Article

Stand-alone AF Surgery: Do the Risks Justify a Class IIA Indication?

Citation:Arrhythmia & Electrophysiology Review 2017;6(4 Suppl 1):6

Open access:

The copyright in this work belongs to Radcliffe Medical Media. Only articles clearly marked with the CC BY-NC logo are published with the Creative Commons by Attribution Licence. The CC BY-NC option was not available for Radcliffe journals before 1 January 2019. Articles marked ‘Open Access’ but not marked ‘CC BY-NC’ are made freely accessible at the time of publication but are subject to standard copyright law regarding reproduction and distribution. Permission is required for reuse of this content.

Member of the 2016 ESC guideline committee, Dr Bart P van Putte of Nieuwegein and Amsterdam, the Netherlands, spoke about how the risks and benefits of the different ablation recommendations should be balanced if there is a Class IIa or a Class I indication.

Dr van Putte started by highlighting the three surgical recommendations with a Class IIa indication in the guidelines:8

  1. Catheter or surgical ablation should be considered for patients suffering from symptomatic, persistent, or longstanding persistent AF refractory to drugs to improve symptoms.
  2. Surgery should be considered when catheter ablation has failed.
  3. Minimally invasive surgery should be considered for patients suffering from persistent or post-ablation AF.

Dr van Putte defined the meaning of stand-alone AF surgery. This term comprises three different types of surgery – thoracoscopic Maze surgery (a thoracoscopic procedure without extracorporal circulation); a Maze-IV procedure done by sternotomy, necessitating extracorporal circulation (a somewhat invasive procedure); and the Maze-IV procedure performed through port access, i.e. a minithoractomy necessitating extracorporal circulation (becoming more of a priority treatment in hospitals). He compared these three procedures with AF ablation, including short- and long-term results, and complication rates.

The overall 1-to-5-year success rates are at least comparable with catheter ablation, which means that the freedom-from-AF rates after 1 to 5 years vary from 65 to 80 %.8 In addition, overall complication rates in most papers are approximately 9 %,13 which is comparable with 11 % for patients who undergo a single-catheter ablation.8

Dr van Putte believes that the risks do justify a Class IIa indication. There seems to be a balanced relationship between risks and benefits. What is the consequence of this Class IIa indication for stand-alone AF surgery for the near future? He thinks more patients will be referred for this treatment, and secondly, more trials will be done. More evidence will result in a change of indication.8

References

  1. Zoni-Berisso M, Lercari F, Carazza T, Domenicucci S. Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol 2014;6:213–20.
    Crossref PubMed
  2. Goette A, Kalman JM, Aguinaga L, et al. EHRA/HRS/APHRS/ SOLAECE expert consensus on atrial cardiomyopathies: Definition, characterisation, and clinical implication. J Arrhythm 2016;32:247–78.
    Crossref PubMed
  3. Wijesurendra RS, Liu A, Eichhorn C, et al. Lone atrial fibrillation is associated with impaired left ventricular energetics that persists despite successful catheter ablation. Circulation 2016;134:1068–81.
    Crossref PubMed
  4. Kolb C, Nürnbuger S, Ndrepepa G, et al. Modes of initiation of paroxysmal atrial fibrillation from analysis of spontaneously occurring episodes using a 12-lead Holter monitoring system. Am J Cardiol 2001;88:853–7.
    Crossref PubMed
  5. Ehrlich JR, Cha TJ, Zhang L, et al. Cellular electrophysiology of canine pulmonary vein cardiomyocytes: action potential and ionic current properties. J Physiol 2003;551: 801–13.
    Crossref PubMed
  6. de Groot N, van der Does L, Yaksh A, et al. Direct proof of endo-epicardial asynchrony of the atrial wall during atrial fibrillation in humans. Circ Arrhythm Electrophysiol 2016;9:pii: e003648.
    Crossref PubMed
  7. Kirchof P, Benussi S, Koetecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016;50:e1- e88.
    Crossref PubMed
  8. Pison L, La Meir M, van Opstal A, et al. Hybrid thoracoscopic surgical and transvenous catheter ablation of atrial fibrillation. J Am Coll Cardiol 2012;60:54–61.
    Crossref PubMed
  9. Dudink E, Essers B, Holvoet W, et al. Acute cardioversion vs a wait-and-see approach for recent-onset symptomatic atrial fibrillation in the emergency department: Rationale and design of the randomized ACWAS trial. Am Heart J 2017;183:49–53.
    Crossref PubMed
  10. Ouyang F, Tilz R, Chun J, et al. Long-term results of catheter ablation in paroxysmal atrial fibrillation: Lessons from a 5-year follow-up. Circulation 2010;122:2368–77.
    Crossref PubMed
  11. Calkins H, Reynolds MR, Spector P, et al. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation. Circ Arrythm Electrophysiol 2009;2:349–61.
    Crossref PubMed
  12. de Vos CB, Pisters R, Nieuwlaat R, et al. Progression from paroxysmal to persistent atrial fibrillation: clinical correlates and prognosis. J Am Coll Cardiol 2010;55:725–31.
    Crossref PubMed
  13. Weimar T, Schena S, Bailey MS, et al. The Cox-Maze procedure for lone atrial fibrillation: a single-center experience over 2 decades. Circ Arrhythm Electrophysiol 2012;5:8–14.
    Crossref PubMed
  14. Gallagher MM, Camm AJ. Classification of atrial fibrillation. Pacing Clin Electrophysiol 1997;20:1603–5.
    Crossref PubMed
  15. January CT, Wann LS, Alpert JS. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014;130:2071–104.
    Crossref PubMed
  16. Platonov PG, Mitrofanova LB, Orshanskaya V, et al. Structural abnormalities in atrial walls are associated with presence and persistency of atrial fibrillation but not with age. J Am Coll Cardiol 2011;58:2225–32.
    Crossref PubMed
  17. Kottkamp H, Schreiber D. The substrate in “early persistent” atrial fibrillation: arrhythmia induced, risk factor induced, or from a specific fibrotic atrial cardiomyopathy? J Am Coll Cardiol Clin Electrophysiol 2016;2:140–2.
    Crossref
  18. Kottkamp H, Schreiber D, Moser F, Rieger A. Therapeutic approaches to atrial fibrillation ablation targeting atrial fibrosis. J Am Coll Cardiol EP 2017;3:643–53.
    Crossref
  19. Gianni C, Atoui M, Mohanty S, et al. Difference in thermodynamics between two types of esophageal temperature probes: Insights from an experimental study. Heart Rhythm 2016;13:2195–200.
    Crossref PubMed
  20. Rahman F, Kwan GF, Benjamin EJ. Global epidemiology of atrial fibrillation. Nat Rev Cardiol 2014;11:639–54.
    Crossref PubMed
  21. Steinberg BA, Holmes DN, Ezekowitz MD, et al. Rate versus rhythm control for management of atrial fibrillation in clinical practice: results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry. Am Heart J 2013;165:622-9.
    Crossref PubMed
  22. Calkins H, Reynolds MR, Spector P, et al. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and metaanalyses. Circ Arrhythm Electrophysiol 2009;2:349-61.
    Crossref PubMed
  23. Medtronic internal estimates
  24. Raatikainen MJ, Arnar DO, Merkely B, et al. Access to and clinical use of cardiac implantable electronic devices and interventional electrophysiological procedures in the European Society of Cardiology Countries: 2016 Report from the European Heart Rhythm Association. Europace 2016;18(Suppl 3):iii1–iii79.
    Crossref PubMed
  25. Reddy VY, Dukkipati SR, Neuzil P, et al. Randomized, controlled trial of the safety and effectiveness of a contact force-sensing irrigated catheter for ablation of paroxysmal atrial fibrillation: Results of the TactiCath Contact Force Ablation Catheter Study for Atrial Fibrillation (TOCCASTAR) Study. Circulation 2015;132:907–15.
    Crossref PubMed
  26. Kuck KH, Brugada J, Fürnkranz A. Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation. N Engl J Med 2016;374:2235–45.
    Crossref PubMed
  27. Wright M, Harks E, Kolen A, et al. Contact force is a poor marker of tissue compression in the left atrium. Utility of a novel intra-tissue visualization & ablation system to assess tissue depth in real time. Europace 2014;16(Suppl 2):9–4, ii5
  28. Shah DC, Mandar M. Real-time contact force measurement: a key parameter for controlling lesion creation with radiofrequency energy. Circ Arrhythm Electrophysiol 2015;8:713– 21.
    Crossref PubMed
  29. Chun KRJ, Brugada J, Elvan A, et al. The Impact of Cryoballoon Versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation on Healthcare Utilization and Costs: An Economic Analysis From the FIRE AND ICE Trial. J Am Heart Assoc 2017;6:pii: e006043.
    Crossref PubMed
  30. Kimura M, Sasaki S, Owada S, et al. Comparison of lesion formation between contact force-guided and non-guided circumferential pulmonary vein isolation: a prospective, randomized study. Heart Rhythm 2014;11:984–91.
    Crossref PubMed
  31. Nakamura K, Naito S, Sasaki T, et al. Randomized comparison of contact force-guided versus conventional circumferential pulmonary vein isolation of atrial fibrillation: prevalence, characteristics, and predictors of electrical reconnections and clinical outcomes. J Interv Card Electrophysiol 2015;44:235– 45.
    Crossref PubMed
  32. Pedrote A, Arana-Rueda E, Arce-León A, et al. Impact of contact force monitoring in acute pulmonary vein isolation using an anatomic approach. A randomized study. Pacing Clin Electrophysiol 2016;39:361–9.
    Crossref PubMed
  33. Reddy VY, Dukkipati SR, Neuzil P, et al. Randomized, controlled trial of the safety and effectiveness of a contact force-sensing irrigated catheter for ablation of paroxysmal atrial fibrillation: results of the TactiCath Contact Force Ablation Catheter Study for Atrial Fibrillation (TOCCASTAR) Study. Circulation 2015;132:907–15.
    Crossref PubMed
  34. Ullah W, McLean A, Tayebjee MH, et al. Randomized trial comparing pulmonary vein isolation using the SmartTouch catheter with or without real-time contact force data. Heart Rhythm 2016;13:1761–7.
    Crossref PubMed
  35. Perna F, Heist EK, Danik SB, et al. Assessment of catheter tip contact force resulting in cardiac perforation in swine atria using force sensing technology. Circ Arrhythm Electrophysiol 2011;4:218–24.
    Crossref PubMed
  36. Quallich SG, Van Heel M, Iaizzo PA. Optimal contact forces to minimize cardiac perforations before, during, and/or after radiofrequency or cryothermal ablations. Heart Rhythm 2015;12:291–6.
    Crossref PubMed
  37. Yokoyama K, Kakagawa H, Shah DC, et al. Novel contact force sensor incorporated in irrigated radiofrequency ablation catheter predicts lesion size and incidence of steam pop and thrombus. Circ Arrhythm Electrophysiol 2008;1:354–62.
    Crossref PubMed
  38. Kuck KH, Reddy VY, Schmidt B, et al. A novel radiofrequency ablation catheter using contact force sensing: Toccata study. Heart Rhythm 2012;9:18–23.
    Crossref PubMed
  39. Natale A, Reddy VY, Monir G, et al. Paroxysmal AF catheter ablation with a contact force sensing catheter: results of the prospective, multicenter SMART-AF trial. J Am Coll Cardiol 2014;64:647–56.
    Crossref PubMed
  40. Perino A, Fan J, Schmitt S, et al. Cost variation and associated outcomes of catheter ablation for atrial fibrillation. J Am Coll Cardiol 2015;65(10S):A277" target="_blank">PubMed
  41. Ho SY, Sanchez-Quintana D, Cabrera JA, Anderson RH. Anatomy of the left atrium: implications for radiofrequency ablation of atrial fibrillation. J Cardiovasc Electrophysiol 1999;10:1525–33.
    CrossrefPubMed
  42. Nakamura K, Funabashi N, Uehara M, et al. Left atrial wall thickness in paroxysmal atrial fibrillation by multislice-CT is initial marker of structural remodeling and predictor of transition from paroxysmal to chronic form. Int J Cardiol 2011;148:139–47.
    Crossref PubMed
  43. Platonov PG, Ivanov V, Ho SY, Mitrofanova L. Left atrial wall thickness in patients with and without atrial fibrillation. J Cardiovasc Electrophysiol 2008;9:689–92.
    Crossref PubMed
  44. Pan NH, Tsao HM, Chang NC, et al. Aging dilates atrium and pulmonary veins. Chest 2008;133:190–6.
    Crossref PubMed
  45. Whitaker J, Rajani R, Chubb H, et al. The role of myocardial wall thickness in atrial arrhythmogenesis. Europace 2016;18:1758–72.
    Crossref PubMed
  46. Mukherjee RK, Chubb H, Harrison JL, et al. Epicardial electroanatomical mapping and radiofrequency ablation in the swine left ventricle under real time MRI guidance. Heart Rhythm 2017;14(Suppl):S191
  47. Jumrussirikul P, Atiga WL, Lardo AC, et al. Prospective comparison of lesions created using a multipolar microcatheter ablation system with those created using a pullback approach with standard radiofrequency ablation in the canine atrium. Pacing Clin Electrophysiol 2000;23:203–13.
    Crossref PubMed
  48. Avitall B, Helms RW, Koblish JB, et al. The creation of linear contiguous lesions in the atria with an expandable loop catheter. J Am Coll Cardiol 1999;33:972–84.
    Crossref PubMed
  49. van Rensburg H, Willems R, Holemans P, et al. Simultaneous creation and evaluation of linear radiofrequency lesions. J Interv Card Electrophysiol 2002;6: 215–24.
    PubMed
  50. Gepstein L, Hayam G, Shpun S, et al. Atrial linear ablations in pigs. Circulation 1999;100:419–26.
    Crossref PubMed
  51. Schwartzman D, Michele JJ, Trankiem CT, Ren JF. Electrogramguided radiofrequency catheter ablation of atrial tissue comparison with thermometry-guide ablation: comparison with thermometry-guide ablation. J Interventional Cardiac Electrophysiol 2001;5:253–66.
    PubMed
  52. Bortone A, Brault-Noble G, Appetiti A, Marijon E. Elimination of the negative component of the unipolar atrial electrogram as an in vivo marker of transmural lesion creation: acute study in canines. Circ Arrhythm Electrophysiol 2015;8:905–11.
    Crossref PubMed
  53. Zghaib T, Ipek EG, Zahid S, et al. Association of left atrial epicardial adipose tissue with electrogram bipolar voltage and fractionation: Electrophysiologic substrates for atrial fibrillation. Heart Rhythm 2016;13:2333–9.
    Crossref PubMed
  54. Iwasaki YK, Nishida K, Kato T, Nattel S. Atrial fibrillation pathophysiology: implications for management. Circulation 2011;124:2264–74.
    Crossref PubMed
  55. Khurram IM, Habibi M, Gucuk IE, et al. Left atrial LGE and arrhythmia recurrence following pulmonary vein isolation for paroxysmal and persistent AF. JACC Cardiovasc Imaging 2016;9:142–8.
    Crossref
  56. Habibi M, Lima JA, Gucuk IE, et al. The association of baseline left atrial structure and function measured with cardiac magnetic resonance and pulmonary vein isolation outcome in patients with drug-refractory atrial fibrillation. Heart Rhythm 2016;13:1037–44.
    Crossref PubMed
  57. Di Biase L, Burkhardt D, Mohanty P, et al. Periprocedural stroke and management of major bleeding complications in patients undergoing catheter ablation of atrial fibrillation: The impact of periprocedural therapeutic international normalized ratio. Circulation 2010;121:2550–6.
    Crossref PubMed
  58. Di Biase L, Burkhardt JD, Santangeli P, et al. Periprocedural stroke and bleeding complications in patients undergoing catheter ablation of atrial fibrillation with different anticoagulation management. Circulation 2014;129:2638–44.
    Crossref PubMed
  59. Calkins H, Willems S, Gerstenfeld EP, et al. Uninterrupted dabigatran versus warfarin for ablation in atrial fibrillation. N Engl J Med 2017;376:1627–36.
    Crossref PubMed