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(BQ) Part 1 book Atrial fibrillation - A multidisciplinary approach to improving patient outcomes presents the following contents: Classification and epidemiology of atrial fibrillation, clinical evaluation of the atrial fibrillation patient, rhythm management, strategies of rate control, nonpharmacologic approaches,...
CARDIOVASCULAR TEAM APPROACH SERIES ATRIAL FIBRILLATION A MULTIDISCIPLINARY APPROACH TO IMPROVING PATIENT OUTCOMES Volume Editors: N.A Mar k Es t es III, MD Alber t L Waldo, MD, PhD (Hon) For eword by A J ohn Camm, MD Atrial Fibrillation A Multidisciplinary Approach to Improving Patient Outcomes The Cardiovascular Team Approach A book series focusing on the interprofessional team approach for the management and prevention of cardiovascular diseases Editors-in-Chief: Joseph S Alpert, MD, FAHA, FACC, MACP, FESC Lynne T Braun, PhD, CNP, FAHA, FAAN Barbara J Fletcher, RN, MN, FAHA, FAAN Gerald Fletcher, MD, FAHA, FACC, FACP Look for these and other forthcoming series titles from Cardiotext Publishing Volume : Heart Failure: Strategies to Improve Outcomes Ileana L Piña, MD, MPH, FACC, FAHA, and Elizabeth A Madigan, PhD, RN, FAAN, editors Volume : Prehospital Management of Acute STEMI: Practical Approaches and International Strategies for Early Intervention Edgardo Escobar, MD, FACC, FAHA, and Alejandro Barbagelata, MD, FAHA, FSCAI, editors Volume : Acute Coronary Syndrome: Urgent and Follow-up Care Eileen Handberg, PhD, ARNP, BC, FAHA, FACC, and R David Anderson, MD, MS, FACC, FSCAI, editors Volume : Atrial Fibrillation: A Multidisciplinary Approach to Improving Patient Outcomes N.A Mark Estes III, MD, FACC, FHRS, FAHA, FESC, and Albert L Waldo, MD, PhD (Hon), FACC, FHRS, FAHA, FACCP, editors Please visit www.cardiotextpublishing.com for more information about this series Atrial Fibrillation A Multidisciplinary Approach to Improving Patient Outcomes The Cardiovascular Team Approach Series VOLUME N.A Mark Estes III, MD, FACC, FHRS, FAHA, FESC Albert L Waldo, MD, PhD (Hon), FACC, FHRS, FAHA, FACCP Volume Editors Joseph S Alpert, MD, FAHA, FACC, MACP, FESC Lynne T Braun, PHD, CNP, FAHA, FAAN Barbara J Fletcher, RN, MN, FAHA, FAAN Gerald Fletcher, MD, FAHA, FACC, FACP Editors-in-Chief Minneapolis, Minnesota © 2015 Joseph S Alpert, Lynne T Braun, Barbara J Fletcher, Gerald Fletcher Cardiotext Publishing, LLC 3405 W 44th Street Minneapolis, Minnesota 55410 USA www.cardiotextpublishing.com Any updates to this book may be found at: www.cardiotextpublishing.com/atrial-fibrillation-a-multidisciplinary-approachto-improving-patient-outcomes Comments, inquiries, and requests for bulk sales can be directed to the publisher at: info@cardiotextpublishing.com All rights reserved No part of this book may be reproduced in any form or by any means without the prior permission of the publisher All trademarks, service marks, and trade names used herein are the property of their respective owners and are used only to identify the products or services of those owners This book is intended for educational purposes and to further general scientific and medical knowledge, research, and understanding of the conditions and associated treatments discussed herein This book is not intended to serve as and should not be relied upon as recommending or promoting any specific diagnosis or method of treatment for a particular condition or a particular patient It is the reader’s responsibility to determine the proper steps for diagnosis and the proper course of treatment for any condition or patient, including suitable and appropriate tests, medications or medical devices to be used for or in conjunction with any diagnosis or treatment Due to ongoing research, discoveries, modifications to medicines, equipment and devices, and changes in government regulations, the information contained in this book may not reflect the latest standards, developments, guidelines, regulations, products or devices in the field Readers are responsible for keeping up to date with the latest developments and are urged to review the latest instructions and warnings for any medicine, equipment or medical device Readers should consult with a specialist or contact the vendor of any medicine or medical device where appropriate Except for the publisher’s website associated with this work, the publisher is not affiliated with and does not sponsor or endorse any websites, organizations or other sources of information referred to herein The publisher and the authors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this book Unless otherwise stated, all figures and tables in this book are used courtesy of the authors Library of Congress Control Number: 2015933471 ISBN: 978-1-935395-95-9 Printed in the United States of America To our wives, Noël and Rosin, with great appreciation, admiration, and affection Your thoughtfulness, patience, and love have made all the difference —N.A Mark Estes, III and Albert L Waldo Contents About the Editors-in-Chief About the Authors Foreword Preface Abbreviations xiii xv xix xxiii xxv Section 1: Atrial Fibrillatio n: Backg ro und, Evaluatio n, and Manag e me nt Chapter Classification and Epidemiology of Atrial Fibrillation Faisal Rahman and Emelia J Benjamin Introduction Classification Epidemiology Longitudinal History Pathophysiology Conclusions References Chapter Clinical Evaluation of the Atrial Fibrillation Patient Jennifer Cruz and Paul Dorian Introduction A Systematic, Protocol-Based Approach to Patient Evaluation Software Program for Data Collection, Storage, and Decision Aids Decision Making Lifestyle Recommendations Clinical Pearls Conclusion Appendix A: Selected Screenshots from the Data Entry/Management and Decision Aid/Report Generation Software Appendix B: Example of Patient Educational Materials and Relevant Websites References 3 12 12 21 21 21 22 28 31 31 32 33 43 43 vii viii Co nte nts Chapter Rhythm Management: Making the Choice Between Rate and Rhythm Control D George Wyse and Laurie Burland Introduction Rate Control—What Is It? Rhythm Control—What Is It? Comparison of the Impact of Rate- and Rhythm-Control Strategies on Outcomes Other Than Electrocardiographic Objectives Impact of Catheter Ablation in Comparison of Rhythm-Management Strategies Conclusion Acknowledgment References 47 47 47 48 49 56 56 57 58 Chapter Rhythm Control: Cardioversion and Antiarrhythmic Agents Shameer Ahmed and Gerald V Naccarelli Introduction Cardioversion Electrical Cardioversion Pharmacological Cardioversion Conclusion References 61 Chapter Strategies of Rate Control Jonathan Weinstock Introduction Pharmacologic Rate Control Rate-Control Goals AF and Ventricular Preexcitation AV Node Ablation and Pacing AF and CRT Conclusion References 79 Chapter Nonpharmacologic Approaches to Rhythm Control—Ablation Michael P Riley and Andrew E Epstein Patient Selection Techniques Management of Anticoagulation Outcomes Conclusion References 87 61 61 62 65 74 74 79 79 81 82 83 83 84 85 87 88 91 91 93 94 94 Se ct io n 1: At ria l Fib rilla t io n : Ba ckg ro u n d , Eva lu a t io n , a n d Ma n a g e m e n t Despite the enormous amount of effort that has been spent to improve outcomes, there remains a need for additional research to improve long-term outcomes REFERENCES Haissaguerre M, Jais P, Shah DC, et al Spontaneous initiation of atrial fibrillation by ectopic 10 11 12 13 14 15 16 beats originating in the pulmonary veins N Engl J Med 1998;339:659–666 Cappato R, Calkins H, Chen SA, et al Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation Circ Arrhythm Electrophysiol 2010;3:32–38 Calkins H, Brugada J, Packer D, et al 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 2007;4:816–861 Calkins H, Kuck KH, Cappato R, et al 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: A report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation Heart Rhythm 2012;9:632–696 Kucukdurmaz Z, Kato R, Erdem A, et al Catheter ablation for atrial fibrillation results in greater improvement in cardiac function in patients with low versus normal left ventricular ejection fraction J Interv Card Electrophysiol 2013;37:179–187 Jones DG, Haldar SK, Hussain W, et al A randomized trial to assess catheter ablation versus rate control in the management of persistent atrial fibrillation in heart failure J Am Coll Cardiol 2013;61:1894–1903 Boven NV, Theuns D, Bogaard K, et al Atrial fibrillation in cardiac resynchronization therapy with a defibrillator: A risk factor for mortality, appropriate and inappropriate shocks J Cardiovasc Electrophysiol 2013;10:1116–1122 Brooks AG, Stiles MK, Laborderie J, et al Outcomes of long-standing persistent atrial fibrillation ablation: A systematic review Heart Rhythm 2010;7:835–846 Marrouche NF, Wilber D, Hindricks G, et al Association of atrial tissue fibrosis identified by delayed enhancement MRI and atrial fibrillation catheter ablation: The DECAAF study JAMA 2014;311:498–506 Fein AS, Shvilkin A, Shah D, et al Treatment of obstructive sleep apnea reduces the risk of atrial fibrillation recurrence after catheter ablation J Am Coll Cardiol 2013;62:300–305 Chun KR, Schmidt B, Kuck KH, et al Catheter ablation of atrial fibrillation in the young: Insights from the German Ablation Registry Clin Res Cardiol 2013;102:459–468 Guiot A, Jongnarangsin K, Chugh A, et al Anticoagulant therapy and risk of cerebrovascular events after catheter ablation of atrial fibrillation in the elderly J Cardiovasc Electrophysiol 2012;23:36–43 Haegeli LM, Duru F, Lockwood EE, et al Ablation of atrial fibrillation after the retirement age: Considerations on safety and outcome J Interv Card Electrophysiol 2010;28:193–197 Hao SC, Hunter TD, Gunnarsson C, et al Acute safety outcomes in younger and older patients with atrial fibrillation treated with catheter ablation J Interv Card Electrophysiol 2012;35:173–182 Leong-Sit P, Zado E, Callans DJ, et al Efficacy and risk of atrial fibrillation ablation before 45 years of age Circ Arrhythm Electrophysiol 2010;3:452–457 Zado E, Callans DJ, Riley M, et al Long-term clinical efficacy and risk of catheter ablation for atrial fibrillation in the elderly J Cardiovasc Electrophysiol 2008;19:621–626 Chapte r 6 No npharmaco lo g ic Appro ache s 17 Deshmukh A, Patel NJ, Pant S, et al In-hospital complications associated with catheter 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 ablation of atrial fibrillation in the United States between 2000 and 2010: Analysis of 93,801 procedures Circulation 2013;128:2104–2112 Cappato R, Calkins H, Chen SA, et al Prevalence and causes of fatal outcome in catheter ablation of atrial fibrillation J Am Coll Cardiol 2009;53:1798–1803 Dixit S, Gerstenfeld EP, Ratcliffe SJ, et al Single procedure efficacy of isolating all versus arrhythmogenic pulmonary veins on long-term control of atrial fibrillation: A prospective randomized study Heart Rhythm 2008;5:174–181 Guerra JM, Jorge E, Raga S, et al Effects of open-irrigated radiofrequency ablation catheter design on lesion formation and complications: In vitro comparison of different devices J Cardiovasc Electrophysiol 2013;10;1157–1162 Dukkipati SR, Kuck KH, Neuzil P, et al Pulmonary vein isolation using a visually guided laser balloon catheter: the first 200-patient multicenter clinical experience Circ Arrhythm Electrophysiol 2013;6:467–472 Defaye P, Kane A, Chaib A, Jacon P Efficacy and safety of pulmonary veins isolation by cryoablation for the treatment of paroxysmal and persistent atrial fibrillation Europace 2011;13:789–795 Metzner A, Chun KR, Neven K, et al Long-term clinical outcome following pulmonary vein isolation with high-intensity focused ultrasound catheters in patients with paroxysmal atrial fibrillation Europace 2010;12:188–193 Carroll BJ, Contreras-Valdes FM, Heist EK, et al Multi-sensor esophageal temperature probe used during radiofrequency ablation for atrial fibrillation is associated with increased intraluminal temperature detection and increased risk of esophageal injury compared to single-sensor probe J Cardiovasc Electrophysiol 2013;24:958–964 Di Biase L, Dodig M, Saliba W, et al Capsule endoscopy in examination of esophagus for lesions after radiofrequency catheter ablation: a potential tool to select patients with increased risk of complications J Cardiovasc Electrophysiol 2010;21:839–844 Haissaguerre M, Hocini M, Sanders P, et al Catheter ablation of long-lasting persistent atrial fibrillation: clinical outcome and mechanisms of subsequent arrhythmias J Cardiovasc Electrophysiol 2005;16:1138–1147 Haissaguerre M, Sanders P, Hocini M, et al Catheter ablation of long-lasting persistent atrial fibrillation: critical structures for termination J Cardiovasc Electrophysiol 2005;16:1125–1137 Nademanee K, Lockwood E, Oketani N, Gidney B Catheter ablation of atrial fibrillation guided by complex fractionated atrial electrogram mapping of atrial fibrillation substrate J Cardiol 2010;55:1–12 Narayan SM, Krummen DE, Rappel WJ Clinical mapping approach to diagnose electrical rotors and focal impulse sources for human atrial fibrillation J Cardiovasc Electrophysiol 2012;23:447–454 Zhou G, Chen S, Chen G, et al Procedural arrhythmia termination and long-term singleprocedure clinical outcome in patients with non-paroxysmal atrial fibrillation J Cardiovasc Electrophysiol 2013;10;1092–1100 Leong-Sit P, Robinson M, Zado ES, et al Inducibility of atrial fibrillation and flutter following pulmonary vein ablation J Cardiovasc Electrophysiol 2013;24:617–623 Hayashi T, Kumagai K, Naito S, et al Preprocedural therapeutic international normalized ratio influence on bleeding complications in atrial fibrillation ablation with continued anticoagulation with warfarin Circ J 2013;77:338–344 Kim JS, Jongnarangsin K, Latchamsetty R, et al The optimal range of international normalized ratio for radiofrequency catheter ablation of atrial fibrillation during therapeutic anticoagulation with warfarin Circ Arrhythm Electrophysiol 2013;6:302–309 Kaseno K, Naito S, Nakamura K, et al Efficacy and safety of periprocedural dabigatran in patients undergoing catheter ablation of atrial fibrillation Circ J 2012;76:2337–2342 95 96 Se ct io n 1: At ria l Fib rilla t io n : Ba ckg ro u n d , Eva lu a t io n , a n d Ma n a g e m e n t 35 Lakkireddy D, Reddy YM, Di Biase L, et al Feasibility and safety of dabigatran versus war- 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 farin for periprocedural anticoagulation in patients undergoing radiofrequency ablation for atrial fibrillation: Results from a multicenter prospective registry J Am Coll Cardiol 2012;59:1168–1174 Violi F, Pignatelli P Platelet activation after radiofrequency ablation in atrial fibrillation: Is there any clinical implication? Circulation 2014;129:5–7 Gaita F, Leclercq JF, Schumacher B, et al Incidence of silent cerebral thromboembolic lesions after atrial fibrillation ablation may change according to technology used: Comparison of irrigated radiofrequency, multipolar nonirrigated catheter and cryoballoon J Cardiovasc Electrophysiol 2011;22:961–968 Herrera Siklody C, Deneke T, Hocini M, et al Incidence of asymptomatic intracranial embolic events after pulmonary vein isolation: Comparison of different atrial fibrillation ablation technologies in a multicenter study J Am Coll Cardiol 2011;58:681–688 Parkash R, Tang AS, Sapp JL, Wells G Approach to the catheter ablation technique of paroxysmal and persistent atrial fibrillation: A meta-analysis of the randomized controlled trials J Cardiovasc Electrophysiol 2011;22:729–738 Piccini JP, Lopes RD, Kong MH, et al Pulmonary vein isolation for the maintenance of sinus rhythm in patients with atrial fibrillation: a meta-analysis of randomized, controlled trials Circ Arrhythm Electrophysiol 2009;2:626–633 Tzou WS, Marchlinski FE, Zado ES, et al Long-term outcome after successful catheter ablation of atrial fibrillation Circ Arrhythm Electrophysiol 2010;3:237–242 Calkins H, Reynolds MR, Spector P, et al Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: Two systematic literature reviews and meta-analyses Circ Arrhythm Electrophysiol 2009;2:349–361 Charitos EI, Stierle U, Ziegler PD, et al A comprehensive evaluation of rhythm monitoring strategies for the detection of atrial fibrillation recurrence: Insights from 647 continuously monitored patients and implications for monitoring after therapeutic interventions Circulation 2012;126:806–814 Cheema A, Dong J, Dalal D, et al Circumferential ablation with pulmonary vein isolation in permanent atrial fibrillation Am J Cardiol 2007;99:1425–1428 Cheema A, Vasamreddy CR, Dalal D, et al Long-term single procedure efficacy of catheter ablation of atrial fibrillation J Interv Card Electrophysiol 2006;15:145–155 Kapa S, Epstein AE, Callans DJ, et al Assessing arrhythmia burden after catheter ablation of atrial fibrillation using an implantable loop recorder: the ABACUS study J Cardiovasc Electrophysiol 2013;24:875–881 Pedrote A, Arana-Rueda E, Garcia-Riesco L, et al Paroxysmal atrial fibrillation burden before and after pulmonary veins isolation: An observational study through a subcutaneous leadless cardiac monitor J Cardiovasc Electrophysiol 2013;10:1075–1082 Hutchinson MD, Garcia FC, Mandel JE, et al Efforts to enhance catheter stability improve atrial fibrillation ablation outcome Heart Rhythm 2013;10:347–353 Dixit S, Marchlinski FE, Lin D, et al Randomized ablation strategies for the treatment of persistent atrial fibrillation: RASTA study Circ Arrhythm Electrophysiol 2012;5:287–294 Dixit S, Lin D, Frankel DS, Marchlinski FE Catheter ablation for persistent atrial fibrillation: Antral pulmonary vein isolation and elimination of nonpulmonary vein triggers are sufficient Circ Arrhythm Electrophysiol 2012;5:1216–1223 c h a pt e r Hybrid Treatment of Atrial Fibrillation: Thoracoscopic and Catheter Ablation of AF Laurent Pison, MD, PhD, and Mark La Meir, MD, PhD INTRODUCTION The goals of atrial fibrillation (AF) management are the reduction of symptoms and the prevention of complications associated with this arrhythmia The latter relies on antithrombotic therapy, control of ventricular rate, and therapy of concomitant cardiac diseases These therapeutic interventions may suffice to achieve the former goal, but a substantial number of patients will need additional rhythmcontrol therapy to relieve symptoms Additional rhythm control can be achieved by cardioversion, antiarrhythmic drug (AAD) therapy, or ablation therapy According to the most recent Heart Rhythm Society (HRS)/European Heart Rhythm Association (EHRA)/European Cardiac Arrhythmia Society (ECAS) consensus statement, both endocardial and stand-alone surgical AF ablations can be considered in patients with symptomatic AF refractory or intolerant to at least one Vaughan-Williams Class or AADs, but the current evidence supporting surgical ablation is mainly based on expert consensus and clinical experience The indication for endocardial ablation is based on results from randomized clinical trials and/or meta-analyses.1 Because both techniques have shortcomings, related to their specific approaches and the available technologies, several groups have tried to combine the endocardial and epicardial procedure to overcome their mutual weaknesses and improve results of AF ablation In this chapter, we will first briefly review the current status of endocardial and surgical epicardial ablation techniques to better understand the rationale for a hybrid or convergent concept The second part will focus on the several aspects of the hybrid AF ablation with the emphasis on techniques, follow-up, and outcomes ENDOCARDIAL ABLATION The cornerstone of endocardial catheter procedures for AF is ablation of the ostium or antrum of the pulmonary veins (PVs) with the end point of electrical Atrial Fibrillation: A Multidisciplinary Approach to Improving Patient Outcomes © 2015 Joseph S Alpert, Lynne T Braun, Barbara J Fletcher, Gerald Fletcher, Editors-in-Chief, Cardiotext Publishing, ISBN: 978-1-935395-95-9 97 98 Se ct io n 1: At ria l Fib rilla t io n : Ba ckg ro u n d , Eva lu a t io n , a n d Ma n a g e m e n t isolation of these veins from the left atrium (LA) The rationale for this is the seminal observation by Haïssaguerre et al.2 that AF was almost always triggered by ectopic beats arising from the muscle sleeves of PVs The one-year success rate of this approach is greater than 80% in patients with paroxysmal AF.3 Unipolar radiofrequency (RF) is the most frequently used energy source to perform PV isolation Cryoablation and laser are two alternatives.4,5 Whatever energy source is used, one of the most frequent reasons for AF recurrence after PV isolation remains PV reconduction.6 Long-term results of catheter ablation for paroxysmal AF are somewhat disappointing: in a recently published prospective study, sinus rhythm was maintained in only 46% of patients after the initial procedure without AAD during a median follow-up period of years.7 As AF progresses from paroxysmal to persistent and longstanding persistent AF, the atrial substrate itself plays an increasingly important role in the maintenance of the arrhythmia.8 This may explain why PV isolation alone results in success rates of less than 25% in patients with persistent AF.9 To improve these results, we can modify the atrial substrate by creating linear lesions and/or ablating complex fractionated atrial electrograms (CFAE) In patients with (longstanding) persistent AF, this approach seems to result in better outcomes than PV isolation alone, but there is an important variation in success rates ranging from 11% to 75% Furthermore, the incidence of iatrogenic atrial tachycardias (AT) after these procedures is substantial (up to 40%).10,11 As for paroxysmal AF, there seems to be a slow but steady decline in arrhythmia-free survival after catheter ablation for persistent AF.12 The creation of linear lesions was inspired by the surgical Cox-Maze procedure.13 These linear lesions are thought to prevent sustained multiple reentry circuits by compartmentalization of the atria The two most frequently deployed endocardial linear lesions are the roofline connecting both superior PVs and the mitral isthmus line going from the left inferior PV to the mitral annulus Performing these linear lesions can be very challenging and incomplete lines may act as a substrate for macro-reentrant circuits.14 Nademanee et al.15 reported a one-year success rate of 87% in patients with persistent AF (4% with AAD) and 78% in patients with longstanding persistent AF (11% with AAD) after CFAE (defined as fractionated electrograms with or more deflections and a mean cycle length shorter than 120 ms) ablation only However, those results could not be reproduced by other groups, and the electrophysiological mechanisms underlying CFAEs are still a source of debate.16–18 Sites demonstrating high-dominant frequency seem to be interesting ablation sites as well In an animal model, these sites correspond to functional reentry and are called rotors.19 Recently, localized rotors have been visualized in human AF by computational mapping, and ablation of these rotors results in acute termination of AF or substantial organization of the arrhythmia.20,21 This discovery could hold the potential for an important step toward a tailored substrate ablation approach, especially in patients with persistent AF Chapte r 7 Hybrid Tre atme nt o f Atrial Fibrillatio n EPICARDIAL SURGICAL ABLATION The surgical treatment of AF is based on the Cox-Maze III procedure, also known as the “cut-and-sew” Maze This operation involves the creation of numerous incisions in both atria to direct the sinus impulse propagation through the atria while interrupting macro-reentrant circuits.22 This procedure results in impressive long-term success rates with 92% of patients free from symptomatic AF and 80% withdrawn from AAD.23 Because the uses of Holter monitors, pacemaker interrogation, and implantable monitoring devices were not common, the results most likely overestimate the success An advantage of the surgical approach is the possibility of removing the left atrial appendage (LAA), which may help to decrease the risk for stroke, especially in patients with a contraindication for warfarin.24 According to the HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of AF, stand-alone AF surgery should be considered for symptomatic AF patients who are refractory or intolerant to at least one Class or AAD, prefer a surgical approach or have failed one or more attempts at catheter ablation.1 Nevertheless, the Cox-Maze III procedure did not gain widespread implementation because of its complexity and technical challenge In an effort to simplify the procedure, several groups replaced these incisions with linear lines of ablation Shen et al.25 introduced the Cox-Maze IV procedure using bipolar RF devices to isolate the PVs and create linear lesions.25 The results of the Cox-Maze III and IV procedure in terms of rate of freedom from AF at 3, 6, and 12 months are comparable.26 The last decade has been marked by a quest for new surgical ablation devices using unipolar and bipolar RF, microwave, laser, cryoablation, or high-frequency ultrasound that would enable the cardiac surgeon to perform a curative lesion epicardially on the beating heart without the need for cardiopulmonary bypass.27 Unfortunately, none of the currently existing technology is able to guarantee reliable, transmural lesions in all patients An important shortcoming of the surgical approach is the inability to map and selectively ablate any reentrant or focal tachycardia occurring during surgical AF ablation Current techniques for the minimally invasive surgical treatment of stand-alone AF result in success rates (defined as freedom from any AF episode longer than 30 seconds off AAD) at 12 months from 65% to 92% in paroxysmal AF and from 67% to 80% in persistent AF.27 HYBRID ABLATION Given the current knowledge about etiology and pathophysiology of AF, an optimal ablation procedure would (1) isolate the PVs permanently, (2) define the specific properties of the underlying atrial electrical substrate to customize 99 100 Se ct io n 1: At ria l Fib rilla t io n : Ba ckg ro u n d , Eva lu a t io n , a n d Ma n a g e m e n t Ta b le Complementary Aspects of Endocardial and Epicardial Surgical Ablation Techniques Advantages Disadvantages Endocardial approach • Arrhythmia mapping • Electrophyiological end points • Endocardial touch-up • • • • Epicardial surgical approach • Minimally invasive and fast procedure • Exclusion LAA • Superior transmurality • Limited lesion set • Limited end points Long procedures Collateral damage Fluoroscopy Virtual imaging the subsequent ablation strategy, (3) always create completely transmural linear lesions when indicated, and (4) be minimally invasive To date, neither the endocardial approach nor the epicardial surgical ablation procedure is able to meet all these criteria However, both techniques seem to be complementary as, performed in combination (hence the nomenclature “hybrid” or “convergent” procedure), they bear the potential to overcome their respective shortcomings (Table 7.1) The epicardial surgical approach seems to result in superior transmurality of the lesions, resulting in long-lasting PV isolation and permanent conduction block, especially when using bipolar RF.28,29 The endocardial AF ablation procedure on the other hand, using multipolar catheters and three-dimensional electroanatomical mapping systems, is the most efficacious setting to guide substrate modification and ablation of ATs known to occur during the stepwise ablation of persistent AF.30 Another important advantage of the hybrid approach is the possibility of performing endocardial touch-up in case of an epicardial lesion that is not completely transmural There appears to be a wide variation in the possible combinations of epicardial surgical and transvenous endocardial techniques, and lesion sets used for hybrid or convergent AF ablation procedures (Table 7.2).31,32 Gehi et al.33 described a cohort of 101 consecutive patients who underwent a hybrid epicardial-endocardial AF ablation procedure Patients were considered for this procedure if they had: (1) paroxysmal or persistent AF and failed prior endocardial catheter ablation with concomitant Class or AAD therapy, (2) persistent AF with dilated LA or structural heart disease, or (3) longstanding persistent AF The surgical part of the procedure was performed using a transdiaphragmatic pericardioscopic approach via an incision below the xiphoid process Linear epicardial lesions were created with an irrigated, unipolar RF ablation device to isolate the PVs, the posterior wall of the LA, and the ligament of Marshall In addition, other linear lesions were performed: from the inferior left ; , t t , a l i a d r r e a c at y l h o c n a o t m al i c r i p at o c T s o A ac ; l l a i a l i d a d r s i r a t d a r c c a o o c n i s s d d o n n d e e n e + + + B e o P c c d A n E M B O O O d D T T T n T a ; r r e o t h u t l f , M al i r O T at ; l , a L r F e t A a ; l i n b o / / / 8 / S , s c i L / ) t F A % s i r ( s r e F e A t c P / s F r 4 / / / / e a r A a P r 5 a P h C l i c i a l p l i ) a r s r u o r c b s i f o ac 9 a d e Y ( e c al i r r o h at ± ± ± ± 7 3 5 6 e g o r P A t , F B A O ; T f , s c i o t s g u c r i d t r n e s i r e b i at c i m m h 2 t e m a u t c P a r N a ag t r y h h r ap i ar i d t s an an r , t D , A D A T o t t r h C o e h e r e n i l t u A n o h u u s e r i G P M K t n i e l l e b s s r i F a a T B , R L I t an l p m i e l ab p o o l ; r e s d r o c e r , r , a n e , y , o y r i t e , t a v s s a e g g h h t o t t r r n r i a e e n n r r t t r l o o l e u t e o o d t m m n l i H H s o 2 r r y h l H 1 t R u u h L n o o y t I d d o h h a n f n n - - d o a a o m - 4 M 2 p u - w o l l o F , S L ; g n i d n a t s g n o l , r a P ; l a m s y x o r a p , s t s i s r e p ; t n e 0 ) % ( , , F F 9 A A F s e s g e a c F s s r r A A e e r r P P a t c n u e S c r a P P e P r e P s % 0 d s 3 e n t o u c > > n e > i T T s m A A n / / e L L d F s F r > > A A u / / D D b F F F F A A F A A A A A t n i o P A A f f f f f f o o o o r f f o o o e e e e d d d d s s D D o o o o d d A A s s s s n n i i i i A A o o p p p p c c f f e e e e f f e e o s o s o o o o N N N N d n E 102 Se ct io n 1: At ria l Fib rilla t io n : Ba ckg ro u n d , Eva lu a t io n , a n d Ma n a g e m e n t PV to the coronary sinus (CS), from the right inferior PV toward the inferior right atrium near the Thebesian valve, and onto the inferior vena cava Because of the pericardial reflections, the epicardial linear lesions had to be completed endocardially at the superior right and left PV and at the inferior right PV CFAEs were also targeted Finally, the cavotricuspid isthmus (CTI) was ablated endocardially If AF organized into either atrial flutter (AFL) or AT during this stepwise approach, these arrhythmias were mapped and ablated The endocardial end points of this procedure were entrance and exit block of the PVs, entrance block of the LA posterior wall, and block across mitral isthmus and CTI Patients who remained in AF were cardioverted A Class or AAD was initiated in all patients postoperatively and not stopped before weeks There were major complications: deaths, rebleedings requiring reoperation, and pericardial tamponades Overall, 12-month arrhythmia-free survival after a single hybrid procedure off AAD was 68% and 73%, including repeat endocardial ablation In 2012, we reported on long-term follow-up of minimally invasive epicardial bilateral PV isolation and linear lesions in combination with endocardial proof of Fig u r e The electrophysiologist and cardiac surgeon are working simultaneously during a hybrid atrial fibrillation ablation procedure Chapte r 7 Hybrid Tre atme nt o f Atrial Fibrillatio n conduction block and endocardial touch-up if indicated in a single AF ablation procedure in a cohort of 26 consecutive patients (Figure 7.1).34 Inclusion criteria were previously failed catheter ablation, LA volume ≥ 29 mL/m 2, persistent or longstanding persistent AF, or patient preference for a hybrid procedure The first steps of this procedure consisted of gaining endocardial access to the LA with a transseptal puncture via femoral venous approach and thoracoscopic isolation of the PVs as ipsilateral pairs by using a bipolar RF clamp If AF did not terminate or was still inducible after PV isolation, a roof line and an inferior line were created with a bipolar RF linear pen device By making those linear lesions, the posterior LA was isolated (a so-called box lesion) If entrance and exit block were not reached within this box lesion, the conduction gaps were identified and ablated endocardially with a cooled tip RF catheter This was needed in patients (23%) If the right atrium was dilated, additional epicardial linear lesions were deployed: one encircling the superior vena cava (SVC), the other connecting both caval veins If AF persisted at this point, a left isthmus linear lesion was created using a bipolar RF pen device, but in all cases endocardial touch-up was necessary to obtain bidirectional block In patients with known typical AFL or if this arrhythmia became apparent during the procedure, the CTI was ablated endocardially and the end point was bidirectional block The ganglionated plexi (GP) were not selectively ablated No deaths or conversions to cardiopulmonary bypass were reported After the procedure, patients reinitiated their preoperative AAD regimen Acenocoumarol and AADs were discontinued after the 6-month monitoring visit confirmed the absence of any atrial arrhythmia According to current guidelines, success was defined as no episode of AF/AFL/AT lasting more than 30 seconds off AAD after the 3-month blanking One-year success was 93% for patients with paroxysmal AF and 90% for patients with persistent AF Several groups analyzed the feasibility and effectiveness of a staged hybrid procedure The epicardial surgical and transvenous endocardial approach are performed in separate procedures with an interval of at least several days Muneretto et al.35 performed a staged hybrid AF ablation procedure in 24 consecutive patients with lone persistent or longstanding persistent AF The mean LA dimension was 50 mm and the mean AF duration was 83 months The surgical procedure consisted of a monolateral, right-sided, thoracoscopic approach to deliver a continuous lesion encircling “en bloc” the ostium of all PVs and the posterior wall of the LA This lesion was applied using an internally cooled, RF monopolar device with suction adherence Once the box lesion had been completed, the presence of entrance and exit block was assessed using a quadripolar catheter placed in the middle of the lesion epicardially and a decapolar CS catheter Bidirectional block was achieved in 88% of the patients During the surgical 103 104 Se ct io n 1: At ria l Fib rilla t io n : Ba ckg ro u n d , Eva lu a t io n , a n d Ma n a g e m e n t procedure, all patients were equipped with an implantable subcutaneous loop recorder No surgical complications were reported The endocardial ablation procedure was performed 30 to 45 days after surgery In 21% of the patients, bidirectional block could not be confirmed at the level of the box lesion because of gaps, which were subsequently closed using endocardial ablation catheters In 62% of patients, additional endocardial lesions were deployed at sites of focal triggers for AF, CFAE, and CTI At a mean follow-up of 28 months, 87% of the patients had no AF recurrence, and 75% were off AAD The feasibility of a completely epicardial hybrid procedure has also been investigated Krul et al.36 performed thoracoscopic PV isolation, GP ablation, and linear lesions (only in nonparoxysmal AF patients) in combination with epicardial assessment of conduction block during the same procedure in 31 patients [15 with (longstanding) persistent AF] Surgery was performed through ports bilaterally The GPs were localized and subsequently ablated with a bipolar RF pen The PVs were isolated using a bipolar RF clamp and a custom-made multielectrode was positioned on the epicardial surface of those PVs to assess conduction block In patients with persistent AF, additional linear lesions were deployed on the LA: superior line, inferior line, and trigone line (between the superior line and left fibrous trigone) Electrical isolation of the box and conduction block across the trigone line were tested using the same custom-made multielectrode The LAA was removed with an endoscopic stapling device During this procedure, patients had a sternotomy because of uncontrolled bleeding Three months after the procedure, AADs were discontinued Oral anticoagulants were stopped at months in patients with a CHADS2 score ≤1 and in sinus rhythm off AAD Patients were followed up with a 24-hour Holter every months The primary end point was freedom from episodes of AF/AFL/AT lasting more than 30 seconds without the use of AAD after 12 months Eighty-six percent of the patients reached this primary end point CONCLUSION The multidisciplinary hybrid approach makes it possible to create and evaluate an extensive biatrial lesion set, without sternotomy or cardiopulmonary bypass To date, the number of patients who underwent a hybrid AF ablation remains relatively small but, especially in patients with persistent and longstanding persistent AF, one-year success rates off AAD are promising However, different hybrid or convergent ablation strategies, various energy sources and divergent definitions of success are being used, which makes it quite difficult to compare outcomes It is therefore not clear which lesions or lesion sets, and which end points are needed The only lesion they all have in common is PV isolation Isolation of the Chapte r 7 Hybrid Tre atme nt o f Atrial Fibrillatio n posterior wall of the LA is also a preferred target as ectopy initiating AF frequently arises in this part of the LA.37 The added value of GP ablation is still an area of debate In an animal model, Sakamoto et al.38 demonstrated functional reinnervation within weeks The concern has been raised that if this reinnervation is nonuniform, this could create a new substrate for AF that was not originally present in a given patient Another advantage of the hybrid approach, is the possibility to exclude the LAA, as this is the site of most of the clot formation that eventually leads to thromboembolic events in patients with nonvalvular AF.39 In addition, there may be a small number of patients with recurrent AF owing to a trigger nestled in the LAA, which could be eliminated with exclusion of this appendage.40 Combining the epicardial surgical and the endocardial approaches in one single procedure makes it possible to perform an endocardial touch-up whenever epicardial lesions are not completely transmural This can be facilitated by the anatomic guiding of the surgeon showing the cardiologist where the epicardial lesions are exactly located Another advantage is that the immediate add-on endocardial lesion adds up to form a firm transmural lesion However, organizing this kind of procedures requires robust logistical capacities, as both the cardiac surgeon and electrophysiologist need to be in the same room at the same time A possible concern is that performing an endocardial ablation immediately after epicardial ablation rather than staging endocardial ablation at a later date, may limit endocardial 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Introduction 15 6 15 9 15 9 16 3 16 3 16 3 16 7 16 8 17 0 17 0 17 3 17 3 17 3 17 4 17 8 17 9 18 0 18 0 18 3 18 3 18 5 18 5 18 7 18 9 19 0 19 3 19 5 19 5 2 01 2 01 Co nte nts Patient Decision-Making Models Types of Decision Making... f? ?Atrial? ??Fibrillatio n January CT, Wann LS, Alpert JS, et al AHA/ACC/HRS guideline for the management of 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 patients with atrial fibrillation: A