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Thorac Cardiovasc Surg 2023; 71(04): 264-272
DOI: 10.1055/s-0041-1731772
Original Cardiovascular

Surgical Ablation of Permanent Atrial Fibrillation: Age, LV Dilatation, Obesity

Susanne Rohrbach‡   *
1   Institute of Physiology, Justus Liebig University Giessen, Hessen, Germany
,
Elisabeth Dominik‡   *
2   Department of Cardiac and Vascular Surgery, University Hospital of Giessen and Marburg, Giessen and Justus-Liebig-University Giessen, Giessen, Germany
,
Nikolas Mirow
3   Department of Cardiac and Vascular Surgery, University Hospital of Giessen and Marburg, Marburg Philipps University Marburg, Marburg, Germany
,
Sebastian Vogt
3   Department of Cardiac and Vascular Surgery, University Hospital of Giessen and Marburg, Marburg Philipps University Marburg, Marburg, Germany
,
Andreas Böning
2   Department of Cardiac and Vascular Surgery, University Hospital of Giessen and Marburg, Giessen and Justus-Liebig-University Giessen, Giessen, Germany
,
Bernd Niemann
2   Department of Cardiac and Vascular Surgery, University Hospital of Giessen and Marburg, Giessen and Justus-Liebig-University Giessen, Giessen, Germany
› Author Affiliations Funding The Rusche grant of the German Society of Thoracic and Cardiovascular Surgery (DGTHG) and the German Heart Foundation (Deutsche Herzstiftung) as well as UKGM research funding supported B.N. S.R. was funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) – Projektnummer 268555672–SFB 1213, Project B03 and B06. The Rusche grant of the German Society of Thoracic and Cardiovascular Surgery (DGTHG) and the German Heart Foundation (Deutsche Herzstiftung) UKGM research funding. Deutsche Forschungsgemeinschaft (DFG, German Research Foundation). Projektnummer 268555672–SFB 1213, Project B03 and B06.
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Abstract

Objectives Although concomitant surgical ablation can help to reach freedom from atrial fibrillation (FREEAF) even in patients with permanent atrial fibrillation (AF), some cardiac surgeons hesitate to perform concomitant ablation to avoid perioperative risk escalation. Here, we investigated outcome and predicators of therapeutic success of concomitant surgical ablation in an all-comers study.

Methods Ablation-naïve patients with formerly accepted permanent AF (FAP, n = 41) or paroxysmal AF (parAF, n = 24) underwent concomitant epicardial bipolar radio frequency ablation and implantable loop recorder (ILR) at two surgical departments. Follow-up examination for 24 months included electrocardiogram, ILR readout, 24h Holter monitoring, echocardiography, and blood sampling.

Results Eighty-six percent of parAF and 70% of FAP patients reached FREEAF (month 24). Mortality was low (parAF/FAP: 5.3 ± 0.2%/4.1 ± 0.3%; p < 0.05; EuroScoreII; 6.1 ± 0.7%/6.4 ± 0.4%, p = ns) and no strokes occurred. FREEAF induced atrial reverse remodeling (left atrial [LA] diameter: −6.7 ± 2.2 mm) and improved cardiac function (left ventricular ejection fraction [LVEF]: +7.3 ± 2.8%), while AF resulted in further atrial dilation (+8.0 ± 1.0 mm, p < 0.05) and LVEF reduction (−7.0 ± 1.3%, p < 0.05). Higher LV (odds ratio [OR]: 1.164) and LA diameter (OR: 1.218), age (OR: 1.180) and body mass index (BMI) (OR: 1.503) increased the risk factors of AF recurrence. Patients remaining in sinus rhythm (SR) demonstrated a decrease in BMI, while AF recurrence was associated with stable overweight. Further aging did not reduce FREEAF.

Conclusions Long-term SR is achievable by concomitant surgical ablation even in FAP patients. Therefore, it should be offered routinely. Obesity influences therapeutic long-term success but may also offer addressable therapeutic targets to reach higher FREEAF rates.

Keywords

surgical atrial fibrillation therapy - obesity - outcomes

Authors' Contribution

SR, ED, LL, FK, SV, NM, AB, and BN participated and contributed to conception and design of the study. SR, ED, SV, NM, AB, and BN contributed to conception, design, and interpretation of clinical science data. SR, AB, ED, and BN participated in drafting of the manuscript.


* Both authors contributed equally.


Supplementary Material



Publication History

Received: 16 February 2021

Accepted: 27 April 2021

Article published online:
14 September 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Schnabel RB, Yin X, Gona P. et al. 50 year trends in atrial fibrillation prevalence, incidence, risk factors, and mortality in the Framingham Heart Study: a cohort study. Lancet 2015; 386 (9989): 154-162
    CrossrefPubMedGoogle Scholar
  • 2 Ball J, Carrington MJ, McMurray JJ, Stewart S. Atrial fibrillation: profile and burden of an evolving epidemic in the 21st century. Int J Cardiol 2013; 167 (05) 1807-1824
    CrossrefPubMedGoogle Scholar
  • 3 Gammie JS, Haddad M, Milford-Beland S. et al. Atrial fibrillation correction surgery: lessons from the Society of Thoracic Surgeons National Cardiac Database. Ann Thorac Surg 2008; 85 (03) 909-914
    CrossrefPubMedGoogle Scholar
  • 4 Musharbash FN, Schill MR, Sinn LA. et al. Performance of the Cox-maze IV procedure is associated with improved long-term survival in patients with atrial fibrillation undergoing cardiac surgery. J Thorac Cardiovasc Surg 2018; 155 (01) 159-170
    CrossrefPubMedGoogle Scholar
  • 5 Badhwar V, Rankin JS, Ad N. et al. Surgical ablation of atrial fibrillation in the united states: trends and propensity matched outcomes. Ann Thorac Surg 2017; 104 (02) 493-500
    CrossrefPubMedGoogle Scholar
  • 6 Ad N, Henry L, Hunt S. The impact of surgical ablation in patients with low ejection fraction, heart failure, and atrial fibrillation. Eur J Cardiothorac Surg 2011; 40 (01) 70-76
    CrossrefPubMedGoogle Scholar
  • 7 Dilaveris PE, Kennedy HL. Silent atrial fibrillation: epidemiology, diagnosis, and clinical impact. Clin Cardiol 2017; 40 (06) 413-418
    CrossrefPubMedGoogle Scholar
  • 8 Wang X, Wang C, Ye M. et al. Left atrial concomitant surgical ablation for treatment of atrial fibrillation in cardiac surgery: a meta-analysis of randomized controlled trials. PLoS One 2018; 13 (01) e0191354 DOI: 10.1371/journal.pone.0191354.
    CrossrefPubMedGoogle Scholar
  • 9 Kirchhof P, Benussi S, Kotecha D. et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50 (05) e1-e88
    CrossrefPubMedGoogle Scholar
  • 10 Belley-Cote EP, Singal RK, McClure G. et al. Perspective and practice of surgical atrial fibrillation ablation: an international survey of cardiac surgeons. Europace 2019; 21 (03) 445-450
    CrossrefPubMedGoogle Scholar
  • 11 Benussi S, de Maat GE. Atrial remodelling and function: implications for atrial fibrillation surgery. Eur J Cardiothorac Surg 2018; 53 (Suppl. 01) i2-i8
    CrossrefPubMedGoogle Scholar
  • 12 Thomas L, Abhayaratna WP. Left atrial reverse remodeling: mechanisms, evaluation, and clinical significance. JACC Cardiovasc Imaging 2017; 10 (01) 65-77
    CrossrefPubMedGoogle Scholar
  • 13 Staerk L, Sherer JA, Ko D, Benjamin EJ, Helm RH. Atrial fibrillation: epidemiology, pathophysiology, and clinical outcomes. Circ Res 2017; 120 (09) 1501-1517
    CrossrefPubMedGoogle Scholar
  • 14 Calkins H, Hindricks G, Cappato R. et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017; 14 (10) e275-e444
    CrossrefPubMedGoogle Scholar
  • 15 Lau DH, Nattel S, Kalman JM, Sanders P. Modifiable risk factors and atrial fibrillation. Circulation 2017; 136 (06) 583-596
    CrossrefPubMedGoogle Scholar
  • 16 Dzeshka MS, Lip GY, Snezhitskiy V, Shantsila E. Cardiac fibrosis in patients with atrial fibrillation: mechanisms and clinical implications. J Am Coll Cardiol 2015; 66 (08) 943-959
    PubMedGoogle Scholar
  • 17 Jamaly S, Carlsson L, Peltonen M, Jacobson P, Sjöström L, Karason K. Bariatric surgery and the risk of new-onset atrial fibrillation in Swedish obese subjects. J Am Coll Cardiol 2016; 68 (23) 2497-2504
    CrossrefPubMedGoogle Scholar
  • 18 Phan K, Xie A, Kumar N. et al. Comparing energy sources for surgical ablation of atrial fibrillation: a Bayesian network meta-analysis of randomized, controlled trials. Eur J Cardiothorac Surg 2015; 48 (02) 201-211
    CrossrefPubMedGoogle Scholar
  • 19 Whitlock R, Healey J, Vincent J. et al. Rationale and design of the Left Atrial Appendage Occlusion Study (LAAOS) III. Ann Cardiothorac Surg 2014; 3 (01) 45-54
    PubMedGoogle Scholar
  • 20 Rohla M, Weiss TW, Pecen L. et al. Risk factors for thromboembolic and bleeding events in anticoagulated patients with atrial fibrillation: the prospective, multicentre observational PREvention oF thromboembolic events - European Registry in Atrial Fibrillation (PREFER in AF). BMJ Open 2019; 9 (03) e022478 DOI: 10.1136/bmjopen-2018-022478.
    CrossrefPubMedGoogle Scholar
  • 21 Badhwar V, Rankin JS, Damiano Jr RJ. et al. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. Ann Thorac Surg 2017; 103 (01) 329-341
    CrossrefPubMedGoogle Scholar
  • 22 Iribarne A, DiScipio AW, McCullough JN. et al; Northern New England Cardiovascular Disease Study Group. Surgical atrial fibrillation ablation improves long-term survival: a multicenter analysis. Ann Thorac Surg 2019; 107 (01) 135-142
    CrossrefPubMedGoogle Scholar
  • 23 Ad N, Henry L, Hunt S, Holmes SD. Impact of clinical presentation and surgeon experience on the decision to perform surgical ablation. Ann Thorac Surg 2013; 96 (03) 763-768 , discussion 768–769
    CrossrefPubMedGoogle Scholar
  • 24 Ad N, Holmes SD, Patel J, Pritchard G, Shuman DJ, Halpin L. Comparison of EuroSCORE II, Original EuroSCORE, and The Society of Thoracic Surgeons Risk Score in Cardiac Surgery Patients. Ann Thorac Surg 2016; 102 (02) 573-579
    CrossrefPubMedGoogle Scholar
  • 25 Atti V, Anantha-Narayanan M, Turagam MK. et al. Surgical left atrial appendage occlusion during cardiac surgery: a systematic review and meta-analysis. World J Cardiol 2018; 10 (11) 242-249
    CrossrefPubMedGoogle Scholar
  • 26 Wanahita N, Messerli FH, Bangalore S, Gami AS, Somers VK, Steinberg JS. Atrial fibrillation and obesity--results of a meta-analysis. Am Heart J 2008; 155 (02) 310-315
    CrossrefPubMedGoogle Scholar
  • 27 Niemann B, Rohrbach S, Miller MR, Newby DE, Fuster V, Kovacic JC. Oxidative stress and cardiovascular risk: obesity, diabetes, smoking, and pollution: part 3 of a 3-part series. J Am Coll Cardiol 2017; 70 (02) 230-251
    CrossrefPubMedGoogle Scholar
  • 28 Wong CX, Sullivan T, Sun MT. et al. Obesity and the risk of incident, post-operative, and post-ablation atrial fibrillation: a meta-analysis of 626,603 individuals in 51 studies. JACC Clin Electrophysiol 2015; 1 (03) 139-152
    CrossrefPubMedGoogle Scholar