Hybrid thoracoscopic and transvenous catheter ablation of atrial fibrillation

The hybrid approach combines an epicardial ablation with a percutaneous endocardial ablation in a single-step or sequential procedure. This study provides an overview of the hybrid procedure for the treatment of stand-alone atrial fibrillation (AF). Papers selected for this review were identified on PubMed and the final selection included nine studies. The total number of patients was 335 (range 15-101). Mean age ranged from 55.2 to 62.9 years. The hybrid approach achieved satisfactory results, with AF-antiarrhythmic drug-free success rates higher than those in isolated procedures. In particular, the bilateral approach with a bipolar device showed a high success rate independently of the AF type and seems to be the better choice for the hybrid procedure. Despite good preliminary results, large, multicentre trials of hybrid AF ablation that target a population of patients with long-standing persistent disease are necessary to establish whether this approach may represent, in the future, a gold-standard treatment for AF

A Prospective Randomized Multicenter Comparison on Health-Related Quality of Life: The Value of Add-On Arrhythmia Surgery in Patients with Paroxysmal, Permanent or Persistent Atrial Fibrillation Undergoing Valvular and/or Coronary Bypass Surgery

Methods: 150 patients with documented atrial fibrillation were randomly assigned to undergo cardiac surgery with or without add-on surgery. Patients completed quality of life questionnaires, comprising the RAND 36-item Health Survey 1.0 (SF-36), Multidimensional Fatigue Inventory-20 (MFI-20) and EuroQoL (EQ-5D and VAS) at baseline and 3, 6, and 12 months following operation. Results: 132 patients completed the questionnaires at a minimum of one time-point during follow-up. At baseline patient characteristics, operative data and health-related quality of life were comparable. At 12-month follow-up 62 patients were free of atrial fibrillation without significant differences between groups (P = 0.28). Conversion to SR occurred in 69.8% (37/53) of patients with paroxysmal AF, in 28.2% (11/39) of patients with permanent AF and in 44.4% (12/27) of patients in persistent AF. Cardiac surgery in general resulted in an overall improvement of the RAND SF-36 and the MFI-20. However, the EQ-5D showed a significant deterioration in the subscale Pain/Discomfort for both groups (P <0.001), with a significant worse outcome for the control group (P = 0.006). Conclusions: Health-related quality of life in patients with paroxysmal, permanent and persistent atrial fibrillation improves after cardiac surgery regardless of giving add-on surgery or not, but this improvement is presumably more affected by treating the underlying heart disease than by restoring sinus rhythm. (J Cardiovasc Electrophysiol, Vol. 21, pp. 511-520, May 2010)

Guideline adherence in antithrombotic treatment after concomitant ablation surgery in atrial fibrillation patients

OBJECTIVES: We investigated real-life oral anticoagulation (OAC) treatment after surgical ablation and examined its adherence to current recommendations. We also explored factors related to OAC use preoperatively and at follow-up. METHODS: One hundred and fifteen patients with atrial fibrillation (AF) were evaluated during 12-month follow-up after surgery. Patients were divided into two categories according to the congestive heart failure, hypertension, age ≥75 years, diabetes and prior stroke [or transient ischaemic attack or thromboembolism] (CHADS(2)) score: 60 patients were assigned to the high-risk group (CHADS(2) score ≥2) and 55 to the low-risk group (CHADS(2) score ≤1). OAC use was defined as guideline adherent, undertreatment or overtreatment. RESULTS: Baseline overall guideline adherence was 62%. OAC was underprescribed in high-risk patients and overprescribed in low-risk patients (both, P < 0.001). The only factor associated with OAC use after logistic regression analysis were age >75 years (P = 0.01) and preoperative AF > paroxysmal (P = 0.013). Overall guideline adherence at 12-month follow-up showed a trend towards a better adherence in the sinus rhythm (SR) subgroup (74% vs 55%, P = 0.02). OAC was underprescribed in high-risk patients and overprescribed in low-risk patients (both P < 0.001). After logistic regression analysis, preoperative OAC use (P = 0.007) and other indications for OAC (P = 0.01) were predictors of anticoagulation treatment. CONCLUSIONS: Real-life OAC prescription in AF patients showed a moderate guideline adherence, with high-risk patients being undertreated and low-risk patients being overtreated. These findings stress the importance that antithrombotic treatment in patients undergoing AF surgery needs to be critically re-evaluated

Does sinus rhythm conversion after cardiac surgery affect postoperative health- related quality of life?

BACKGROUND: We investigated the impact and the predictive value of sinus rhythm at 12 months (SR(12)) on subscales of three different HrQoL questionnaires: SF-36., EuroQoL and MFI 20. METHODS: Data of 125 cardiac surgery patients with pre-operative AF from our previous randomized trial were used. Based on their rhythm outcome patients were divided in two groups: SR(12) or AF at 12 months follow up (non-SR(12)). All questionnaires were self-administered pre-operatively and at 3 months, 6 months and 12 months after surgery. RESULTS: Synus rhytm at 12 months was predictive of improvement of SF36- mental score (MS, p = 0.021), Euro-QoL-MS (p = 0.009), VAS (p = 0.006), and MFI 20-MS (p = 0.009). We failed to find any significant interactions between SR(12) and any of the other significant risk factors: age <65 years, paroxysmal type of AF and preoperative AF duration <12 months. In contrast, SR(12) was not significant in predicting physical score (PS) subscales of any of the questionnaires (all, p > 0.05) which were predicted by age <65 years (SF36-PS, p = 0.029) by paroxysmal type of AF and age <65 years (Euro-QoL-PS, p = 0.017 and p = 0.04, respectively) and by AF duration <12 months, paroxysmal type of AF and age < 65 years (MFI 20-PS, p = 0.019, p = 0.020 and p = 0.015, respectively). CONCLUSIONS: Specific mental-related HrQoL scales are much more sensitive to sinus rhythm conversion. Sinus rithm mantainance shows significant effects on mental scores independently of other cofactors. Successful conversion to sinus rhythm after surgical ablation during cardiac surgery does not significantly affect phisical health related quality of life during 1 year follow up

Maintenance of sinus rhythm after electrical cardioversion for recurrent atrial fibrillation following mitral valve surgery with or without associated radiofrequency ablation

Background: This study reports the outcomes of patients who underwent electrical cardioversion for atrial fibrillation recurrence following mitral valve surgery and associated radiofrequency ablation compared to those who did not undergo concomitant atrial fibrillation ablation. Methods: The population consisted of 116 patients with persistent/long-standing persistent AF who underwent mitral valve surgery with (Group A, n = 54) or without (Group B, n = 62) associated radiofrequency ablation between January 2007 and January 2011 at three institutions and who subsequently underwent cardioversion for persistent atrial fibrillation within 12 months of their initial procedure. Results: The mean follow-up duration was 30.7 +/- 9.4 months. Of the 104 patients with acute restoration of SR 42 (40.3%) had AF recurrence. The average time to recurrence after cardioversion was 7.3 +/- 4.2 days. Recurrence was significantly lower in patients undergoing ablation surgery (21.4%) than in those undergoing no ablation surgery (78.6%, p &lt;0.001). Non-performed ablation procedure (p &lt;0.001), time from surgery &gt;= 88 days and left atrial dimensions &gt;= 45.5 mm before cardioversion (both, p = 0.005) were multivariable predictors of atrial fibrillation recurrence. In Group B the use of amiodarone was inversely correlated with recurrence of AF (p &lt;0.001). This correlation was not significant (r = -0.02, p = 0.85) in Group A. Conclusions: Electrical cardioversion for recurrent AF showed better results and stable recovery of sinus rhythm in patients undergoing concomitant surgical ablation during mitral valve surgery. This might be attributable to substrate modification caused by surgical lesions. Amiodarone improved the ECV-success rate only in patients with no associate ablation. Further larger randomized studies are necessary to confirm our findings