The efficacy of intraoperative atrial radiofrequency ablation for atrial fibrillation during concomitant cardiac surgery—the Surgical Atrial Fibrillation Suppression (SAFS) Study
- 289 Downloads
Studies assessing radiofrequency ablation (RFA) for atrial fibrillation (AF) performed at the time of concomitant cardiac surgery have reported high success rates. The efficacy of this treatment has primarily been determined by a single electrocardiogram (ECG) or 24-h Holter monitor at follow-up. We sought to assess the true efficacy of this procedure using prolonged cardiac rhythm monitoring.
One hundred patients with paroxysmal (n = 47) and persistent AF (n = 53) requiring cardiac surgery were enrolled. Patients were clinically reviewed 6 weeks post-operatively and were monitored with 7-day Holter with full disclosure, 6 months post-surgery. A cohort of 50 patients also underwent 7 day Holter monitoring preoperatively. AF recurrence was defined as >30 s of AF.
At 6 months, 75% of patients were in sinus rhythm according to a single ECG. However, only 62% of patients were free from AF on 7-day Holter; all AF episodes in these patients were asymptomatic. The procedure resulted in a significant decrease in AF burden from 56.2% at baseline to 27.5% at 6 months follow-up, (p < 0.001). Predictors of AF recurrence were (1) pre-operative AF duration; (2) persistent compared with paroxysmal AF; (3) increasing left atrial diameter and (4) requirement for mitral valve surgery.
Surgical RFA for the treatment of AF, during concomitant cardiac surgery, is a successful procedure and significantly reduces AF burden. However, 13% of patients have asymptomatic AF episodes only identified with continuous monitoring. This has important implications for post-operative anti-arrhythmic and anticoagulant management and for the definition of surgical AF ablation success.
KeywordsAtrial fibrillation Surgical RF ablation Prolonged Holter monitoring Cardiac surgery
Conflicts of Interest
- 3.(1994) Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 154(13):1449–57.Google Scholar
- 14.Calkins, H., Brugada, J., Packer, D. L., Cappato, R., Chen, S. A., Crijns, H. J., et al. (2007). HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: Recommendations for personnel, policy, procedures and follow-up. A report of the heart rhythm society (HRS) task force on catheter and surgical ablation of atrial fibrillation. Heart Rhythm, 4(6), 816–861.PubMedCrossRefGoogle Scholar
- 15.Fuster, V., Ryden, L. E., Cannom, D. S., Crijns, H. J., Curtis, A. B., Ellenbogen, K. A., et al. (2006). ACC/AHA/ESC 2006 guidelines 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 European society of cardiology committee for practice guidelines (writing committee to revise the 2001 guidelines for the management of patients with atrial fibrillation). Journal of the American College of Cardiology, 48(4), 854–906.PubMedCrossRefGoogle Scholar
- 17.Abreu Filho, C. A., Lisboa, L. A., Dallan, L. A., Spina, G. S., Grinberg, M., Scanavacca, M., et al. (2005). Effectiveness of the maze procedure using cooled-tip radiofrequency ablation in patients with permanent atrial fibrillation and rheumatic mitral valve disease. Circulation, 112(9 Suppl), I20–I25.PubMedGoogle Scholar
- 19.Deneke, T., Khargi, K., Grewe, P. H., Laczkovics, A., von, D. S., Lawo, T., et al. (2002). Efficacy of an additional MAZE procedure using cooled-tip radiofrequency ablation in patients with chronic atrial fibrillation and mitral valve disease. A randomized, prospective trial. European Heart Journal, 23(7), 558–566.PubMedCrossRefGoogle Scholar
- 21.Geidel, S., Ostermeyer, J., Lass, M., Geisler, M., Kotetishvili, N., Aslan, H., et al. (2006). Permanent atrial fibrillation ablation surgery in CABG and aortic valve patients is at least as effective as in mitral valve disease. Thoracic and Cardiovascular Surgeon, 54(2), 91–95.PubMedCrossRefGoogle Scholar
- 22.Gillinov, A. M., McCarthy, P. M., Blackstone, E. H., Rajeswaran, J., Pettersson, G., Sabik, J. F., et al. (2005). Surgical ablation of atrial fibrillation with bipolar radiofrequency as the primary modality. The Journal of Thoracic and Cardiovascular Surgery, 129(6), 1322–1329.PubMedCrossRefGoogle Scholar
- 24.Prasad, S. M., Maniar, H. S., Camillo, C. J., Schuessler, R. B., Boineau, J. P., Sundt, T. M., III, et al. (2003). The Cox maze III procedure for atrial fibrillation: Long-term efficacy in patients undergoing lone versus concomitant procedures. The Journal of Thoracic and Cardiovascular Surgery, 126(6), 1822–1828.PubMedCrossRefGoogle Scholar
- 30.Senatore, G., Stabile, G., Bertaglia, E., Donnici, G., De, S. A., Zoppo, F., et al. (2005). Role of transtelephonic electrocardiographic monitoring in detecting short-term arrhythmia recurrences after radiofrequency ablation in patients with atrial fibrillation. Journal of the American College of Cardiology, 45(6), 873–876.PubMedCrossRefGoogle Scholar
- 33.Purerfellner, H., Aichinger, J., Martinek, M., Nesser, H. J., Ziegler, P., Koehler, J., et al. (2004). Quantification of atrial tachyarrhythmia burden with an implantable pacemaker before and after pulmonary vein isolation. Pacing and Clinical Electrophysiology, 27(9), 1277–1283.PubMedCrossRefGoogle Scholar
- 34.Veasey, R. A., Silberbauer, J., Schilling, R. J., Morgan, J. M., Paul, V., Furniss, S. S., et al. (2010). The evaluation of pulmonary vein isolation and wide-area left atrial ablation to treat atrial fibrillation in patients with implanted permanent pacemakers: The previously paced pulmonary vein isolation study. Heart, 96(13), 1037–1042.PubMedCrossRefGoogle Scholar
- 35.Montenero, A. S., Quayyum, A., Franciosa, P., Mangiameli, D., Antonelli, A., Barbieri, L., et al. (2004). Implantable loop recorders: A novel method to judge patient perception of atrial fibrillation. Preliminary results from a pilot study. Journal of Interventional Cardiac Electrophysiology, 10(3), 211–220.PubMedCrossRefGoogle Scholar
- 36.Hong, P. S. G., Freemantle, N., Shubber, S., Fonseka, M., Nahhas, A., Athulathmudali, C., et al. (2008). Comparing remote monitoring of syncope patients with protocol driven management: The Eastbourne Syncope Assessment study II (EaSyAS II). Journal of Interventional Cardiac Electrophysiology, 21, 137.CrossRefGoogle Scholar
- 37.Defaye, P., Dournaux, F., & Mouton, E. (1998). Prevalence of supraventricular arrhythmias from the automated analysis of data stored in the DDD pacemakers of 617 patients: The AIDA study. The AIDA multicenter study group. Automatic interpretation for diagnosis assistance. Pacing and Clinical Electrophysiology, 21(1 Pt 2), 250–255.PubMedCrossRefGoogle Scholar
- 38.Israel, C. W., Gronefeld, G., Ehrlich, J. R., Li, Y. G., & Hohnloser, S. H. (2004). Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: Implications for optimal patient care. Journal of the American College of Cardiology, 43(1), 47–52.PubMedCrossRefGoogle Scholar