Left Atrial Radiofrequency Ablation During Mitral Valve Surgery for Continuous Atrial Fibrillation

Abstract

Context Although left atrial radiofrequency ablation (RFA) is increasingly used for the treatment of chronic atrial fibrillation during mitral valve surgery, its efficacy to restore sinus rhythm and any resulting benefits have not been examined in the context of an adequately powered randomized trial. Objective To determine whether intraoperative RFA of the left atrium increases the long-term restoration of sinus rhythm and improves exercise capacity. Design, Setting, and Patients Randomized, double-blind trial performed in a single UK tertiary referral center with enrollment between December 2001 and November 2003. A total of 101 patients referred for mitral valve surgery with at least 6 months' history of uninterrupted atrial fibrillation were assessed for eligibility; 97 were enrolled. Patients were followed up for 12 months. Intervention Patients were randomly assigned to undergo mitral valve surgery and RFA of the left atrium (n=49) or mitral valve surgery alone (controls; n=48). Main Outcome Measures The primary outcome measure was presence of sinus rhythm at 12 months; secondary measures were patient functional status and exercise capacity (assessed by shuttle-walk test), left atrial contractility, and left atrial and left ventricular dimension and function and plasma levels of B-type natriuretic peptide. Results At 12 months, sinus rhythm was present in 20 (44.4%) of 45 RFA patients and in 2 (4.5%) of 44 controls (rate ratio, 9.8; 95% CI, 2.4-86.3; PϽ.001). Restoration of sinus rhythm in the RFA group was accompanied by a greater improvement in mean (SD) shuttle-walk distance compared with controls (ϩ94 [102] m vs ϩ48 [82] m; P=.003) and a greater reduction in the plasma level of B-type natriuretic peptide (−104 [87] fmol/mL vs −51 [82] fmol/mL; P=.03). Patients randomized to receive RFA had similar rates of postoperative complications and deaths as control patients. Conclusions Radiofrequency ablation of the left atrium during mitral valve surgery for continuous atrial fibrillation significantly increases the rate of sinus rhythm restoration 1 year postoperatively, improving patient exercise capacity. On the basis of its efficacy and safety, routine use of RFA of the left atrium during mitral valve surgery may be justified. Trial Registration ClinicalTrials.gov Identifier: NCT00238706.

Tratamento cirúrgico de fibrilação atrial utilizando ablação com radiofrequência bipolar em doença mitral reumática

“…However, mortality and thromboembolic events during follow-up were low and similar in both groups. Doukas et al [18] in a randomized study of 97 patients found low efficacy of ablation (45% in one year), but it was possible to determine the benefits of maintaining sinus rhythm, especially the main and most functional capacity in walk test and smaller serum B-type natriuretic peptide. It was not possible to find differences in mortality or embolic complications during one year of follow-up.…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…W następstwie zabiegu labiryntowania według Coxa wytworzony więc zostaje elektryczny labirynt (maze), w którym pobudzenie z węzła zatokowo-przedsionkowego znajduje drogę do węzła przedsionkowo-komorowego, a jednocześnie zapobiega się przewodzeniu migoczącemu. Zabieg labiryntowania według Coxa oraz inne, często prostsze, metody chirurgicznego leczenia AF wykonuje się głównie u pacjentów poddawanych innej operacji na otwartym sercu [461,466,[784][785][786][787][788][789][790][791][792][793][794][795][796][797][798]. W przeglądzie systematycznym zamówionym na potrzeby niniejszych wytycznych stwierdzono, że chirurgiczne leczenie AF przy okazji innej operacji kardiochirurgicznej zwiększało odsetek pacjentów bez AF, trzepotania przedsionków lub częstoskurczu przedsionkowego w porównaniu z niestosowaniem takiego leczenia (RR 1,94; 95% CI 1,51-2,49; n = 554 w 7 RCT) (dodatkowa ryc.…”

2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Patient Selection, Procedural Techniques, Patient Management and Follow-up, Definitions, Endpoints, and Research Trial Design

“…1290 Several other RCTs and meta-analyses are available to evaluate AF surgery at the time of concomitant mitral procedures. 1327,1328,1329,1330,1331,1332,1333,1334 Large LA, AF duration, advanced age, and failure to isolate the entire posterior LA are common predictors of reduced long-term efficacy. High baseline comorbid risk is a common reason cited for not performing surgical ablation, though many institutional studies note that this is not a contraindication to surgical ablation.…”

“…Several recent RCTs and meta-analyses indicate that concomitant surgical ablation at the time of MVRR reduces the longitudinal incidence of postoperative AF greater than 50% for at least 1 year, with results ranging from 60%–90%. 1327,1328,1329,1330,1331,1333, 1334,1337,1338 In addition to LA size and preoperative AF duration, there is a procedural learning curve that can impact efficacy, and thus surgeons should seek appropriate training prior to performing surgical ablation.…”