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Contains fulltext : 229201.pdf (Publisher’s version ) (Closed access) AIMS: In the SCALAF trial, catheter-based pulmonary vein isolation (PVI) was as effective in long-term prevention of atrial fibrillation (AF) as minimally invasive thoracoscopic PVI and left atrial appendage ligation (MIPI). Catheter ablation (CA) resulted in significantly less major complications as compare to MIPI. We report quality of life (QOL) outcome in these patients. METHODS: In this study, 52 patients with symptomatic paroxysmal or early persistent AF were randomized to either MIPI or CA. QOL was assessed at baseline, 3, 6, and 12 months follow-up using the SF-36 Health Survey Questionnaire. AF-related symptoms were quantified at each follow-up visit using the European Heart Rhythm Association (EHRA) score. RESULTS: Median age was 57 years and 78% was male. Paroxysmal AF was present in 74%. At 3 months follow-up, physical role limitations (88.2 +/- 29.5; versus 40.9 +/- 44.0; P = 0.001, respectively) and bodily pain scores (95.5 +/- 8.7; versus 76.0 +/- 27.8; P = 0.021, respectively) were significantly higher after CA compared to MIPI, indicating less limitation in daily activity caused by physical problems and less pain after CA than after MIPI. AF symptoms assessed by the EHRA scores improved significantly at 3, 6, 12, and 24 months compared to baseline in both treatment groups (P < 0.001), with no significant differences between treatment groups. CONCLUSIONS: CA and MIPI ablation of AF both resulted in an improvement in several QOL measurements, although CA resulted in significantly less physical problems and bodily pain 3 months after treatment compared to MIPI. CLINICAL TRIAL NUMBER: ClinicalTrials.gov identifier: NCT00703157.

Background: Current guidelines recommend both percutaneous catheter ablation (CA) and surgical ablation in the treatment of atrial fibrillation, with different levels of evidence. No direct comparison has been made between minimally invasive thoracoscopic pulmonary vein isolation with left atrial appendage ligation (surgical MIPI) versus percutaneous CA comprising of pulmonary vein isolation as primary treatment of atrial fibrillation. We, therefore, conducted a randomized controlled trial comparing the safety and efficacy of these 2 treatment modalities. Methods: Eighty patients were enrolled in the study and underwent implantable loop recorder implantation. Twenty-eight patients did not reach randomization criteria. A total of 52 patients with symptomatic paroxysmal or early persistent atrial fibrillation were randomized, 26 to CA and 26 to surgical MIPI. The primary end point was defined as freedom of atrial tachyarrhythmias, without the use of antiarrhythmic drugs. The safety end point was freedom of complications. Results: Median age was 57 years (range, 37–75), and 78% were men. Paroxysmal atrial fibrillation was present in 74%. Follow-up duration was ≥2 years in all patients. CA was noninferior to MIPI in terms of single-procedure arrhythmia-free survival after 2 years of follow-up (56.0% versus 29.2%; HR, 0.56; 95% CI, 0.26–1.20; log-rank P =0.059). Procedure-related major adverse events occurred significantly more often in MIPI than CA (20.8% versus 0%; P =0.029). Conclusions: Percutaneous pulmonary vein isolation was noninferior to MIPI in terms of efficacy and resulted in less complications. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00703157.

Studies have shown that continuous rhythm monitoring enables the detection of significantly more atrial fibrillation (AF) episodes than routine follow-up of patients, i.e. based on perception of symptoms or on 24-48 h Holter monitoring. The positive outcome of radiofrequency ablation (RFA) may be easily overestimated, especially in patients with paroxysmal AF. Thirty-three consecutive patients, aged 59.4+/-8.9 years (range 38-75 years) participated in this study. All patients had documented AF episodes with an AF duration of 9.4+/-7.1 years (range 1.5-25 years). A new monitoring device, the AF-Alarm was used to more accurately assess the outcome after surgical isolation of pulmonary veins. The AF-Alarm was applied for a duration of 128+/-42.5 h (range 49-191 h) during a period of 8-15 days. The success rate was 87% based on serial electrocardiograms (ECGs) and 24-48 h Holter monitoring during regular outpatient visits. Combination of ECG, Holter and AF-Alarm data yielded a significantly lower success rate, i.e. at the latest follow-up 69% of the patients were free from AF after surgical ablation (P

Background— The objective of the present study was to evaluate the relation between freedom from atrial fibrillation (AF) and left atrial (LA) size in patients who underwent circumferential pulmonary vein (PV) isolation and LA ablation. Methods and Results— One hundred five consecutive patients with symptomatic and drug-refractory paroxysmal or persistent AF were included in the present study. The mean age was 52±9.5 years (range, 27 to 75 years); 74 patients (70%) were male. Paroxysmal AF was present in 52 (49.5%) and persistent AF in 53 (50.5%) patients. Mean AF duration was 6.0±5.1 years in the paroxysmal AF group and 7.6±6.0 years in the persistent AF group. A 3D electroanatomic map of the LA including the PV ostia was constructed with a nonfluoroscopic navigation system (Carto, Biosense Webster). Left- and right-sided PVs were encircled by continuous radiofrequency ablation lines. We performed 128 ablation procedures in 105 patients, ie, 23 redo procedures. The mean long-term follow-up duration was 14.6±4.9 months (range, 6 to 24 months). Sinus rhythm was present in 45 patients (86.5%) in the paroxysmal AF group and in 41 patients (77.3%) in the persistent AF group at the latest follow-up. Six months after ablation, LA dimension in the persistent AF subjects who remained in sinus rhythm decreased from 44.0±5.8 to 40±4.5 mm (range, 31 to 51 mm). In contrast, in patients with recurrences of AF, LA dimension increased from 45±6.5 to 49±5.4 mm (range, 32 to 59 mm). In the successfully treated paroxysmal AF group, LA dimension decreased from 40.5±4.4 to 37.5±3.5 mm ( P Conclusions— In radiofrequency ablation of AF using an electroanatomic approach, there is a statistically significant relationship between medium-term procedural success and LA size: persistent sinus rhythm is associated with reduced and recurrent AF with increased LA dimensions.

Objective : Postoperative atrial tachyarrhythmias (POATs) after coronary artery bypass grafting (CABG) are reported in 11% to 40% of patients. Several etiologic factors are mentioned. Prophylactic intervention with sotalol is reported to reduce the incidence of POAT. The authors studied the effect of magnesium chloride (MgCl2) in addition to sotalol in the prevention of POAT. Design : Prospective, randomized, double-blinded, placebo-controlled trial. Setting : Single center. Participants and interventions : After institutional approval and written informed consent, patients undergoing CABG with use of cardiopulmonary bypass were included in a prospective, randomized, placebo-controlled double-blind study. In 74 patients, intravenous MgCl2, 50 mmol/24 hours, was continuously administered after the induction of anesthesia during 36 hours; 73 patients received placebo. In both groups, sotalol orally was started 16 to 24 hours after CABG. The incidence and duration of in-hospital POAT were evaluated. Measurements and main results : A total of 147 patients could be evaluated: in the magnesium-treated group (n = 74), 25 patients developed POAT (34%) and in the placebo group (n = 73) 19 patients (26%) (p = 0.36). There was no statistically significant difference in duration of POAT between the groups. In the magnesium-treated group, 9 patients experienced serious bradyarrhythmias (12%), and in the placebo group no serious bradyarrhythmias were observed (p = 0.003). There was no mortality in either group. Conclusions : These results show that MgCl2, in addition to sotalol, is not more effective than sotalol alone in the prevention of tachyarrhythmias after CABG. The data showed that this combination may also induce serious bradyarrhythmias.

Objective: In the majority of patients with chronic atrial fibrillation the arrhythmia will persist after correction of the underlying structural abnormality. The maze procedure is an effective surgical method to eliminate atrial fibrillation and to restore atrial contractility. Methods: In this study we used radiofrequency energy to create lines of conduction block in both atria during cardiac surgery as a modification of the maze III procedure. One hundred twenty-two patients with atrial fibrillation for at least 1 year and structural heart disease underwent open heart operation and a radiofrequency modified maze procedure. Results: In 108 (89%) of 122 patients mitral valve surgery was performed, and in this group 86 patients (80%) underwent 121 concomitant procedures. Fourteen patients (11%) underwent cardiac surgery not involving the mitral valve. The additional crossclamp time required for the left atrial part of the radiofrequency modified maze procedure was 14 ± 3 minutes. The in-hospital mortality rate was 4.1%. The overall 39-month survival was 90%, and freedom of atrial flutter or atrial fibrillation was 78.5% ± 5.1%. Eighty-nine survivors with sinus, atrial rhythm, or atrioventricular sequential pacemaker had Doppler echocardiography, and right atrial transport function was documented in 83% and left atrial transport function in 77% of patients. Conclusion: We concluded that the radiofrequency modified maze procedure as an adjunctive procedure is safe, time-sparing, and effective in eliminating atrial fibrillation and restoring atrial transport function. J Thorac Cardiovasc Surg 2001;122:249-56

BACKGROUND The electrophysiologic effects of acute atrial dilatation and dedilatation in humans with chronic atrial fibrillation remains to be elucidated. OBJECTIVE To study the electrophysiological effects of acute atrial dedilatation and subsequent dilatation in patients with Long-standing persistent atrial fibrillation (AF) with structural heart disease undergoing elective cardiac surgery. METHODS Nine patients were studied. Mean age was 71 +/- 10 years, and Left ventricular ejection was 46% +/- 6%. Patients had at Least moderate mitral valve regurgitation and dilated atria. After sternotomy and during extracorporal circulation, mapping was performed on the beating heart with 2 multielectrode arrays (60 electrodes each, interelectrode distance 1.5 mm) positioned on the lateral wall of the right atrium (RA) and Left atrium (LA). Atrial pressure and size were altered by modifying extracorporal circulation. AF electrograms were recorded at baseline after dedilation and after dilatation of the atria afterward. RESULTS At baseline, the median AF cycle Length (mAFCL) was 184 +/- 27 ms in the RA and 180 +/- 17 ms in the LA. After dedilatation, the mAFCL shortened significantly to 168 +/- 13 ms in the RA and to 168 +/- 20 ms in the LA. Dilatation Lengthened mAFCL significantly to 189 +/- 17 ms in the RA and to 185 +/- 23 ms in the LA. Conduction Mock (CB) at baseline was 14.3% +/- 3.6% in the RA and 17.3% +/- 5.5% in the LA. CB decreased significantly with dedilatation to 7.4% +/- 2.9% in the RA and to 7.9% +/- 6.3% in the LA. CB increased significantly with dilatation afterward to 15.0% +/- 8.3% in the RA and to 18.5% +/- 16.0% in the LA. CONCLUSIONS Acute dedilatation of the atria in patients with Long-standing persistent AF causes a decrease in the mAFCL in both atria. Subsequent dilatation increased the mAFCL. The amount of CB decreased with dedilatation and increased with dilatation afterward in both atria.

We describe a technical challenge in a 17-year-old patient with incessant epicardial focal ventricular arrhythmia and diminished LV function. Failure of ablation at the earliest activated endocardial site during ectopy suggested an epicardial origin, which was supported by specific electrocardiographic criteria. Epicardial ablation was not possible due to the localization of the origin of the ventricular tachycardia adjacent to the phrenic nerve. Minimal invasive surgical multielectrode high-density epicardial mapping was performed to localize the arrhythmia focus. Epicardial surgical RF ablation resulted in the termination of ventricular ectopy. After 2 years, the patient is still free from arrhythmias.

Background Preoperative atrial fibrillation (AF) in patients scheduled for elective open-heart surgery is a well-known phenomenon. The cut and sew Maze procedure or variant Maze procedures abolish AF in 45-95% of patients during short- to intermediate-term follow-up. We determined preoperative and postoperative factors predictive of sustained sinus rhythm (SR) and recurrent AF in an elderly cohort of patients with structural heart disease who underwent cardiac surgery. Patients and methods From November 1995 to November 2003, 285 patients with structural heart disease and permanent AF were scheduled for elective cardiac surgery. All patients underwent a radiofrequency (RF) modified Maze procedure as an adjunct to the open-heart operation. Patients were followed in the outpatient clinic or follow-up data were obtained from attending doctors. Patients are being followed in an ongoing registry; however for the patients who are the subject of this paper follow-up ended November 2006. Preoperative factors predicting recurrent AF postoperatively were assessed, as were factors associated with sustained SR. Results Two hundred and eighty-five patients (mean age 68.0+/-9.6 years) underwent a total of 655 open-heart procedures and concomitant RF Maze surgery. In-hospital mortality was 4.6% (13 patients). Mean and median duration of AF were 60.9+/-68.7 months and 26 months (range 6-396), respectively. Median follow-up was 36.5 months (range 27-114 months). Sustained SR, including atrial rhythm or an atrial-based paced rhythm was present in 59% of patients at 1 year, in 54.4% at 3 years, in 53.4% at 5 years and in 57.1% of patients at the latest follow-up. Stroke was reported in six patients (2.1%). Factors predictive of postoperative AF recurrence were duration of permanent AF, preoperative atrial fibrillation wave and preoperative left atrial (LA) size. Postoperative angiotensin converting enzyme (ACE) inhibitor therapy was associated with SR during follow-up. LA size decreased during follow-up in patients with sustained SR, whereas LA size increased in case of recurrent AF. Conclusions In this group of elderly patients with permanent AF in the setting of structural heart disease who underwent cardiac surgery and a RF Maze procedure as a concomitant procedure, the duration of AF, preoperative atrial fibrillation wave and preoperative LA size were predictive of recurrent AF, whereas left ventricular ejection fraction, left ventricular diameters and invasive hemodynamic parameters were not. Postoperative ACE inhibitor therapy was associated with sustained SR. Furthermore, sustained SR after RF Maze surgery was associated with decreased LA dimensions.

Background Of patients scheduled for elective open heart surgery, a substantial number of patients have preoperative atrial fibrillation (AF). The cut-and-sew Maze procedure and variant Maze procedures abolish AF in 45% to 95% during short- to intermediate-term follow-up. Limited data are available about maintenance of sinus rhythm during intermediate- to long-term follow-up. The objective of the present study was to assess the association between postoperative rhythm and mortality and stroke. Methods From November 1995 to November 2003, 258 patients with structural heart disease and permanent AF with a duration of longer than 12 months were scheduled for elective cardiac surgery and included in a registry. They underwent a radiofrequency modified Maze procedure as an adjunct to the open heart operation. Patients were followed in the outpatient clinic, and follow-up data were obtained from medical correspondence of attending physicians. For this paper, follow-up ended November 2006; however, patients are being followed in an ongoing registry. Results Two hundred fifty-eight patients (mean age, 68.1 ± 9.5 years) with permanent AF underwent cardiac surgical procedures and concomitant radiofrequency Maze surgery; 213 patients (82.5%) underwent more than one procedure. Mean duration of permanent AF was 66.6 ± 69.8 months (range, 16 to 96). Preoperatively, 82.9% of patients were in New York Heart Association class III. In-hospital mortality was 3.9% (10 patients), and during a mean follow-up of 43.7 ± 25.9 months (range, 27 to 114), 73 patients (28.3%) died. Left ventricular ejection fraction was normal in 44.6%, moderately decreased in 42.5%, and poor in 12.9% of patients. Sustained sinus rhythm, including atrial rhythm or an atrial-based paced rhythm was present in 69% of patients at 1 year, in 56% at 3 years, in 52% at 5 years, and in 57% of patients at the latest follow-up. Antiarrhythmic drugs were used by 64% of survivors who were free of atrial fibrillation. Oral anticoagulation therapy was taken by 99% of patients. Stroke was reported in 4 patients (1.6%). Conclusions The RF modified Maze procedure abolishes AF in the majority of patients with structural heart disease and longstanding permanent AF. Postoperative rhythm was not predictive of all-cause mortality, cardiac mortality, and stroke, neither in the whole group nor in the subgroups defined by preoperative left ventricular ejection fraction and New York Heart Association class. The stroke rate was very low in this group with longstanding AF.

Background The Cox maze procedure is considered an effective surgical treatment of atrial fibrillation in patients with and without organic heart disease. Radiofrequency energy offers an alternative to the complex surgical maze procedure. We used the radiofrequency modified maze III procedure in patients with atrial fibrillation undergoing elective concomitant cardiac surgery. This study evaluated the long-term results of the irrigated radiofrequency ablation to create linear lines of conduction block endocardially. Methods Between November 1995 and June 2001, 200 patients with mainly structural heart disease and chronic atrial fibrillation underwent intraoperative radiofrequency linear ablation in both atria with concomitant cardiac surgery. Results The in-hospital mortality rate was 3.5% (7 patients) and during the mean follow-up of 40 months (range, 12 to 80) 27 patients (13.5%) died. Eight patients (4%) were lost from follow-up and complete data were available in 158 survivors. Sinus or atrial rhythm was present in 116 patients (73.4%) and an atrial driven rhythm in 10 patients (6.3%) with an atrioventricular pacemaker. Atrial fibrillation or flutter was documented in 32 patients (20.3%). Antiarrhythmic drugs were used in 49% of survivors who were free of atrial fibrillation or flutter. Conclusions Intraoperative radiofrequency endocardial ablation is an effective technique to eliminate atrial fibrillation with promising long-term results.

Objective: Patients with mitral valve disease and suffering of atrial fibrillation of more than 1 year’s duration have a low probability of remaining in sinus rhythm after valve surgery alone. Intraoperative radiofrequency ablation was used as an alternative to simplify the surgical maze procedure. Methods: Seventy-two patients with mitral valve disease, aged 63 ^ 11 years ranging from 31 to 80 years, underwent valve surgery and radiofrequency energy applied endocardially, based on the maze III procedure to eliminate the arrhythmia. The right-sided maze was performed on the beating heart and the left-sided maze during aorta cross-clamping. Results: Surgical procedures included mitral valve repair (na 38) or replacement (na 34) and in addition tricuspid valve repair (na 42), closure of an atrial septal defect (na 2) and correction of cor triatriatum (na 1). The left-sided maze needed 14 ^ 3 min extra ischemic time. There were two in-hospital deaths (2.7%) and three patients (4.2%) died during follow-up of 20 ^ 15 months. Among 67 surviving patients, 51 patients (76%) were in sinus rhythm, two patients (3%) had an atrial rhythm and eight patients (12%) had persistent atrial fibrillation or atrial flutter. Four patients had a pacemaker implanted, in one patient because of sinus node dysfunction. Doppler echocardiography in 64 patients demonstrated right atrial contractility in 89% and left atrial transport in 91% of patients. Conclusions: Intraoperative radiofrequency ablation of atrial fibrillation is an effective and less invasive alternative for the original maze procedure to eliminate atrial fibrillation. q 2001 Elsevier Science B.V. All rights reserved.

In recent years the right gastroepiploic artery (GEA) has been used as an in situ graft in coronary artery bypass grafting (CABG). The specific anatomical course of the GEA graft enables the use of color Doppler imaging technique to evaluate its patency. The results in 21 patients demonstrate the efficiency of this technique; postoperative angiography to establish patency can therefore be avoided.