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Cutting edge for atrial fibrillation: surgery and hybrid procedures

Atrial Fibrillation

Whether concomitant surgical ablation on top of another surgical procedure is beneficial for the patient was discussed from various perspectives. In several retrospective studies analysing whether existing preoperative atrial fibrillation is a risk factor for a poorer outcome, it was shown that while atrial fibrillation did not seem to have any effect on in-hospital mortality, it did increase the risk of late death or cardiovascular related readmissions by 55% according to a large retrospective analysis including 9796 patients.

A recent retrospective analysis demonstrated that the 5 year survival rate was significantly higher in patients with sinus rhythm preoperatively (86.8%) as compared with those who suffered from atrial fibrillation (67.1%). The other question raised was whether concomitant AF procedures are effective and safe and whether it affects the outcome. According to several retrospective studies and large databases, concomitant AF ablation seems to lower the rate of atrial fibrillation recurrences and the risk of thromboembolic events, which has resulted in new recommendations in the AF guidelines, stating a Class IIA recommendation but still a level of evidence C, indicating the lack of randomised trials.
It was further discussed when hybrid procedures make sense and the results of minimally invasive surgery as a stand-alone procedure.

A new technology with a specially designed suction tool was presented that delivers bipolar radiofrequency (RF) ablation epicardially for the creation of a left atrial box lesion combined right atrial lesions and endocardial lesions when needed, in patients with persistent AF. After 28 months follow up, there was a 90 % freedom from AF with a very low complication rate. Another hybrid technique with thoracoscopic bipolar RF ablation lesions epicardially combined with conventional endocardial catheter based RF lesions for the creation of a box lesion, mitral line and in some cases right sided lesions, reported freedom from AF in 85 – 92 % of cases. The rate of left atrial reentrant tachycardias was less than 5 %.

The need for randomised clinical trials comparing hybrid AF ablation procedures with conventional catheter based AF ablation procedures was emphasised.
The value and results of various techniques for left atrial exclusion were presented and compared with percutaneous implants. A new surgical device using a left percutaneous epicardial atrial appendage ligation with closed chest was presented, and reported a 96 % success rate in obtaining complete ligation without residual cavities. The technique is new and no follow up in terms of long term thrombo-embolic events is available as yet.


Session Title: Cutting edge for atrial fibrillation: surgery and hybrid procedures

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.