Mark La Meir

Hybrid thoracoscopic surgical and transvenous catheter ablation of atrial fibrillation.

OBJECTIVESnThe purpose of this study was to evaluate the feasibility, safety, and clinical outcomes up to 1 year in patients undergoing combined simultaneous thoracoscopic surgical and transvenous catheter atrial fibrillation (AF) ablation.nnnBACKGROUNDnThe combination of the transvenous endocardial approach with the thoracoscopic epicardial approach in a single AF ablation procedure overcomes the limitations of both techniques and should result in better outcomes.nnnMETHODSnA cohort of 26 consecutive patients with AF who underwent hybrid thoracoscopic surgical and transvenous catheter ablation were followed, with follow-up of up to 1 year.nnnRESULTSnTwenty-six patients (42% with persistent AF) underwent successful hybrid procedures. There were no complications. The mean follow-up period was 470 ± 154 days. In 23% of the patients, the epicardial lesions were not transmural, and endocardial touch-up was necessary. One-year success, defined according to the Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society consensus statement for the catheter and surgical ablation of AF, was 93% for patients with paroxysmal AF and 90% for patients with persistent AF. Two patients underwent catheter ablation for recurrent AF or left atrial flutter after the hybrid procedure.nnnCONCLUSIONSnA combined transvenous endocardial and thoracoscopic epicardial ablation procedure for AF is feasible and safe, with a single-procedure success rate of 83% at 1 year.

Minimally invasive surgical treatment of lone atrial fibrillation: Early results of hybrid versus standard minimally invasive approach employing radiofrequency sources

BACKGROUNDnWe compared short-term results of a hybrid versus a standard surgical bilateral thoracoscopic approach employing radiofrequency (RF) sources in the surgical treatment of lone atrial fibrillation (LAF).nnnMETHODSnBetween January 2008 and July 2010 sixty-three consecutive patients with LAF underwent minimally invasive surgery. Thirty-five (55.5%) underwent surgery with the hybrid approach whereas 28 (45.5%) underwent bilateral thoracoscopic standard procedure (no-hybrid group). All patients underwent continuous 7-day Holter Monitoring (HM) at 3 months, 6 months and 1 year.nnnRESULTSnAt 1 year, 91.4% and 82.1% (time-related prevalence 5.2% vs.6.0% [p=0.56]) of the patients were free of AF and AAD. The hybrid group yielded better results in long standing persistent AF (8.2% [time related prevalence 81.8% vs. 44.4%, p=0.001] vs.14.9%, p=0.04). One-year success rates were 87.5% vs. 100% (p=0.04) in persistent [time related prevalence 3.8% vs. 0%, p<0.001] and 87.5% vs. 100% (p=0.04) in paroxysmal AF [time related prevalence 3.2% vs. 0%, p<0.001] in the two groups. One-year prevalence of Warfarin use was significantly higher in the hybrid group (29.0% [26.2-33.1] and 13.4% [9.9-16.3]) with no difference by AF type. LA reverse remodeling occurred in 81.7% (n=30) of hybrid patients and 67.8% (n=19) of no-hybrid patients at latest control (p=0.02). Left atrial emptying fraction increased in both groups (50 ± 14%, p<0.001 and 52 ± 12%, p=0.004 in hybrid and no-hybrid, respectively) without differences between groups (p=0.6).nnnCONCLUSIONSnThe hybrid procedure yielded excellent results in long-standing persistent AF. Our findings need to be confirmed by further larger studies.

Atrial Fibrillation After Cardiac Surgery: Incidence, Risk Factors, and Economic Burden

OBJECTIVEnTo evaluate the incidence of postoperative atrial fibrillation (POAF), the predisposing factors, the results of treatment before discharge, and the impact on duration and costs of hospitalization.nnnDESIGNnA prospective observational study.nnnMETHODSnPatients who underwent cardiac surgery from January 1, 2007 to December 31, 2007.nnnINTERVENTIONSnElectrocardiography was continuously monitored after surgery. Patients with symptomatic new-onset atrial fibrillation or lasting >15 minutes were treated with amiodarone and with DC shock in prolonged cases.nnnRESULTSnPOAF occurred in 29.7%, with the higher incidence between the 1st and 4th postoperative day. Age (p < 0.001), atrial size >40 mm (p < 0.001), previous episodes of AF (p < 0.001), female sex (p = 0.010), and combined valve and bypass surgery (p = 0.012) were multivariate predictors of POAF at logistic regression. Sinus rhythm was restored by early treatment in 205 of 215 patients. This was associated with a low incidence of cerebrovascular events (<0.5%) and with a limited increase of average length of hospitalization (24 hours) in patients with POAF.nnnCONCLUSIONSnThe overall incidence of POAF in the authors center is close to 30%; 95.3% of patients were discharged in sinus rhythm. The increase in length and costs of hospitalization (on average, 1.0 day with a burden of about €1,800/patient) were significantly lower than in previous investigations.

Surgical left atrial appendage occlusion during cardiac surgery for patients with atrial fibrillation: a meta-analysis

OBJECTIVESnConcomitant left atrial appendage occlusion (LAAO) during surgical ablation has emerged as a potential treatment strategy to reduce stroke and perioperative mortality in patients with atrial fibrillation (AF). The present meta-analysis aims to assess current evidence on the efficacy and safety between LAAO and LAA preservation cohorts for patients undergoing cardiac surgery.nnnMETHODSnElectronic searches were performed using six electronic databases from their inception to November 2013, identifying all relevant comparative randomized and observational studies comparing LAAO with non-LAAO in AF patients undergoing cardiac surgery. Data were extracted and analysed according to predefined endpoints including mortality, stroke, postoperative AF and reoperation for bleeding.nnnRESULTSnSeven relevant studies identified for qualitative and quantitative analyses, including 3653 patients undergoing LAAO (n = 1716) versus non-LAAO (n = 1937). Stroke incidence was significantly reduced in the LAAO occlusion group at the 30-day follow-up [0.95 vs 1.9%; odds ratio (OR) 0.46; P = 0.005] and the latest follow-up (1.4 vs 4.1%; OR 0.48; P = 0.01), compared with the non-LAAO group. Incidence of all-cause mortality was significantly decreased with LAAO (1.9 vs 5%; OR 0.38; P = 0.0003), while postoperative AF and reoperation for bleeding was comparable.nnnCONCLUSIONSnWhile acknowledging the limitations and inadequate statistical power of the available evidence, this study suggests LAAO as a promising strategy for stroke reduction perioperatively and at the short-term follow-up without a significant increase in complications. Larger randomized studies in the future are required, with clearer surgical and anticoagulation protocols and adequate long-term follow-up, to validate the clinical efficacy of LAAO versus non-LAAO groups.

Surgical ablation for treatment of atrial fibrillation in cardiac surgery: a cumulative meta-analysis of randomised controlled trials

Introduction Concomitant surgical ablation is a treatment modality for patients with atrial fibrillation (AF) undergoing cardiac surgery, however, its efficacy and clinical outcomes are not well established. The present study is the first cumulative meta-analysis of randomised controlled trials (RCT) on clinical outcomes of surgical ablation versus no ablative treatment in all patients with cardiac surgery. Methods Electronic searches were performed using six databases from their inception to October 2013, identifying all relevant RCTs comparing surgical ablation versus no ablation in patients with AF undertaking cardiac surgery. Data were extracted and analysed according to predefined clinical endpoints. Results Sixteen relevant RCTs were identified for the present study. Higher prevalence of sinus rhythm in the surgical ablation group was evident at all ≥12u2005month follow-up (OR, 6.72; 95% CI 4.88 to 9.25; p<0.00001). There were no significant differences between surgical ablation versus no ablation in terms of mortality (OR, 1.05; 95% CI 0.66 to 1.68; p=0.83), pacemaker implantations (OR, 0.88; 95% CI 0.51 to 1.51; p=0.64), and neurological events (OR, 0.86; 95% CI 0.37 to 2.04; p=0.74). Cumulative meta-analysis demonstrated that these trends have remained consistent over the years, with recent studies narrowing the CIs of the summary estimates. Conclusions The evaluation of the current randomised trials demonstrates that concomitant surgical ablation and cardiac surgery is safe and effective at restoring sinus rhythm.

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.

Effectiveness and safety of simultaneous hybrid thoracoscopic and endocardial catheter ablation of lone atrial fibrillation

BACKGROUNDnWe evaluated the safety and effectiveness of the hybrid thoracoscopic endocardial epicardial technique for the treatment of lone atrial fibrillation.nnnMETHODSnBetween 2009 and 2012, a cohort of 78 consecutive patients (median age 60.5 years, 77% male) underwent ablation of atrial fibrillation (AF) as a stand-alone procedure using a thoracoscopic, hybrid epicardial-endocardial technique. All patients underwent continuous 7-day Holter monitoring at 3 months, 6 months, 1 year and yearly thereafter. All patients reached 1-year follow-up. Median follow-up was 24 months [interquartile range 12-36].nnnRESULTSnNo death or conversion to cardiopulmonary bypass occurred. No patient demonstrated paralysis of the phrenic nerve. Overall, the incidence of perioperative complications was 8% (n=6). At the end of follow-up, sixty-eight patients (87%) were in sinus rhythm (SR) with no episode of AF, atrial flutter or atrial tachycardia lasting longer than 30 seconds and off antiarrhythmic drugs (ADD). Among patients with long-standing persistent AF, 15 (100%) were in SR and off AAD. Success rates were 82% (n=28) in persistent and 76% (n=22) in paroxysmal AF (P=0.08). No patient died and no thromboembolic/bleeding events or procedure-related complications occurred during the follow-up.nnnCONCLUSIONSnThoracoscopic hybrid epicardial endocardial technique proved to be effective and safe in the treatment of LAF and to represent an important new suitable option to treat stand-alone AF. Our findings need to be confirmed by further larger studies.

Treatment of lone atrial fibrillation: a look at the past, a view of the present and a glance at the future.

Despite its proven efficacy, the Cox-Maze III procedure did not gain widespread acceptance for the treatment of lone atrial fibrillation (LAF) because of its complexity and technical difficulty. Surgical ablation for LAF can now be successfully performed utilizing minimally invasive techniques. This article provides an overview of the current state of the art in the surgical treatment of LAF. A brief review of pathophysiology, pharmacological treatment as well as catheter ablation is also provided. The most widely employed minimally invasive approach to LAF has been the video-assisted bilateral mini-thoracotomy or thoracoscopic pulmonary vein island creation and left atrial appendage removal or exclusion, usually with ganglionic plexi evaluation and destruction. Recently, a hybrid approach has been introduced, which combines a mono or bilateral epicardial approach with a percutaneous endocardial ablation in a single-step procedure to limit the shortcomings of both techniques. Suboptimal results of both catheter ablation and surgery suggest that success in the treatment of LAF will probably rely on a close collaboration between the surgeon and the electrophysiologist. Further studies are warranted to determine whether the hybrid approach is effective, especially in patients with long-standing persistent and persistent LAF.

Minimally invasive thoracoscopic hybrid treatment of lone atrial fibrillation: early results of monopolar versus bipolar radiofrequency source

We compare results of a hybrid monopolar vs. a hybrid bipolar thoracoscopic approach employing radiofrequency (RF) sources for the surgical treatment of lone atrial fibrillation (LAF). From January 2008 to June 2010, 19 patients (35.1%) underwent RF monopolar/monolateral RF ablation, whereas 35 (64.9%) had RF bipolar/bilateral thoracoscopic ablation. One-year time-related prevalence of postoperative AF was 13.3 (11.0-17.4) and 5.2% (4.2-6.7), in monopolar and bipolar groups, respectively (P < 0.001). It was 21.1 (17.6-24.9) vs. 8.2% (5.1-11.6) in long standing persistent (P < 0.001), 13.2 (10.6-17.8) vs. 3.8% (1.4-6.9) in persistent (P < 0.001) and 5.6 (2.8-8.3) vs. 3.2% (1.0-6.5) in paroxysmal AF (P = 0.64). At 12 months, estimated prevalence of anti-arrhythmic drugs was 26 (22.4-30.1) and 18.0% (15.5-21.7, P = 0.04), whereas prevalence of warfarin use was 48.2 (44.2-52.2) and 29.0% (26.2-33.1, P < 0.001) in the monopolar and bipolar groups, respectively. Left atrial (LA) reverse remodelling occurred in 47.3% of monopolar patients (n = 9) and in 77.1% of bipolar patients (P = 0.03). The hybrid bilateral approach with a bipolar device for the treatment of LAF showed a good 1-year success rate independently of the AF type and seems to be the better choice for longstanding persistent and persistent LAF.

Expert consensus guidelines: Examining surgical ablation for atrial fibrillation

From the Department of Cardiovascular and Thoracic Surgery, and WVU Heart and Vascular Institute, West Virginia University Morgantown, WVa; Washington Adventist Hospital, Adventist HealthCare, Takoma Park, Md; Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, Mo; Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md; Department of Cardiothoracic Surgery, Academic Hospital Maastricht, Maastricht, The Netherlands; Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan; Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany; Center for the Study of Chronic Illness and Disability, George Mason University, Fairfax, Va; and Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio. Received for publication Dec 21, 2016; revisions received Jan 27, 2017; accepted for publication Feb 1, 2017; available ahead of print April 5, 2017. Address for reprints: Niv Ad, MD, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, 1 Medical Center Drive, Morgantown, WV 26506 (E-mail: nivadmd14@gmail.com). J Thorac Cardiovasc Surg 2017;153:1330-54 0022-5223/