Surgical treatment of atrial fibrillation. Immediate results
FEDERICO BENETTI, JOSÉ AMERISO, NATALIA SCIALACOMO
Depto. Cirugía Cardiaca Fundación Benetti.
(2000) Rosario, Santa Fe, Argentina E-mail
Recibido el 19-DIC-2017 – ACEPTADO despues de revisión el 27-ENERO 2018.
There are no conflicts of interest to disclose.
Dr. Benetti is an inventor and shareholder of Cyberheart.
In USA, atrial fibrillation (AF) is the second leading cause of heart disease after high blood pressure, affecting 4 million Americans every year. In addition, atrial fibrillation doubles the risk of cardiovascular mortality from all causes. Rhythm control of AF requires drugs of low toxicity and many times is not enough. Material and Methods: Between 2000 and 2017, 27 patients were operated on due to atrial fibrillation; 18 concomitantly with off-pump coronary artery bypass surgery (OPCAB), 5 during a mitral valve surgery and 4 with a MINI MAZE for paroxysmal atrial fibrillation. Results: the operative mortality was 0%. The average hospitalization stay was 7.7 (+/- 4.6) for 14 of the coronary patients underwent microwave ablation, 72% were discharged with sinus rhythm. Three of 4 with radiofrequency (68%) were discharged with sinus rhythm. Three of the mitral valve patients (68%) treated with radiofrequency were discharged with sinus rhythm, and 1 (50%) treated with microwaves was also in sinus rhythm. Three of 4 treated with MINI MAZE procedure (68%) were discharged with sinus rhythm. Conclusions: This series of case reports show the reproducibility of different techniques.
Atrial fibrillation. Atrial fibrillation surgery. Mini Maze procedure.
In the United States of America, atrial fibrillation (AF) is the second cause of heart disease after hypertension, affecting 4 million Americans every year .
The prevalence of this pathology is 6% in ages >65 years and 0% in >80 years. 70% of individuals with AF have ages from 65 to 85 years [2,3]. The proportion between men and women is similar, but when >75 years, the proportion of women in 60%.
The current incidence between the population from 20 to 59 years of age is 15.8%, but with the increase in obesity and hypertension, a significant increase is expected in this pathology in the next few years [4,5].
Rhythm control in atrial fibrillation requires low-toxicity drugs . For many patients, heart rhythm control is inappropriate to improve its quality of life or decrease heart failure symptoms. The lack of heart rhythm control generates multiple hospitalizations and often, a significant state of anxiety and depression, with a recurrence reported of up to 80% per year. Moreover, atrial fibrillation doubles the risk of cardiovascular mortality by all causes, independently from the anticoagulation condition and the existence of added risk factors [7,8,9,10,11].
Since year 2000, there was an exponential increase in the treatment of atrial fibrillation by catheterization using radiofrequency, with recurrence ranging from 20 to 50% in 1 to 3 years [12,13]. Recently, in a series of 4200 patients ablated by catheter, the incidence of complications related to the procedure was 5% and the need to readmit patients in 30 days, 9% .
Traditional Cox Maze surgery is highly effective but requires the prolongation of surgery times that entails more morbidity and mortality, more bleeding and a high incidence of pacemaker implantation . Some years ago, different sources of energy started to be used to simplify this intervention . Recently, in patients in whom surgical ablation was performed with radiofrequency as a supplement to valve or coronary surgery, sinus rhythm maintenance was reported in 84-7% over 6 months and 58.8% over 8 years of follow-up . The surgical results in patients with isolated AF, with ablation of both atria show 59% of success per year, and 38% in 5 years, with advantages over conventional sternotomy [18,19]. New modalities of AF treatment generate a certain expectation to improve the current results [20,21].
MATERIAL AND METHODS
The experience of the surgical team of the Fundación Benetti is presented, in regard to the surgical treatment of AF, with different sources of ablation, over the 2000-2017 term.
Twenty-seven patients were surgically intervened due to atrial fibrillation, with different procedures, on the occasion of paroxysmal atrial fibrillation with no associated pathology, or concomitantly with coronary revascularization procedures with no extracorporeal circulation, or during valve surgery.
RESULTS Eighteen patients were operated concomitantly with coronary artery surgery with no use of extracorporeal circulation; 14 with microwaves, and 4 with radiofrequency. The average age was 62 (±5-7); 3 were women (30%) and the average of bypasses was 3.2 in this series.
Five patients received treatment for their AF during mitral valve surgery, with mitral valve replacement in 4 patients and plastic surgery in 1. The technique used was bipolar ablation with radiofrequency in 3 and microwaves in 2. Three were women (60%). The average age was 53.9 years (±9.5). The size of the left atrium had a range of 48.5 to 76.6 mm, with an average of (62±7 mm). Aortic clamping time ranged from 53 to 144 minutes, with an average of 91.1±21.6, and the pumping time was from 69 min to 153 min, with an average of 111.8 (±32.3 min).
Four patients were intervened because of paroxysmal AF with the Mini Maze technique, with videothoracoscopy, using radiofrequency, with ablation of both pulmonary veins. Two were women (50%). The mean age was 53 years (±8.7).
Intraoperative mortality in this series was 0%.
Hospital stays ranged from 3 to 12 days, with an average of 7.7 (±4.6) in the 14 patients who underwent coronary artery surgery, not using extracorporeal circulation, ablated with microwaves. Eleven patients (72%) were discharged in sinus rhythm. From the 4 patients in whom radiofrequency was used, 3 (68%) were discharged in sinus rhythm. From the 5 patients referred to concomitant mitral valve surgery, 3 were ablated by radiofrequency (68%) and discharged in sinus rhythm; while in the 2 ablated with microwaves, only 1 (50%) was discharged in sinus rhythm. From the 4 patients in whom a Mini Maze was practiced, 3 (68%) were discharged in sinus rhythm
The Cox Maze III and Cox Maze IV procedures are surgical options for the treatment of isolated atrial fibrillation. In spite of its verified efficacy, these procedures were not adopted in a widespread manner because they are invasive, complex and pose technical difficulties.
There was much debate between cardiac surgeons and electrophysiologists, as to which is the best technique to treat atrial fibrillation resistant to pharmacological treatment.
It is clear that both the treatment by catheter and surgery are superior to the isolated pharmacological treatment in patients with nonparoxysmal AF according to the results, with less recurrence, less need for cardioversion and lower number of admissions by cardiac causes .
The cut-and-sew surgical technique of Cox Maze applied in the left atrium, and eventually the right one, plus cryoablation points, is a very effective technique but requires cardiopulmonary bypass with a high incidence of bleeding and requirement of permanent pacemaker .
The initial mortality of surgical ablation was 0% and immediate results similar to those reported by most authors. Surgical ablation is a procedure that is increasingly conducted, and it has clearly displayed a reduction in mortality and incidence of immediate stroke .
Both catheter ablation and surgery have limitations by not presenting an absolute effectiveness . The combination of both treatment modalities, according to initial results, would yield an effectiveness above either technique in isolation.
The combination of surgical and electrophysiological treatment (hybrid treatment) , configuring a procedure customized to the patient, undoubtedly represents a valid alternative to take into account to optimize both the immediate and distant results of the treatment for atrial fibrillation.
The surgical experience of the Fundación Benetti in patients with isolated atrial fibrillation, or in association to CAD or valvulopathy, shows the reproducibility of its results with different techniques.
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