Anders Albåge

Extracorporeal membrane oxygenation as a rescue of intractable ventricular fibrillation and bridge to heart transplantation.

Extracorporeal membrane oxygenation (ECMO) systems have undergone rapid technological improvements and are now feasible options for medium‐term support of severe cardiac or pulmonary failure. Intractable ventricular arrhythmia is a rare but well‐established indication for heart transplantation. We report a case of persistent ventricular fibrillation (VF) that was rescued by insertion of peripheral veno‐arterial ECMO during cardiopulmonary resuscitation, which provided support for 30 h of continuous VF and subsequently permitted urgent heart transplantation.

Long-Term Health-Related Quality of Life After Maze Surgery for Atrial Fibrillation

BACKGROUND Atrial fibrillation (AF) significantly impairs health-related quality of life (QoL). As pharmacologic treatment may have intolerable side effects and is not always effective, other techniques for curing AF have evolved. The maze III procedure has a high long-term success rate in restoring and maintaining sinus rhythm, but the long-term impact on QoL has not been sufficiently demonstrated. METHODS Thirty-four patients underwent the maze III procedure for paroxysmal (n = 9), persistent (n = 15) or permanent (n = 10) AF. Quality of life was assessed with the Swedish Short Form-36 survey. Mean follow-up time was 35 +/- 6 months. RESULTS Sinus rhythm was maintained in 32 patients (94%). For all domains except bodily pain, all patients reported substantial worse QoL at baseline as compared with healthy controls. Postoperatively all scores improved significantly to the level of the general population, and for the majority of the scoring items this was observed after 12 months. Improvement was maintained during the remaining observation period. CONCLUSIONS The maze III procedure significantly improves QoL in patients with AF. The results are consistent during an observation time of 35 months. Based on QoL effects in a long-term perspective, maze surgery should be considered in symptomatic patients with AF refractory to pharmacologic treatment or catheter ablation.

A Swedish consensus on the surgical treatment of concomitant atrial fibrillation

Abstract Atrial fibrillation (AF) is a common arrhythmia among patients scheduled for open heart surgery and is associated with increased morbidity and mortality. According to international guidelines, symptomatic and selected asymptomatic patients should be offered concomitant surgical AF ablation in conjunction with valvular or coronary surgery. The gold standard in AF surgery is the Cox Maze III (“cut-and-sew”) procedure, with surgical incisions in both atria according to a specified pattern, in order to prevent AF reentry circuits from developing. Over 90% of patients treated with the Cox Maze III procedure are free of AF after 1 year. Recent developments in ablation technology have introduced several energy sources capable of creating nonconducting atrial wall lesions. In addition, simplified lesion patterns have been suggested, but results with these techniques have been unsatisfactory. There is a clear need for standardization in AF surgery. The Swedish Arrhythmia Surgery Group, represented by surgeons from all Swedish units for cardiothoracic surgery, has therefore reached a consensus on surgical treatment of concomitant AF. This consensus emphasizes adherence to the lesion pattern in the Cox Maze III procedure and the use of biatrial lesions in nonparoxysmal AF.

Learning what works in surgical cryoablation of atrial fibrillation: results of different application techniques and benefits of prospective follow-up

Atrial fibrillation (AF) in cardiac surgical patients is detrimental in the long perspective. Concomitant surgical ablation of AF is recommended in guidelines and performed in most centers. The article describes the experiences in a single institution with concomitant surgical argon-based cryoablation in 115 patients using three different application techniques (epicardial left atrium, endocardial left atrium, biatrial cryo-maze) and a structured local follow-up to one year postoperatively. Results showed cryoablation to be safe with few complications related to the ablation procedure and few thromboembolic events. In this study, a complete biatrial lesion set according to the classic Cox-maze III (CM III) lesion pattern yielded a higher success rate than left atrial procedures. At 12 months, patients in sinus or pacing rhythm, free of AF without antiarrhythmic drugs, were 27/39 (69%), 24/32 (74%) and 36/44 (82%) in the EpiLA, EndoLA and cryo-maze groups, respectively. A consistent prospective follow-up is essential not only for research purposes but also for assessing the local results of AF surgery in everyday practice. It may direct and develop the surgical ablation program, guide individual postoperative arrhythmia management and is needed to increase overall quality of surgical AF ablation.

The biatrial cryo-maze procedure for treatment of atrial fibrillation: A single-center experience

Abstract Objectives. The Cox-maze III procedure is the benchmark for atrial fibrillation (AF) surgery but has been replaced by surgical ablation. We evaluated our experience with biatrial cryoablation using the full Cox-maze III lesion pattern, and adhering follow-up to current guidelines. Design. Forty-three patients underwent the biatrial cryo-maze procedure as a concomitant (n = 37) or stand-alone procedure (n = 6). Mean age was 64.8 ± 9.5 years. Overall, AF was paroxysmal/persistent/permanent in 28/14/58%. Mean AF duration was 5.2 ± 6.5 years. Follow-up included prospective evaluation at 1, 3 and 12 months, long-term monitoring and transthoracic echocardiography. Results. No mortality and no complications related to the ablation procedure occurred. One patient suffered a stroke at 12 months. In the concomitant group, rhythm was sinus/pacing without AF/AF in 65/16/19% at three months, and 59/22/19% at 12 months. Five patients received new pacemakers (12%). In the stand-alone group, 5/6 (83%) patients had sinus rhythm with no AF at three and 12 months. Overall, 35/43 patients (81%) had sinus/paced rhythm at 12 months with no AF and no anti-arrhythmic drugs. Echocardiography showed satisfactory results in all patients. Conclusions. The biatrial cryo-maze procedure is safe and effective in surgical patients with concomitant AF, and could be considered for selected patients with lone AF.

Surgery for ventricular tachycardia and left ventricular aneurysm provides arrhythmia control

Objectives. Report long-term freedom from ventricular tachycardia (VT), survival, and causes of death in patients with left ventricular aneurysm and VT, who underwent a combined procedure for VT and surgical ventricular restoration (SVR). Design. The primary outcome measures VT, survival, and cause of death, were ascertained by review of patients’ records, interrogation of implanted cardioverter-defibrillators and use of national registers. Results. Mean follow-up was 5.2 years. Overall survival was 62% at 5 years and 51% at 9 years. Freedom from spontaneous VT was 89%. In 32 patients who were non-inducible at postoperative testing, there was no occurrence of VT during a mean follow-up of 6.0 years. Causes of death were cardiac in 17 patients, and non-cardiac in 6 patients. No patient died from ventricular arrhythmia. Conclusions. Direct surgery for VT combined with SVR resulted in a very low risk of late recurrence of VT and good long-term survival. Implantation of a cardioverter-defibrillator can safely be withheld in patients who are non-inducible on postoperative programmed electrical stimulation.

Hemodynamics at rest do not match clinical improvement after surgical ventricular restoration

Objectives. The aim was to study the change in cardiac index (CI) and pulmonary artery pressure (PAP) by intra-cardiac measurements after surgical ventricular restoration (SVR) in patients with left ventricular aneurysm and symptoms of heart failure. Aspects of functional improvement were analyzed as secondary outcomes. Design. Mean PAP and CI were obtained before and 6 months postoperatively in 22 patients who underwent SVR. Results. There were no significant changes in CI (2.3 vs. 2.4 L/min/m2; p=0.91) or mean PAP (22 vs. 22 mmHg; p=0.64) at rest before and six months after surgery. Left ventricular ejection fraction improved from 25 to 38% (p<0.001). Before surgery 15 patients (68%) were in NYHA class III–IV and 6 months after the operation 19 (86%) patients were in NYHA class I–II (p<0.001). Conclusions. Invasive hemodynamic measurements under resting conditions do not correspond well to the significant clinical improvement noted in these patients. Studies during exercise conditions are necessary to further evaluate this procedure.

Atrial fibrillation surgery--a dedicated approach is the key to success. In-my-opinion.

Surgical treatment of atrial fibrillation (AF) began in the late 1980’s with the introduction of the Maze procedure by James Cox in St. Louis. Cox and associates started out with WPW-surgery but subsequently turned their attention to AF, performing extensive experimental mapping work both in humans and dogs (1). Their theory was that AF, as interpreted on the ECG, was a result of several electrical macro-reentrant circuits in both atria, creating electrical chaos, and resulting in a fast irregular ventricular rate. Thus, there was a substrate in the atrial myocardium responsible for the maintenance of AF. Cox’ group developed the Maze procedure as a way to break or abolish macroreentrant circuits anywhere and everywhere in the atria, by surgical incisions and suturing. The pattern of incisions was designed to preclude AF, without interfering with normal AV-conduction, leading to reestablishment of normal sinus rhythm (SR) and atrioventricular synchrony (2). This translated into a major and quite invasive cardiac operation, but the presented results were extraordinary. Cox reported a 98% freedom from AF in 65 patients after two years (3), and subsequent long-term follow-up has been in a similar range (4). The Maze procedure was introduced in Sweden in 1994 and has been performed in over 400 patients in four centers over the years, predominantly as a stand-alone procedure but also in combination with other cardiac operations. Lately, there has been an increasing interest in this niche of cardiac surgery, and many new, down-sized and less invasive methods have been introduced and evaluated by different surgeons. Surgical incisions have been replaced by intraoperative linear ablation. Surgical ablation by radiofrequency, micro waves, laser, cryo therapy and ultrasound has been reported (5 9), and these new methods have almost exclusively been used in combination with valve or CABG procedures. The rapid development has been eagerly supported by the medical device industry. With these new techniques, success-rates in terms of freedom from AF have been in the 60 80% range. As a result, the role of the classical Maze procedure has diminished. This fact can probably be regarded as a sign of medical progress, but it also brings a problem of consistency and how to interpret what is really the best for a surgical patient with AF. We still don’t know what is optimal for the patient in terms of energy source, lesion set and mode of application on the atrial wall; beating-heart epicardially or arrested heart endocardially? The whole field appears quite confusing, partly due to lack of randomized evaluation. Still, AF surgery is now marketed as a new growing frontier for many cardiac surgeons to explore. However, as more surgeons involve themselves in the mysteries of AF and its surgical treatment, it is very important to take a serious approach to the associated options and problems. In my opinion, this is essential for getting the best possible outcome of AF surgery. First, it is not yet proven that all patients with concomitant AF, scheduled for a CABG or valve procedure, should have an additive arrhythmia procedure with the objective of permanent conversion to SR. Potential benefits for the patient, such as relief of AF symptoms and possible future discontinuation of anticoagulants, must be weighed against the increased risk of a larger operation. For example, pure epicardial ablation procedures may carry an increased risk of thromboembolic complications,