[show abstract][hide abstract] ABSTRACT: BACKGROUND: Catheter ablation is an effective treatment for medically refractory, disabling atrial fibrillation (AF). Ablation success may be limited in patients with persistent or long-standing persistent AF. A pericardioscopic, hybrid epicardial-endocardial technique for AF ablation may be a preferred approach for such patients. Limited data are available by using such an approach. OBJECTIVE: XXX METHODS: A cohort of 101 patients underwent AF ablation using a transdiaphragmatic pericardioscopic, hybrid epicardial-endocardial technique. Patients were followed with 24-hour Holter monitors at 3-, 6-, and 12-month intervals. Symptom severity was assessed at baseline and follow-up by using the Canadian Cardiovascular Society Severity of Atrial Fibrillation scale. RESULTS: Mean AF duration was 5.9 years; 47% were persistent and 37% were long-standing persistent. Mean left atrial size was 5.1 cm (range 3.3-7 cm). Overall, 12-month arrhythmia-free survival was 66.3% after a single ablation procedure and 70.5% including repeat ablation. Repeat ablation was required in 6% of the patients and antiarrhythmic drug therapy in 37% of the patients. Quality of life improved significantly and was durable over 12-month follow-up. There were 2 deaths, which occurred in the early postoperative period: one due to atrioesophageal fistula and the second due to sudden cardiac death without apparent cause by autopsy. CONCLUSIONS: We report the largest series to date of a hybrid epicardial-endocardial, stand-alone ablation procedure using a pericardioscopic technique for the treatment of AF. While respecting the identified complications, our results demonstrate a high potential for successful treatment in a challenging patient population with AF.
Heart rhythm: the official journal of the Heart Rhythm Society 09/2012; · 4.56 Impact Factor
[show abstract][hide abstract] ABSTRACT: Atrial fibrillation (AF) is a common arrhythmia affecting approximately 1% to 2% of the general population.
The aim of the study was to evaluate the efficacy and safety of thoracoscopic ablation in patients with AF.
A total of 25 patients aged from 42 to 77 years (mean 56.4 years) with persistent or long-standing persistent AF were scheduled for the procedure. Thoracoscopic epicardial ablation of the right atrium, pulmonary veins, and left atrium was performed on the beating heart using the Cox MAZE III-based diagram, via 3 ports and 2 cm incision below the xiphoid. Exit block was always assessed. Patients were prospectively followed for 12 months after the procedure. 24-hour electrocardiography (Holter monitoring) was used to confirm the results.
Conduction block across ablation lines was achieved in 21 patients (84%). At 1 month of follow-up, the sinus rhythm (SR) was observed in 18 of 20 patients. At 3 months, the SR was observed in 19 patients (76%). Two patients had atrial flutter, while 3 still experienced AF. At 6 months, the SR was observed in 21 patients (84%); 2 patients still had AF, 1 patient atrial flutter, and 1 patient had a pacemaker implanted. Results of follow-up at 1 year did not differ from those at 6 months. No changes in the size of the left atrium and left ventricular ejection fraction, no deaths, stroke, transient ischemic attack, or infectious complications were observed.
The efficacy of epicardial thoracoscopic ablation of the left and right atrium was high, reaching 84% during 1-year follow-up. No serious complications were observed in the postoperative period (except for the need for pacemaker implantation in 1 patient).
Polskie archiwum medycyny wewnȩtrznej 04/2012; 122(5):189-94. · 1.83 Impact Factor
[show abstract][hide abstract] ABSTRACT: Transmural and contiguous ablations and a comprehensive lesion pattern are difficult to create from the surface of a beating heart but are critical to the successful treatment of persistent, isolated atrial fibrillation. A codisciplinary simultaneous epicardial (surgical) and endocardial (catheter) procedure (Convergent procedure) addresses these issues.
Patients with symptomatic atrial fibrillation who failed medical treatment were evaluated. Using only pericardioscopy, the surgeon performed near-complete epicardial isolation of the pulmonary veins and a "box" lesion on the posterior left atrium using unipolar radiofrequency ablation. Simultaneous endocardial catheter radiofrequency ablation completed pulmonary vein isolation, performed a mitral annular and cavotricuspid isthmus line of block, and debulked the coronary sinus. Twelve-month results for the Convergent procedure were compared with 12-month results for concomitant and pericardioscopic (stand-alone transdiaphragmatic/thoracoscopic) atrial fibrillation procedures using unipolar radiofrequency ablation.
Sixty-five patients underwent the Convergent procedure (mean age, 62 y; mean body surface area, 2.17 m²; mean atrial fibrillation duration, 4.8 y; mean left atrial size, 5.2 cm). Ninety-two percent were in persistent or long-standing persistent atrial fibrillation. At 12 months, evaluation with 24-hour Holter monitors found 82% of patients in sinus rhythm, while only 47% of pericardioscopic and 77% of concomitant patients treated with unipolar radiofrequency ablation were in sinus rhythm.
Simultaneous epicardial and endocardial ablation improves outcomes for patients with persistent or longstanding persistent atrial fibrillation. This successful collaboration between cardiac surgeon and electrophysiologist is an important treatment option for patients with large left atriums and chronic atrial fibrillation.
Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery 07/2011; 6(4):243-7.
[show abstract][hide abstract] ABSTRACT: Atrial fibrillation (AF) is the most frequently diagnosed cardiac arrhythmia. Anti-arrhythmic drugs may be used to suppress ectopic foci and interrupt reentry circuits, but are often insufficient to treat recurrent AF and have a number of adverse effects. Alternative therapies, such as catheter and surgical ablation, have been explored. This investigation examines the importance of assessing exit block when performing surgical ablation during beating-heart treatment of AF.
This was an evaluation of pooled data from multicenter prospective results obtained in AF patients who received ablation with a new, irrigated, vacuum-integrated device that creates linear lesions during beating-heart/open-chest or minimally invasive, port-access procedures. Electrocardiogram or Holter data were collected intra-operatively and at 1, 3, 6, and 12 months. Outcomes were also evaluated for patients who were or 'were not' tested for exit block following the ablation procedure.
A total of 93 patients were treated (61 open-chest surgeries, 32 port-access procedures). There were no device-related complications and no operative mortality. At 341 days' average follow-up, 71/86 (83%) patients were free from AF, 66/86 (77%) were in sinus rhythm, and 60/86 (70%) were free from AF and off Class I and III anti-arrhythmic drugs (AADs). At 12 months, 23/23 (100%) patients with exit block confirmed were AF free compared with 13/21 (62%) patients with exit block not tested (p≤0.01, Fisher's exact test); 20/23 (87%) were in sinus rhythm compared with 12/21 (57%) patients with exit block not tested (p≤0.05, Fisher's exact test); and 20/23 (87%) were AF free without Class I and III AADs compared with 10/21 (48%) patients with exit block not tested (p≤0.01, Fisher's exact test). Both open-chest and port-access procedures yielded decreases in left-atrial size from baseline to 6 months' follow-up. Patients undergoing port-access procedures also observed an increase in left-ventricular ejection fraction, which was also significant at 6 months.
Patients in whom exit block was confirmed following an ablation procedure were more likely to have successful clinical outcomes. Since testing for exit block must be performed on a beating heart, total epicardial beating-heart ablation may provide an important treatment for AF, providing intra-operative feedback indicative of long-term outcomes.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 06/2011; 41(1):113-8. · 2.40 Impact Factor
[show abstract][hide abstract] ABSTRACT: Persistent atrial fibrillation (AF) and long-standing persistent AF (LSPAF) are difficult to treat. Epicardial surgical and percutaneous catheter ablations have lower success rates in these patients. The convergent procedure, an endoscopic transdiaphragmatic ablation procedure with conventional percutaneous endocardial ablation, is examined.
Twenty-eight patients with persistent AF or LSPAF underwent the convergent procedure. All underwent combined surgical epicardial radiofrequency ablation and electrophysiological transseptal endocardial ablation to electrically isolate the 4 pulmonary veins, to exclude the posterior left atrium, to ablate the coronary sinus, and to confirm block at the cavotricuspid isthmus. Follow-up was with 24-hour Holter monitoring at 3 months, and 24-hour or 7-day monitoring at 6 and 12 months.
The mean duration of the procedure was 187 minutes (102 surgical ablation minutes; 85 endocardial ablation minutes). The mean total fluoroscopy time was 35.1 minutes. Two patients developed symptomatic pericardial effusions requiring percutaneous drainage, and 1 patient has demonstrated phrenic nerve paresis. There were no deaths. At 3 months, 87% were in sinus rhythm, and 43% were free of AF and antiarrhythmic medications (AADs). At 6 months, 76% were free from AF and AADs.
The convergent procedure effectively combines surgical and electrophysiological AF expertise to provide a viable treatment option to patients with persistent AF or LSPAF. Long-term follow-up is under way.
Heart Surgery Forum 10/2010; 13(5):E317-21. · 0.63 Impact Factor
[show abstract][hide abstract] ABSTRACT: Surgical and catheter treatments for atrial fibrillation remain invasive or ineffective for most patients. A novel system developed to create epicardial ablation lesions during beating-heart surgical procedures was evaluated in an in vivo ovine model.
This novel ablation device integrates radiofrequency, suction, and perfusion to create transmural lesions by remaining consistently in contact with the irregular and curved surface of the beating heart.
Two epicardial ablation patterns were generated in five adult sheep: left atrial appendage and left pulmonary vein isolation. The 2-cm and 5-cm coagulation devices generated linear and curved lesions and maintained intimate contact against the epicardium using suction. Significant increases in bipolar pacing thresholds demonstrated trans-lesion conduction block in all animals. Histopathologic examination verified transmurality and showed changes normally observed after coagulation procedures. All lesions demonstrated mural degeneration throughout the lesion. No charring, vaporization, thromboembolic events, nor other complications were observed.
This novel epicardial coagulation system successfully created continuous and transmural atrial lesions in a beating-heart ovine model.
The Annals of thoracic surgery 02/2008; 85(1):300-3. · 3.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: Current surgical treatments for atrial fibrillation (AF) lack intraoperative metrics that predict long-term outcomes. The extracardiac maze (Ex-Maze) procedure is a beating-heart maze procedure that causes spontaneous conversion to sinus rhythm (SR) during lesion creation. Spontaneous conversion and confirmation of pulmonary vein exit block are 2 important predictors of long-term freedom from AF.
A beating-heart Ex-Maze procedure was performed in 54 AF patients (paroxysmal, n = 2; persistent, n = 11; longstanding persistent, n = 41) undergoing concomitant cardiac surgery (mitral valve replacement [MVR] = 23, aortic VR [AVR] = 7, coronary artery bypass graft [CABG] = 17, CABG +/- AVR = 3, CABG +/- MVR = 2, atrial-septal defect = 2). The Ex-Maze lesion set is a comprehensive, biatrial ablation pattern created epicardially with unipolar, radiofrequency energy applied by a vacuum-integrated device. Electrocardiogram data were collected during the procedure and at 1, 3, 6, and 12 months postoperatively; 24-hour Holter monitors data were also obtained 12 month postprocedure.
Mean left atrial size was 5.4 cm. Average procedure time was 39 minutes. There were no device- or procedure-related complications. At the time of surgery 48 patients were in AF; 32 (67%) patients spontaneously converted to SR during lesion creation. At a mean follow-up of 262 days, 42 of 48 patients (88%) were free from AF, 39 of 48 (81%) were in SR; and 35 of 47 (74%) were free from AF and had discontinued class I and III antiarrhythmic drugs. In 32 of 33 patients (97%), exit block at 15 mA was confirmed, in which pulmonary vein isolation was tested. Follow-up was completed for 30 of the exit-block patients; freedom from AF was observed in 29 of 30 (97%), SR in 26 of 30 (87%), and freedom from AF and class I/III antiarrhythmic drugs in 25 of 29 (86%).
Recent advances in techniques and technologies permit the creation of a comprehensive biatrial lesion pattern on the epicardium of a beating heart. Observation of spontaneous conversion and confirmation of pulmonary vein exit block are important metrics that predict improved long-term outcomes.
Heart Surgery Forum 02/2008; 11(4):E237-42. · 0.63 Impact Factor
[show abstract][hide abstract] ABSTRACT: The cut-and-sew Cox Maze III procedure is a complex operation. A novel vacuum-integrated radiofrequency ablation device was developed to attenuate the complexity. This device has enabled the development of a totally extracardiac Maze (Ex-Maze) procedure. We describe the Ex-Maze procedure, which closely mimics the gold standard Maze III pattern and includes lines of ablation that isolate the pulmonary veins, interconnect the left and right atria, and a line that extends from the right inferior pulmonary vein to the medial inferior vena cava.
The Annals of thoracic surgery 12/2007; 84(5):1783-5. · 3.74 Impact Factor