM, Shuman DJ, Pritchard G, Ad N. Health-Related Quality of Life after Minimally Invasive Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sari D. Holmes
- Inova Heart and Vascular Institute, Falls Church, VA USA
| | | | | | | | - Niv Ad
- Inova Heart and Vascular Institute, Falls Church, VA USA
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Kyprianou K, Pericleous A, Stavrou A, Dimitrakaki IA, Challoumas D, Dimitrakakis G. Surgical perspectives in the management of atrial fibrillation. World J Cardiol 2016; 8:41-56. [PMID: 26839656 PMCID: PMC4728106 DOI: 10.4330/wjc.v8.i1.41] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/08/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and a huge public health burden associated with significant morbidity and mortality. For decades an increasing number of patients have undergone surgical treatment of AF, mainly during concomitant cardiac surgery. This has sparked a drive for conducting further studies and researching this field. With the cornerstone Cox-Maze III “cut and sew” procedure being technically challenging, the focus in current literature has turned towards less invasive techniques. The introduction of ablative devices has revolutionised the surgical management of AF, moving away from the traditional surgical lesions. The hybrid procedure, a combination of catheter and surgical ablation is another promising new technique aiming to improve outcomes. Despite the increasing number of studies looking at various aspects of the surgical management of AF, the literature would benefit from more uniformly conducted randomised control trials.
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29
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Chernyavskiy A, Kareva Y, Pak I, Rakhmonov S, Pokushalov E, Romanov A. Quality of Life after Surgical Ablation of Persistent Atrial Fibrillation: A Prospective Evaluation. Heart Lung Circ 2015; 25:378-83. [PMID: 26775547 DOI: 10.1016/j.hlc.2015.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/27/2015] [Indexed: 11/27/2022]
Abstract
AIM To compare the quality of life (QoL) of patients with persistent atrial fibrillation (AF) and ischaemic heart disease after modified mini-maze (MM) procedure or pulmonary vein isolation (PVI) using radiofrequency ablation (RFA) with patients in the control group (coronary artery bypass graft [CABG]) alone. METHODS In this prospective randomised study, we included 95 patients with persistent AF and coronary heart disease who underwent open-heart surgery combined with intraoperative irrigated RFA (irrRFA). Patients were randomly assigned to three groups: CABG and PVI using irrRA (CABG+PVI, n=31), CABG and MM procedure using irrRA (CABG+MM, n=30), and isolated CABG (CABG alone, n=34). All patients received implantable loop recorders (ILRs). Patient QoL was assessed using the Short Form 36 (SF-36) preoperatively, and one and two years post-operatively. The study primary end point was freedom from AF one year after operation, measured by implantable loop recorders (ILRs); secondary endpoint included long-term clinical outcomes. RESULTS No reoperations or hospital mortalities were recorded. Mean follow-up was 14.4±9.7 months. The percentages of patients free from AF determined by ILR were 80%, 86.2%, and 44.1% in the CABG+PVI, CABG+MM, and in the CABG alone groups, respectively. The QoL significantly improved in CABG+PVI and CABG+MM groups compared with CABG alone group in most domains. CONCLUSION Effective elimination of AF during CABG surgery improves QoL in all physical health domains of the SF-36 and the role-emotional functioning domain. Thus, patients with concomitant AF and coronary heart disease may benefit from intraoperative radiofrequency ablation to prevent relapse of the arrhythmia.
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Affiliation(s)
- Alexander Chernyavskiy
- Department of Surgery, Aorta, Coronary and Peripheral Arteries, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Yulia Kareva
- Department of Surgery, Aorta, Coronary and Peripheral Arteries, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Inessa Pak
- Department of Surgery, Aorta, Coronary and Peripheral Arteries, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Sardor Rakhmonov
- Department of Surgery, Aorta, Coronary and Peripheral Arteries, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Evgeny Pokushalov
- Department of Rhythm Disorders of the Heart, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Alexander Romanov
- Department of Rhythm Disorders of the Heart, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, Russia
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Abo-Salem E, Lockwood D, Boersma L, Deneke T, Pison L, Paone RF, Nugent KM. Surgical Treatment of Atrial Fibrillation. J Cardiovasc Electrophysiol 2015; 26:1027-1037. [PMID: 26075595 DOI: 10.1111/jce.12731] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 05/25/2015] [Accepted: 05/27/2015] [Indexed: 11/30/2022]
Abstract
Atrial fibrillation (AF) is the most common chronic arrhythmia in the adult population. Ablation lines have largely replaced the historical and challenging cut and sew techniques. Surgical ablation of AF is commonly performed in cases with other indications for cardiac surgery and less commonly as a stand-alone therapy. Pulmonary vein isolation is the cornerstone of this procedure. Extended left atrial ablation lines may increase efficacy in cases with longstanding persistent or permanent AF. Additional efficacy by adding right atrial ablation is controversial but is often performed in cases undergoing right atrial or atrial septal surgery. Left atrial volume reduction is recommended in cases with large left atria and AF undergoing another cardiac surgery. Arrhythmia recurrence is not uncommon after surgical ablation of AF and varies among studies due to heterogeneity in patient population, lesion set and endpoints. Freedom from AF recurrence was 65-87% at 12 months and 58-70% at 2 years follow-up. Long-term monitoring is recommended due to an increased prevalence of asymptomatic recurrences. The strongest predictors of AF recurrence are longstanding or persistent AF and a large left atrium. The most common mechanisms of recurrence are pulmonary vein reconnection, nonpulmonary vein triggers, and gaps in the ablation lines. About 20% of atrial tachyarrhythmia recurrences are atrial flutter or atrial tachycardia. There are not enough data in the surgical literature to support withdrawal of anticoagulation after surgical AF ablation. Patients selected for stand-alone surgical ablation usually have low risk profiles and low postoperative mortality rates (0.2%).
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Affiliation(s)
- Elsayed Abo-Salem
- Division of Cardiovascular Health and Diseases, University of Cincinnati, Cincinnati, Ohio
| | - Deborah Lockwood
- Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Lucas Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Thomas Deneke
- Department of Cardiology, BG-Kliniken Bergmannsheil, University of Bochum, Bochum, Germany
| | - Laurent Pison
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ralph F Paone
- Department of Surgery, Texas Tech University HSC, Lubbock, Texas, USA
| | - Kenneth M Nugent
- Division of Pulmonary and Critical Care Medicine, Texas Tech University HSC, Lubbock, Texas, USA
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Surgical Treatment of Concomitant Atrial Fibrillation: Focus onto Atrial Contractility. BIOMED RESEARCH INTERNATIONAL 2015; 2015:274817. [PMID: 26229956 PMCID: PMC4502278 DOI: 10.1155/2015/274817] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 04/12/2015] [Accepted: 05/01/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Maze procedure aims at restoring sinus rhythm (SR) and atrial contractility (AC). This study evaluated multiple aspects of AC recovery and their relationship with SR regain after ablation. METHODS 122 mitral and fibrillating patients underwent radiofrequency Maze. Rhythm check and echocardiographic control of biatrial contractility were performed at 3, 6, 12, and 24 months postoperatively. A multivariate Cox analysis of risk factors for absence of AC recuperation was applied. RESULTS At 2-years follow-up, SR was achieved in 79% of patients. SR-AC coexistence increased from 76% until 98%, while biatrial contraction detection augmented from 84 to 98% at late stage. Shorter preoperative arrhythmia duration was the only common predictor of SR-AC restoring, while pulmonary artery pressure (PAP) negatively influenced AC recuperation. Early AC restoration favored future freedom from arrhythmia recurrence. Minor LA dimensions correlated with improved future A/E value and vice versa. Right atrial (RA) contractility restoring favored better left ventricular (LV) performance and volumes. CONCLUSIONS SR and left AC are two interrelated Maze objectives. Factors associated with arrhythmia "chronic state" (PAP and arrhythmia duration) are negative predictors of procedural success. Our results suggest an association between postoperative LA dimensions and "kick" restoring and an influence of RA contraction onto LV function.
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Liu H, Chen L, Xiao Y, Ma R, Hao J, Chen B, Qin C, Cheng W. Early Efficacy Analysis of Biatrial Ablation versus Left and Simplified Right Atrial Ablation for Atrial Fibrillation Treatment in Patients with Rheumatic Heart Disease. Heart Lung Circ 2015; 24:789-95. [DOI: 10.1016/j.hlc.2015.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 01/26/2015] [Accepted: 02/08/2015] [Indexed: 02/05/2023]
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Phan K, Xie A, Kumar N, Wong S, Medi C, La Meir M, Yan TD. Comparing energy sources for surgical ablation of atrial fibrillation: a Bayesian network meta-analysis of randomized, controlled trials. Eur J Cardiothorac Surg 2015; 48:201-211. [PMID: 25391388 DOI: 10.1093/ejcts/ezu408] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 09/30/2014] [Indexed: 12/21/2022] Open
Abstract
Simplified maze procedures involving radiofrequency, cryoenergy and microwave energy sources have been increasingly utilized for surgical treatment of atrial fibrillation as an alternative to the traditional cut-and-sew approach. In the absence of direct comparisons, a Bayesian network meta-analysis is another alternative to assess the relative effect of different treatments, using indirect evidence. A Bayesian meta-analysis of indirect evidence was performed using 16 published randomized trials identified from 6 databases. Rank probability analysis was used to rank each intervention in terms of their probability of having the best outcome. Sinus rhythm prevalence beyond the 12-month follow-up was similar between the cut-and-sew, microwave and radiofrequency approaches, which were all ranked better than cryoablation (respectively, 39, 36, and 25 vs 1%). The cut-and-sew maze was ranked worst in terms of mortality outcomes compared with microwave, radiofrequency and cryoenergy (2 vs 19, 34, and 24%, respectively). The cut-and-sew maze procedure was associated with significantly lower stroke rates compared with microwave ablation [odds ratio <0.01; 95% confidence interval 0.00, 0.82], and ranked the best in terms of pacemaker requirements compared with microwave, radiofrequency and cryoenergy (81 vs 14, and 1, <0.01% respectively). Bayesian rank probability analysis shows that the cut-and-sew approach is associated with the best outcomes in terms of sinus rhythm prevalence and stroke outcomes, and remains the gold standard approach for AF treatment. Given the limitations of indirect comparison analysis, these results should be viewed with caution and not over-interpreted.
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Affiliation(s)
- Kevin Phan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia Westmead Hospital, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Ashleigh Xie
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
| | - Narendra Kumar
- Department of Cardiothoracic Surgery and Cardiology, Academic Hospital Maastricht and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Sophia Wong
- Gosford District Hospital, Gosford, Australia
| | - Caroline Medi
- Department of Cardiology and Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark La Meir
- Department of Cardiothoracic Surgery and Cardiology, Academic Hospital Maastricht and Cardiovascular Research Institute Maastricht, Maastricht, Netherlands University Hospital Brussels, Brussels, Belgium
| | - Tristan D Yan
- The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia Department of Cardiology and Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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Padanilam BJ, Foreman J, Prystowsky EN. Patients with minimal atrial fibrillation events should not undergo concomitant atrial ablation during open heart procedures. Card Electrophysiol Clin 2015; 7:395-401. [PMID: 26304518 DOI: 10.1016/j.ccep.2015.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Several randomized controlled trials and meta-analyses have demonstrated improved freedom from atrial fibrillation with intraoperative atrial ablation. However, the increased bypass time and the risk for ablation-related complications should be weighed against the benefits in the decision-making. It is important to establish reasonable criteria to define candidates for surgical ablation. Furthermore, the efficacy and short- and long-term risks related to surgical ablation need to be considered. This article reviews the data on surgical ablation of atrial fibrillation as it pertains to these important issues. As shown the evidence does not support surgical ablation at the time of coronary artery bypass graft in some patients.
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Affiliation(s)
- Benzy J Padanilam
- St. Vincent Medical Group, St. Vincent Hospital, Indianapolis, IN, USA.
| | - Jason Foreman
- St. Vincent Medical Group, St. Vincent Hospital, Indianapolis, IN, USA
| | - Eric N Prystowsky
- St. Vincent Medical Group, St. Vincent Hospital, Indianapolis, IN, USA
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Gillinov AM, Gelijns AC, Parides MK, DeRose JJ, Moskowitz AJ, Voisine P, Ailawadi G, Bouchard D, Smith PK, Mack MJ, Acker MA, Mullen JC, Rose EA, Chang HL, Puskas JD, Couderc JP, Gardner TJ, Varghese R, Horvath KA, Bolling SF, Michler RE, Geller NL, Ascheim DD, Miller MA, Bagiella E, Moquete EG, Williams P, Taddei-Peters WC, O'Gara PT, Blackstone EH, Argenziano M. Surgical ablation of atrial fibrillation during mitral-valve surgery. N Engl J Med 2015; 372:1399-409. [PMID: 25853744 PMCID: PMC4664179 DOI: 10.1056/nejmoa1500528] [Citation(s) in RCA: 348] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Among 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. METHODS We 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). RESULTS More 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. CONCLUSIONS The 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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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Creager MA, Curtis LH, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Stevenson WG, Yancy CW. 2014 AHA/ACC guideline for the management of patients with valvular heart disease. J Thorac Cardiovasc Surg 2014; 148:e1-e132. [DOI: 10.1016/j.jtcvs.2014.05.014] [Citation(s) in RCA: 711] [Impact Index Per Article: 64.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Toeg HD, Al-Atassi T, Lam BK. Atrial Fibrillation Therapies: Lest We Forget Surgery. Can J Cardiol 2014; 30:590-7. [DOI: 10.1016/j.cjca.2014.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 01/31/2014] [Accepted: 02/02/2014] [Indexed: 10/25/2022] Open
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Chen L, Xiao Y, Ma R, Chen B, Hao J, Qin C, Cheng W, Wen R. Bipolar radiofrequency ablation is useful for treating atrial fibrillation combined with heart valve diseases. BMC Surg 2014; 14:32. [PMID: 24884667 PMCID: PMC4039985 DOI: 10.1186/1471-2482-14-32] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 05/14/2014] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common arrhymia, and it results in increased risk of thromboembolism and decreased cardiac function. In patients undergoing cardiac surgery, concomitant radiofrequency ablation to treat AF is effective in restoring sinus rhythm (SR). This study is an observational cohort study aimed to investigate the safety and efficacy of bipolar radiofrequency ablation (BRFA) for treating AF combined with heart valve diseases. METHODS Clinical data were analyzed retrospectively from 324 cases of rheumatic heart disease combined with persistent AF patients who underwent valve replacement concomitant BRFA. The modified left atrial and the simplified right atrial ablation were used for AF treatments. Of the 324 patients, 248 patients underwent mitral valve replacement and 76 patients underwent double valve replacement. Meanwhile, 54 patients underwent concomitant thrombectomy and 97 underwent tricuspid valvuloplasty. And all of them received temporary pacemaker implantation. The 24 hours holter electrocardiogram (ECG) monitoring and echocardiography was performed before the operation, on the first day after operation, on discharge day, and at 6 and 12 months after operation. RESULTS There were 299 patients with SR on the first day after operation (92.30%), 12 patients with junctional rhythm (3.70%), 11 patients with AF (3.39%), and 2 patients with atrial flutter (0.62%). The temporary pacemaker was used in 213 patients (65.74%) with heart rates less than 70 beat/minute in the ICU. Two patients died early and the mortality rate was 0.62%. Two patients had left ventricular rupture and the occurrence rate was 0.62%. They both recovered. There was no degree III atrioventricular blockage and no permanent pacemaker implantation. Overall survival rate was 99.38% (322 cases) with SR conversion rate of 89.13% (287 cases) at discharge. The SR conversion rate was 87.54% and 87.01% at 6 and 12 months after operation. Sinus bradycardia occurred in 3.42% of patients at 6 months after operation and in 3.03% of patients at 12 months after operation. Echocardiography showed that the left atrial diameter was significantly decreased, and ejection fraction and fractional shortening were significantly improved. CONCLUSIONS BRFA for treating AF in concomitant valve replacement is safe and with good efficacy.
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Affiliation(s)
- Lin Chen
- Department of Cardiovascular Surgery, Xinqiao Hospital, Third Military Medical University, 7F, Second in-Patient Building, 183 Xinqiao St, Shapingba District, Chongqing 400037, P, R, China.
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Phan K, Xie A, La Meir M, Black D, Yan TD. Surgical ablation for treatment of atrial fibrillation in cardiac surgery: a cumulative meta-analysis of randomised controlled trials. Heart 2014; 100:722-30. [DOI: 10.1136/heartjnl-2013-305351] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129:e521-643. [PMID: 24589853 DOI: 10.1161/cir.0000000000000031] [Citation(s) in RCA: 892] [Impact Index Per Article: 81.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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La Meir M. Surgical options for treatment of atrial fibrillation. Ann Cardiothorac Surg 2014; 3:30-7. [PMID: 24516795 DOI: 10.3978/j.issn.2225-319x.2014.01.07] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 01/17/2014] [Indexed: 12/11/2022]
Abstract
If we want to improve the outcomes, increase the success and reduce the complication rate of existing treatment strategies in concomitant and stand-alone atrial fibrillation (AF) procedures, we will have to increase our understanding of the pathophysiology, and of the disease, the limitations of current energy sources and ablation catheters, the different possible lesion sets, as well as improve communication between the electrophysiologist and cardiac surgeon. The technical limitations of percutaneous endocardial ablation procedures and the empirical techniques in surgical AF procedures necessitate new and innovative approaches. Surgeons should aim to improve the quality of the lesion set and minimize the invasiveness of existing techniques. The Maze procedure remains the basis upon which most of the more limited concomitant ablation procedures are and will be designed, but in stand-alone patients, recent progress has directed us towards either a single-step or sequential combined percutaneous endocardial procedure with a thoracoscopic epicardial procedure on the beating heart. A dedicated team of electrophysiologists and cardiothoracic surgeons can now work together to perform AF procedures. This can guide us to determine if there is an additional value of limiting the lesion set of the Maze procedure in concomitant surgery, and of an epicardial access in the treatment of stand-alone AF on the beating heart. If so, we will better understand which energy sources, lesion sets and surgical techniques are able to give us a three-dimensional knowledge and a three-dimensional treatment of AF. As a result, we can expect to obtain a higher single procedure long-term success rate with an acceptable low complication rate.
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Affiliation(s)
- Mark La Meir
- University Hospital of Brussels, Belgium and University Hospital Maastricht, The Netherlands
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The effect of the Cox-maze procedure for atrial fibrillation concomitant to mitral and tricuspid valve surgery. J Thorac Cardiovasc Surg 2013; 146:1426-34; discussion 1434-5. [DOI: 10.1016/j.jtcvs.2013.08.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/22/2013] [Accepted: 08/01/2013] [Indexed: 11/21/2022]
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Pizon M, Friedel N, Pizon M, Freundt M, Weyand M, Feyrer R. Impact of epicardial ablation of concomitant atrial fibrillation on atrial natriuretic peptide levels and atrial function in 6 months follow-up: does preoperative ANP level predict outcome of ablation? J Cardiothorac Surg 2013; 8:218. [PMID: 24286219 PMCID: PMC3892101 DOI: 10.1186/1749-8090-8-218] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 11/25/2013] [Indexed: 11/13/2022] Open
Abstract
Background Epicardial ablation concomitant to cardiac surgery is an easy and safe approach to treat atrial fibrillation (AF), but its efficacy in longstanding persistent (LsPe) AF remains intermediate. Although larger left atrial size has been associated with worse outcome after ablation, biochemical predictors of success are not well established. The aim of this study was to evaluate relationship between biochemical marker, echo-characteristic and cardiac rhythm in 6 months follow-up after epicardial ultrasound (HIFU) ablation. Methods We included 78 consecutive patients, who underwent elective cardiac surgery. 42 patients with AF (11.9% paroxysmal, 23.8% persistent, 64.3% LsPeAF) underwent concomitant HIFU ablation (AF ablation group), 16 with AF underwent cardiac surgery without ablation (AF control) and 20 had preoperatively normal sinus rhythm (SR control). We measured plasma ANP secretion before, on postoperative day (POD) 1, POD 7 as well as 3 and 6 months after surgery. Moreover, we estimated cardiac rhythm and atrial mechanical function by Atrial Filling Fraction (AFF) and A-wave velocity in follow-up. Results Baseline ANP levels were higher in patients with LsPeAF, as compared to the paroxysmal and permanent AF and to the SR control group. Patients with LsPeAF (n = 27) who converted to SR had preoperatively smaller left atrial diameter (LAD) and LA area (p < 0.05) and higher ANP level (p = 0.009) than those who remained in AF at 6 months after ablation. Multivariate regression analysis revealed that only preoperative ANP level was an independent predictor of cardiac rhythm after ablation. Patients with LsPeAF and preoperative ANP >7.5 nmol/l presented with SR in 80%, in contrast to those with ANP <7.5 nmol/l who converted to SR in 20%. We detected gradual increase of AFF and A-velocity at 6 months after ablation (p < 0.05) solely in AF ablation group. ANP levels were increased on POD 1 in ablation group (p < 0.05), without changes in further follow-up. Conclusion Our results indicate that preoperative ANP levels may be a new biochemical predictor of successful epicardial ablation in patients with concomitant LsPeAF. HIFU ablation caused a significant improvement of atrial mechanical function and gradual increase of AFF and did not associate with alteration of atrial endocrine secretion at 6 months follow-up.
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Affiliation(s)
- Marek Pizon
- Department of Cardiac Surgery, Clinic of Bayreuth, Preuschwitzerstr 101, 95455 Bayreuth, Germany.
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Damiano RJ, Badhwar V, Acker MA, Veeragandham RS, Kress DC, Robertson JO, Sundt TM. The CURE-AF trial: a prospective, multicenter trial of irrigated radiofrequency ablation for the treatment of persistent atrial fibrillation during concomitant cardiac surgery. Heart Rhythm 2013; 11:39-45. [PMID: 24184028 DOI: 10.1016/j.hrthm.2013.10.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Ablation technology has been introduced to replace the surgical incisions of the Cox-Maze procedure in order to simplify the operation. However, the efficacy of these ablation devices has not been prospectively evaluated. OBJECTIVE The purpose of this study was to examine the efficacy and safety of irrigated unipolar and bipolar radiofrequency ablation for the treatment of persistent and long-standing persistent atrial fibrillation (AF) during concomitant cardiac surgical procedures. METHODS Between May 2007 and July 2011, 150 consecutive patients were enrolled at 15 U.S. centers. Patients were followed for 6 to 9 months, at which time a 24-hour Holter recording and echocardiogram were obtained. Recurrent AF was defined as any atrial tachyarrhythmia (ATA) lasting over 30 seconds on the Holter monitor. The safety end-point was the percent of patients who suffered a major adverse event within 30 days of surgery. All patients underwent a biatrial Cox-Maze lesion set. RESULTS Operative mortality was 4%, and there were 4 (3%) 30-day major adverse events. Overall freedom from ATAs was 66%, with 53% of patients free from ATAs and also off antiarrhythmic drugs at 6 to 9 months. Increased left atrial diameter, shorter total ablation time, and an increasing number of concomitant procedures were associated with recurrent AF (P <.05). CONCLUSION Irrigated radiofrequency ablation for treatment of AF during cardiac surgery was associated with a low complication rate. No device-related complications occurred. The Cox-Maze lesion set was effective at restoring sinus rhythm and had higher success rates in patients with smaller left atrial diameters and longer ablation times.
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Affiliation(s)
- Ralph J Damiano
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri.
| | - Vinay Badhwar
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael A Acker
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - David C Kress
- Department of Cardiovascular and Thoracic Surgery, Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | - Jason O Robertson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Incremental risk of the Cox-maze IV procedure for patients with atrial fibrillation undergoing mitral valve surgery. J Thorac Cardiovasc Surg 2013; 146:1072-7. [PMID: 23998785 DOI: 10.1016/j.jtcvs.2013.06.048] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 08/02/2012] [Accepted: 06/24/2013] [Indexed: 01/08/2023]
Abstract
OBJECTIVE More than 50% of atrial fibrillation surgery occurs in the setting of mitral valve surgery. Despite this, no risk models have been validated for concomitant arrhythmia surgery. The purpose of the present study was to quantify the additional risk of performing the Cox-maze IV procedure for patients undergoing mitral valve surgery. METHODS From January 2002 to June 2011, 213 patients with mitral valve disease and preoperative atrial fibrillation underwent mitral valve surgery only (n = 109) or in conjunction with a Cox-maze IV procedure (n = 104). The operative mortality for the mitral valve procedure alone was predicted for each group using the Society of Thoracic Surgeons perioperative risk calculator. The risk attributed to the added Cox-maze IV procedure was calculated by comparing the predicted mortality rate of an isolated mitral valve procedure and the actual mortality rate of mitral valve surgery with a concomitant Cox-maze IV procedure. RESULTS For patients not undergoing a Cox-maze IV procedure, the predicted and actual postoperative mortality rate was 5.5% and 4.6% (5 of 109), respectively. For patients receiving mitral valve surgery and a concomitant Cox-maze IV, the predicted and actual postoperative mortality of the mitral valve procedure was 2.5% and 2.9% (3 of 104), respectively, and not significantly different. Patients not offered a Cox-maze IV procedure had significantly more serious comorbidities. CONCLUSIONS For patients with atrial fibrillation and mitral valve disease undergoing mitral valve surgery, the decision to offer a concomitant Cox-maze IV procedure will be influenced by the underlying comorbid conditions. Nonetheless, in selected lower risk patients, the addition of a Cox-maze IV procedure did not significantly affect the procedural mortality.
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Dunning J, Nagendran M, Alfieri OR, Elia S, Kappetein AP, Lockowandt U, Sarris GE, Kolh PH. Guideline for the surgical treatment of atrial fibrillation. Eur J Cardiothorac Surg 2013; 44:777-91. [PMID: 23956274 DOI: 10.1093/ejcts/ezt413] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its prevalence is ∼1-2% of the general population, but higher with increasing age and in patients with concomitant heart disease. The Cox-maze III procedure was a groundbreaking development and remains the surgical intervention with the highest cure rate, but due to its technical difficulty alternative techniques have been developed to create the lesions sets. The field is fast moving and there are now multiple energy sources, multiple potential lesion sets and even multiple guidelines addressing the issues surrounding the surgical treatment of AF both for patients undergoing this concomitantly with other cardiac surgical procedures and also as stand-alone procedures either via sternotomy or via videothoracoscopic techniques. The aim of this document is to bring together all major guidelines in this area into one resource for clinicians interested in surgery for AF. Where we felt that guidance was lacking, we also reviewed the evidence and provided summaries in those areas. We conclude that AF surgery is an effective intervention for patients with all types of AF undergoing concomitant cardiac surgery to reduce the incidence of AF, as demonstrated in multiple randomized studies. There is some evidence that this translates into reduced stroke risk, reduced heart failure risk and longer survival. In addition, symptomatic patients with AF may be considered for surgery after failed catheter intervention or even as an alternative to catheter intervention where either catheter ablation is contraindicated or by patient choice.
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Affiliation(s)
- Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
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Providência R, Barra S, Pinto C, Paiva L, Nascimento J. Surgery for Atrial Fibrillation: Selecting the Procedure for the Patient. J Atr Fibrillation 2013; 6:743. [PMID: 28496848 DOI: 10.4022/jafib.743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Revised: 01/13/2013] [Accepted: 03/26/2013] [Indexed: 11/10/2022]
Abstract
This manuscript aims to review the current knowledge in the field of surgical ablation of atrial fibrillation (AF), including a brief discussion regarding the standard Maze procedure, its variants, minimally invasive thoracoscopic procedures and hybrid treatments, which briefly summarizes the advantages and differences between each technique. The rationale for the surgical approach of the left atrial appendage, its different techniques and complications will also be briefly covered. To conclude, the current Expert Consensus recommendations will be reviewed and an algorithm for the surgical management of the patient with AF, suggesting which technique applies better to which patient, under specific settings, will also be proposed.
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Affiliation(s)
- Rui Providência
- Cardiology Department, Coimbra's Hospital and University Centre, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Sérgio Barra
- Cardiology Department, Coimbra's Hospital and University Centre, Coimbra, Portugal
| | - Carlos Pinto
- Cardiothoracic Surgery Department, Coimbra's Hospital and University Centre, Coimbra, Portugal
| | - Luís Paiva
- Cardiology Department, Coimbra's Hospital and University Centre, Coimbra, Portugal
| | - José Nascimento
- Cardiology Department, Coimbra's Hospital and University Centre, Coimbra, Portugal
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Hogan EL, Podbielska M, O'Keeffe J. Implications of Lymphocyte Anergy to Glycolipids in Multiple Sclerosis (MS): iNKT Cells May Mediate the MS Infectious Trigger. ACTA ACUST UNITED AC 2013; 4. [PMID: 26347308 PMCID: PMC4557814 DOI: 10.4172/2155-9899.1000144] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Immunogenic lipids may play key roles in host defenses against infection and in generating autoimmune inflammation and organ-specific damage. In multiple sclerosis (MS) there are unequivocal autoimmune features and vulnerability to aggravation or induction by microbial or viral infection. We have found glycolipid-driven anergy of circulating lymphocytes in MS indicating that this immune response is affected in MS and the robust effects of iNKT activation with potent cellular and cytokine activities emphasizes its potential importance. Diverse glycolipids including the endogenous myelin acetylated-galactosylceramides (AcGalCer) can drive activation that could be critical to the inflammatory demyelination in the central nervous system and clinical consequences. The iNKT cells and their invariant or iTCR (Vα24Jα18Vβ11) receptor an innate defense–a discrete immune arm that is separate from peptide-driven acquired immune responses. This offers new possibilities for insight including a likelihood that the pattern recognition of exogenous microbial and myelin immunogens can overlap and cross-react especially in an inflammatory milieu.
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Affiliation(s)
- Edward L Hogan
- Georgia Regents University, Institute of Molecular Medicine and Genetics, Department of Neurology, 1120 15 Street, Augusta, 30912-2620 GA, USA ; National University of Ireland Galway, Department of Microbiology, University Road, Galway, Ireland ; Medical University of South Carolina, Department of Neurosciences, 173 Ashley Avenue, Charleston, SC 29401, USA
| | - Maria Podbielska
- Georgia Regents University, Institute of Molecular Medicine and Genetics, Department of Neurology, 1120 15 Street, Augusta, 30912-2620 GA, USA ; Ludwik Hirszfeld Institute of Immunology & Experimental Therapy, Polish Academy of Sciences, Laboratory of Signaling Proteins, R. Weigla Street 12, 53-114 Wrocław, Poland
| | - Joan O'Keeffe
- Department of Life and Physical Sciences, School of Science, Galway-Mayo Institute of Technology, Galway, Ireland
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Straka Z, Budera P, Osmančík P, Vaněk T, Hulman M, Smíd M, Malý M, Widimský P. Design and rationale of the PRAGUE-12 trial: a large, prospective, randomized, multicenter trial that compares cardiac surgery with left atrial surgical ablation with cardiac surgery without ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation. Clin Cardiol 2012; 36:1-5. [PMID: 23280480 PMCID: PMC3564405 DOI: 10.1002/clc.22085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 11/13/2012] [Indexed: 11/10/2022] Open
Abstract
Surgical ablation procedure can restore sinus rhythm (SR) in patients with atrial fibrillation (AF) undergoing cardiac surgery. However, it is not known whether it has any impact on clinical outcomes. There is a need for a randomized trial with long‐term follow‐up to study the outcome of surgical ablation in patients with coronary and/or valve disease and AF. Patients are prospectively enrolled and randomized either to group A (cardiac surgery with left atrial ablation) or group B (cardiac surgery alone). The primary efficacy outcome is the SR presence (without any AF episode) during a 24‐hour electrocardiogram after 1 year. The primary safety outcome is the combined end point of death, myocardial infarction, stroke, and renal failure at 30 days. Long‐term outcomes are a composite of total mortality, stroke, bleeding, and heart failure at 1 and 5 years. We finished the enrollment with a total of 224 patients from 3 centers in 2 countries in December 2011. Currently, the incomplete 1‐year data are available, and the patients who enrolled first will have their 5‐year visits shortly. PRAGUE‐12 is the largest study to be conducted so far comparing cardiac surgery with surgical ablation of AF to cardiac surgery without ablation in an unselected population of patients who are operated on for coronary and/or valve disease. Its long‐term results will lead to a better recognition of ablation's potential clinical benefits. The PRAGUE‐12 trial is partially funded by the Charles University Research Projects MSM0021620817 and UNCE 204010/2012. The authors have no other funding, financial relationships, or conflicts of interest to disclose.
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Affiliation(s)
- Zbyněk Straka
- Cardiocenter, Charles University Prague, Czech Republic.
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Budera P, Straka Z, Osmančík P, Vaněk T, Jelínek Š, Hlavička J, Fojt R, Červinka P, Hulman M, Šmíd M, Malý M, Widimský P. Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study. Eur Heart J 2012; 33:2644-52. [PMID: 22930458 PMCID: PMC3485575 DOI: 10.1093/eurheartj/ehs290] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aims Surgical ablation procedure can restore sinus rhythm (SR) in patients with atrial
fibrillation (AF) undergoing cardiac surgery. However, it is not known whether it has
any impact on long-term clinical outcomes. Methods and results This multicentre study randomized 224 patients with AF scheduled for valve and/or
coronary surgery: group A (left atrial surgical ablation, n =
117) vs. group B (no ablation, n = 107). The primary efficacy
outcome was the SR presence (without any AF episode) during a 24 h electrocardiogram
(ECG) after 1 year. The primary safety outcome was the combined endpoint of
death/myocardial infarction/stroke/renal failure at 30 days. A Holter-ECG after 1 year
revealed SR in 60.2% of group A patients vs. 35.5% in group B
(P = 0.002). The combined safety endpoint at 30 days occurred
in 10.3% (group A) vs. 14.7% (group B, P = 0.411).
All-cause 1-year mortality was 16.2% (A) vs. 17.4% (B, P
= 0.800). Stroke occurred in 2.7% (A) vs. 4.3% (B) patients
(P = 0.319). No difference (A vs. B) in SR was found among
patients with paroxysmal (61.9 vs. 58.3%) or persistent (72 vs. 50%) AF,
but ablation significantly increased SR prevalence in patients with longstanding
persistent AF (53.2 vs. 13.9%, P < 0.001). Conclusion Surgical ablation improves the likelihood of SR presence post-operatively without
increasing peri-operative complications. However, the higher prevalence of SR did not
translate to improved clinical outcomes at 1 year. Further follow-ups (e.g. 5-year) are
warranted to show any potential clinical benefit which might occur later.
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Affiliation(s)
- Petr Budera
- Cardiocenter, Third Faculty of Medicine, Charles University Prague, Czech Republic.
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