Author + information
- Antoine H.G. Driessen, MD,
- Wouter R. Berger, MD,
- Dean R.P.P. Chan Pin Yin, MD,
- Femke R. Piersma, RN,
- Jolien Neefs, MD,
- Nicoline W.E. van den Berg, MD,
- Sébastien P.J. Krul, MD, PhD,
- WimJan P. van Boven, MD, PhD and
- Joris R. de Groot, MD, PhD∗ ()
- ↵∗Heart Center, Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1100 DD Amsterdam, the Netherlands
Patients with symptomatic atrial fibrillation (AF) may require catheter or surgical ablation after antiarrhythmic drugs (AAD) have failed. Thoracoscopic surgical approaches aim to combine the reported efficacy of Cox-Maze procedures with less invasiveness, but long-term follow-up is unavailable. We investigated the single surgical procedure efficacy of thoracoscopic, electrophysiologically guided surgery for patients with advanced AF, which is usually persistent, with enlarged left atria or failed catheter ablation, after 5 years.
Consecutive patients with AF undergoing thoracoscopic surgery for AF at our center between 2008 and 2010 were included. All patients provided written informed consent. The surgical procedure has been described previously (1). Using the Atricure platform (Mason, Ohio), the pulmonary veins were ablated in all patients; superior, trigone, and inferior (in 12 patients) lines in patients with persistent AF only. The left atrial appendage was removed. Entry and exit block of the pulmonary veins, and bidirectional block across linear lesions were tested. The 4 major ganglionated plexus were ablated, unless patients were included in the AFACT study and randomized to no ganglionated plexus ablation (1).
Prospective follow-up took place for 2 years with 3-monthly 24-h Holter. Thereafter, follow-up was nonstandardized. AAD were discontinued 3 months after surgery. Anticoagulation was continued if CHADSVASc score was ≥1. At 5 years, patients were invited for an office visit, physical examination, and electrocardiogram (ECG). All ECGs and Holter data between 2 and 5 years were collected and included in this analysis. AF symptoms, cardioversions, and ablations were documented. Absence of atrial arrhythmias >30 s without AADs defined AF freedom. Rhythm and the number of recurrences were studied at 5 years.
Complete electrocardiographic data were collected from 100% of patients (n = 66; 57.4 ± 8.9 years; 74% male; 50% paroxysmal; 44% previous catheter ablation; left atrial volume 35.9 ± 11.9 ml/m2; left atrial diameter 4.13 ± 0.56 cm), of whom 58 attended the follow-up visit with ECG after median 66 months (60 to 82). There were no deaths or strokes. A total of 50% of patients (67% paroxysmal, 33% persistent) experienced no AF recurrences and discontinued AAD after 5 years (Kaplan-Meier analysis) (Figure 1A). AF freedom with AAD was 55% (67% paroxysmal, 42% persistent). Exclusion of patients with previous ablations (n = 29) resulted in AF freedom (off AAD) in 60% of patients. To compare, in 137 patients with available rhythm monitoring, out of 300 patients after Cox-Maze surgery, AF freedom was 63.5% (2). Similarly, in 139 patients (prolonged monitoring in 52%) AF freedom was 59% for stand-alone Cox-Maze procedures at 5 years (3). After catheter ablation, AF freedom after a single procedure was 29% in patients with mostly paroxysmal AF after 5 years, which increased to 63% after multiple (≤7) procedures (4). In persistent AF, the single catheter procedure result was 20%, increasing up to 45% after multiple procedures (5).
In our cohort, persistent AF (hazard ratio: 2.28; 95% confidence interval: 1.09 to 4.74; p < 0.028) and previous catheter ablations (hazard ratio: 1.44; 95% confidence interval: 1.02 to 2.05; p < 0.041) were independently associated with AF recurrence (multivariable Cox regression). At 5 years, 51 of 58 patients (88%) were in sinus rhythm and 30% were using AAD. Ad et al. (2) report 85% of patients in sinus rhythm after 5 years, and 71% without AAD.
Our patients had no or <1 AF recurrence per year (74%), no or <3 AF recurrences per year (91%), and only 9% had ≥3 recurrences per year or permanent AF. Hence, AF burden was low. Recurrences were more frequent in persistent AF (Figure 1B). Four patients underwent a redo catheter procedure, and all 4 experienced AF recurrences thereafter.
We may have overlooked asymptomatic AF episodes, but followed up conforming to current consensus. The 5-year ECG excludes asymptomatic AF. Also, all Holters and ECGs performed during the 5 years were included in this analysis.
Therefore, thoracoscopic, electrophysiologically guided surgery for advanced AF is associated with AF absence and AAD discontinuation in 50% of patients during a follow-up period of ≥5 years. At 5 years, 88% of patients had sinus rhythm. A total of 74% of patients had <1, and 91% had <3 recurrences per year. Persistent AF and a history of previous catheter ablations were independently associated with AF recurrence.
Please note: This study was funded in part by personal grants to Dr. de Groot from the Dutch Heart Foundation (2009T021) and NWO/ZonMW (106.146.310). Dr. Driessen is a consultant for Atricure. Dr. de Groot is a consultant for Atricure and Daiichi-Sankyo; has received an unrestricted research grant from Atricure; and has received research funding from Atricure and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Driessen and Berger are joint first authors and contributed equally to this work.
- 2017 American College of Cardiology Foundation
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