Curative surgery for atrial fibrillation. Current status and minimally invasive approaches.
6
Citation
0
Reference
20
Related Paper
Citation Trend
Abstract:
Atrial fibrillation (AF) is the most common disorder of heart rhythm. Affecting 2.2 million Americans and millions more worldwide, AF is a dangerous and costly epidemic. AF is associated with an increased risk of stroke, premature death, and billions of dollars in health care expenditures. Traditional treatments of AF, which include medications aimed at rate or rhythm control, have been disappointing, leaving most patients in AF and failing to eliminate the risk of stroke. In contrast, advances in surgical and catheter-based therapies offer the chance to cure AF. With more than a decade of experience, surgical treatment AF is the most effective means of curing this arrhythmia. The classic Maze procedure eliminates AF in more than 90% of patients. A complex but safe operation, the Maze procedure is applied by relatively few surgeons. Recently, however, there has been a resurgence of interest in surgical treatment of AF. Advances in the understanding of the pathogenesis of AF and development of new ablation technologies enable surgeons to perform pulmonary vein ablation and create linear left atrial lesions rapidly and safely. Such procedures, which are generally applied to patients with AF and valvular heart disease, add 15 minutes to operative time and cure AF in approximately 80% of patients. New ablation technologies have been adapted to enable thoracoscopic and minimally invasive surgical AF ablation in patients with isolated AF, extending the possibility of cure to large numbers of patients.Keywords:
Stroke
valvular heart disease
Cite
Until very recently, physicians considered atrial fibrillation (AF) as a benign arrhythmia which either did not require any treatment or could be managed adequately with some digoxin. During the last decade, however, epidemiological studies have shown that AF carries considerable morbidity and mortality. The concept that "AF begets AF" has further strengthened the need for a more aggressive approach towards prevention and treatment of AF. At the same time, the evolution of cardiac mapping technologies has allowed the development of new, nonsurgical strategies to cure this common arryhythmia.
Cite
Citations (0)
Atrial fibrillation (AF) and mitral valve (MV) disease are often intertwined in cause and consequence, but there is an increasing appreciation of the morbidity associated with the rhythm disorder itself. The headline risk of stroke resultant from AF has long been appreciated, but the reduction in cardiac output ensuing from arrhythmia may be the tipping point into heart failure. In addition, AF is also linked with early cognitive decline. Hence, there are several reasons to believe that patients who remain in sinus rhythm after mitral valve surgery may have lower cardiac morbidity. Around one-third of these patients presenting for mitral valve surgery will have concomitant atrial fibrillation, and the prospect of attempting to establish sinus rhythm by surgical ablation or Maze procedures is certainly appealing. Therefore, the paper published by Rostagno et al . in this issue of European Heart Journal —Quality of Care and Clinical Outcomes1 is of particular interest, highlighting real-world experience of this treatment strategy, which comes on the back of increasing understanding of the results of adjunctive surgical therapy for atrial fibrillation.
Very high proportions of patients maintaining sinus rhythm in the long-term following surgical AF ablation have been reported.2 In a large meta-analysis by Phan et al. , concomitant surgical AF ablation in patients undergoing mitral valve surgery appeared both safe and effective at restoring sinus rhythm, with overall rates of freedom from AF of 75.5 vs. 26% at 12 months.3 Indeed, the indication for initial surgery does not appear to dictate the surgical AF ablation outcomes and similar outcomes are achieved in patients undergoing other forms of cardiac surgery including coronary artery bypass grafting or aortic valve replacement.4
The Cox-Maze 3 procedure has often been referred to as the ‘gold standard’ of surgical AF ablation, but as well as its …
[↵][1]*Corresponding author. Tel: +44 20 7882 5783, Email: malcolm.finlay{at}bartshealth.nhs.uk
[1]: #xref-corresp-1-1
Cite
Citations (1)
Concomitant
Cardiothoracic surgery
Medical Therapy
Cite
Citations (17)
This editorial refers to ‘Successful catheter ablation reduces the risk of cardiovascular events in atrial fibrillation patients with CHA2DS2-VASc risk score of 1 and higher’ by Y.-J. Lin et al. , on page 676
‘Will catheter ablation of atrial fibrillation help me live longer and protect me against stroke?’ patients with this arrhythmia quite frequently ask when the pros and cons as well as alternatives of this approach are being discussed.
We are living in an era where catheter ablation is an increasingly used treatment for atrial fibrillation (AF).1 In general, catheter ablation should be considered for patients with AF who remain symptomatic despite optimal medical therapy, including rate and rhythm control. Whether to undertake an ablation procedure in a symptomatic patient should take into account the following: (i) the stage of atrial disease (i.e. AF type, left atrial size, AF history), (ii) the presence and severity of underlying cardiovascular disease, (iii) potential treatment alternatives (antiarrhythmic drugs, rate control), and (iv) patients' values and preference. According to the 2012 focused update of the ESC Guidelines on management of AF, ablation should even be considered as a first-line therapy in patients with symptomatic, AF and no or minimal heart disease AF.2 Moreover, ablation as adjunct therapy in patients with AF and heart failure treatment is on the horizon.3
What can the patient expect from this procedure? On the one hand, ablation is clearly superior to antiarrhythmic drug therapy with respect to freedom from recurrent AF, which can be achieved in 65–85% patients undergoing ablation, depending on patient characteristics, ablation approaches, and the duration of follow-up.1,3 Consequently, AF-related symptoms are reduced and quality of life as well as functional status are improved. On the other hand, there are severe, potentially life-threatening complications related to this invasive treatment, …
Stroke
Cite
Citations (2)
Although silent atrial fibrillation (AF) accounts for a significant proportion of patients with AF, asymptomatic patients have been excluded from AF ablation trials. This population presents unique challenges to disease management. Recent evidence suggests that patients with asymptomatic AF may have a different risk profile and even worse long-term outcomes compared to patients with symptomatic AF. For the same reasons they might be more prone to side-effects of antiarrhythmic drugs, including pro-arrhythmias. The poor correlation between symptoms and AF demonstrated in several studies should caution physicians against making clinical decisions depending on symptoms. Although current guidelines recommend AF ablation only in patients with symptoms, more attention should be paid to the AF burden and a rhythm control strategy has the potential to improve morbidity and mortality in AF patients. However, limited data exist regarding the use of catheter ablation for asymptomatic AF patients. As ablation techniques have improved, AF ablation has become more widespread and complication rate decreased. As a result, referrals of asymptomatic patients for catheter ablation of AF are on the rise. In this review we discuss the many unresolved questions concerning the role of the ablative approach in asymptomatic patients with AF.
Cardiac Ablation
Cite
Citations (4)
Catheter ablation of atrial fibrillation (AF) is considered to be better than anti-arrhythmic drug therapy in terms of maintaining sinus rhythm, and therefore, it has rapidly evolved to become a commonly performed procedure in major hospitals throughout the world. However, on the basis of the evidence currently available, we support the current guidelines recommending antiarrhythmic drugs as a first-line treatment in most patients with AF except younger patients with symptomatic paroxysmal AF with no evidence of structural heart disease, given the risk of fatal complications associated with the ablation procedure. We would like to emphasize that center volume and individual procedure experience are significant determinants of procedure-related complications. As another effect of AF ablation, preventing atrial remodeling and progression to persistent AF is also noteworthy. Further long-term data is needed to answer the question of whether ablation can prevent or delay the advance of structural remodeling and improve life prognosis, particularly in younger patients.
Cite
Citations (0)
Atrial fibrillation (AF) is the most common disorder of heart rhythm. Affecting 2.2 million Americans and millions more worldwide, AF is a dangerous and costly epidemic. AF is associated with an increased risk of stroke, premature death and billions of dollars in healthcare expenditures. Traditional treatments of AF, which include medications aimed at rate or rhythm control have been disappointing, leaving most patients in AF and failing to eliminate the risk of stroke. In contrast, advances in surgical and catheter-based therapies offer the chance to cure AF. With more than a decade of experience, surgical treatment of AF is the most effective means of curing this arrhythmia. The classic Maze procedure eliminates AF in more than 90% of patients. A complex but safe operation, the Maze procedure is applied by relatively few surgeons. Recently, however, there has been a resurgence of interest in surgical treatment of AF. Advances in the understanding of the pathogenesis of AF and development of new ablation technologies enable surgeons to perform pulmonary vein ablation and create linear left atrial lesions rapidly and safely. Such procedures, which are generally applied to patients with AF and valvular heart disease, add 15 minutes to operative time and cure AF in approximately 80% of patients. New ablation technologies have been adapted to enable thoracoscopic and minimally invasive surgical AF ablation in patients with isolated AF, extending the possibility of cure to large numbers of patients.
Stroke
valvular heart disease
Cite
Citations (11)
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults and is associated with significant morbidity and mortality. Medical treatment often fails to control symptoms and the limited success of drug therapy has incited clinical investigators to explore alternative treatments. Demonstration of focal pulmonary vein activity initiating AF in 1998 heralded a new era of "curative" AF ablation. Over the last years this strategy has been adopted in one form or another by the electrophysiologists worldwide and progressively applied to patients with structural heart disease as well as those with persistent and long-lasting AF. Catheter ablation for AF does not come without risk. Complications have been described in individual center experiences and have recently been summarized in the worldwide survey of AF, with the purpose to provide a survey on the methods, safety, and efficacy of curative catheter ablation of AF over a broader spectrum of electrophysiology laboratories. The encouraging results of AF ablation reported by highly specialized centers in selected subsets of patients are undisputed but long-term prospective randomized studies are warranted to better define the patient population that may derive the greatest benefit from ablation at the lowest risk and at an acceptable cost.
Cardiac Ablation
Cardiac arrhythmia
Cite
Citations (1)
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.
Concomitant
Guideline
Stroke
Median sternotomy
Cite
Citations (63)
Thoracoscopic epicardial radiofrequency ablation for atrial fibrillation (AF) is a new, minimally invasive surgical approach to treating AF. Because this procedure was developed only recently, there are few data documenting results of this new treatment. The National Institute for Health and Clinical Excellence has provided a guidance document concerning thoracoscopic epicardial radiofrequency ablation for AF. The key components of this document include ( a ) indications and current treatments; ( b ) an outline of the procedure; ( c ) reviews of efficacy and safety; ( d ) guidance about appropriate application of the procedure.
AF is the most common arrhythmia, affecting millions of people world wide. The combination of an ageing global population and the increased prevalence of AF in the elderly has set the stage for a dramatic increase in the number of people diagnosed with AF over the next two to three decades. While AF is well-tolerated by many, it is not innocuous. Patients with AF may have uncomfortable symptoms as a consequence of the tachycardia and are at risk for stroke, tachycardia-induced cardiomyopathy and complications of medical treatment. Therefore, there is great interest in the development of interventional treatments designed to treat AF. We have consciously chosen not to use the word “cure” here because this term implies that AF will never recur after treatment. To date, we are not aware of any treatments that have been proved to cure AF.
Today, most people with AF are treated medically with either a strategy of attempted rhythm control or a strategy of rate control with anticoagulation. Most patients treated in this way achieve acceptable control of symptoms and enjoy high freedom from thromboembolism; these approaches are reasonably successful. When a patient for whom medical treatment has failed, …
Stroke
Cite
Citations (0)