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Atrial fibrillation: endoscopic ablation and postoperative studies
Örebro University, School of Medical Sciences.ORCID iD: 0000-0002-2654-9427
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Atrial fibrillation (AF) is associated with an increased risk of stroke, heart failure and cardiovascular death. Initial treatment focuses on rhythm or rate control and anticoagulation after risk assessment. Catheter abla-tion (CA) is an option in highly symptomatic patients but is less effective in long-standing persistent AF(LSPAF). Total endoscopic ablation is an alternative, but its clinical role needs further evaluation. In patients undergoing aortocoronary bypass graft (CABG) surgery, up to 9 % present with preoperative AF. One-third experience postoperative AF, which is associated with increased hospital stay, risk of stroke and decreased long-term survival. The long-term effects on heart rhythm have not been studied.

Methods and Results: 571 patients undergoing CABG from 1999 to 2000 were followed for six years. Postoperative AF was the strongest independent risk factor for late AF and an age-independent risk factor for late mortality. 615 pa-tients from the same cohort, including patients with preoperative AF, were fol-lowed up at 15 years. Death due to cerebral ischaemia, heart failure and sudden death were most common in the pre- and postoperative AF groups. The presence of pre- or postoperative AF was an independent risk factor for late mortality.

In our first ten patients, total endoscopic ablation of AF using a right-sided unilateral approach was feasible and safe with acceptable results. 36 patients with symptomatic LSPAF were then randomized to total endoscopic ablation or rate control. Loop recorders were implanted in all patients. In the control group, all patients were in permanent AF for 12 months. In the ablation group, 12/15 patients (80%) were in SR without antiarrhythmic drugs at 12 months. Median freedom of AF at 3–12 months was 95%, and 8/15 (53%) had an AF burden of < 5%. Myocardial function, physical working capacity(PWC) and subjective physical and mental health improved.

Conclusions: Postoperative AF patients have an eightfold increased risk of future AF and a doubled long-term cardiovascular mortality. Both pre- or post-operative AF in CABG patients is a major risk factor for late cardiovascular morbidity and mortality. Total endoscopic ablation of AF is feasible and safe. In patients with LSPAF, it significantly reduced AF burden at 12 months compared with controls. Myocardial function, PWC and subjective physical and mental health improved.

Place, publisher, year, edition, pages
Örebro: Örebro University , 2017. , p. 111
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 169
Keywords [en]
Atrial fibrillation, Bypass surgery, Cerebral ischemia, Follow-up studies, Survival, Anticoagulation, Ablation, Endoscopy, Randomized trial, Implantable loop recorder
National Category
General Practice
Identifiers
URN: urn:nbn:se:oru:diva-61949ISBN: 978-91-7529-220-5 (print)OAI: oai:DiVA.org:oru-61949DiVA, id: diva2:1152367
Public defence
2018-01-19, Örebro universitet, Campus USÖ, hörsal C2, Södra Grev Rosengatan 32, Örebro, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2017-10-24 Created: 2017-10-24 Last updated: 2018-01-13Bibliographically approved
List of papers
1. Postoperative atrial fibrillation in patients undergoing aortocoronary bypass surgery carries an eightfold risk of future atrial fibrillation and a doubled cardiovascular mortality
Open this publication in new window or tab >>Postoperative atrial fibrillation in patients undergoing aortocoronary bypass surgery carries an eightfold risk of future atrial fibrillation and a doubled cardiovascular mortality
2010 (English)In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 37, no 6, p. 1353-1359Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: This article presents a study of postoperative atrial fibrillation (AF) and its long-term effects on mortality and heart rhythm.

METHODS: The study cohort consisted of 571 patients with no history of AF who underwent primary aortocoronary bypass surgery from 1999 to 2000. Postoperative AF occurred in 165/571 patients (28.9%). After a median follow-up of 6 years, questionnaires were obtained from 91.6% of surviving patients and an electrocardiogram (ECG) from 88.6% of all patients. Data from hospitalisations due to arrhythmia or stroke during follow-up were analysed. The causes of death were obtained for deceased patients.

RESULTS: In postoperative AF patients, 25.4% had atrial fibrillation at follow-up compared with 3.6% of patients with no AF at surgery (p<0.001). An episode of postoperative AF was the strongest independent risk factor for development of late AF, with an adjusted risk ratio of 8.31 (95% confidence interval (CI) 4.20-16.43). Mortality was 29.7% (49 deaths/165 patients) in the AF group and 14.8% (60 deaths/406 patients) in the non-AF group (p<0.001). Death due to cerebral ischaemia was more common in the postoperative AF group (4.2% vs 0.2%, p<0.001), as was death due to myocardial infarction (6.7% vs 3.0%, p=0.041). Postoperative AF was an age-independent risk factor for late mortality, with an adjusted hazard ratio of 1.57 (95% CI 1.05-2.34).

CONCLUSIONS: Postoperative AF patients have an eightfold increased risk of developing AF in the future, and a doubled long-term cardiovascular mortality.

Keywords
Atrial fibrillation; Bypass; Surgery; Follow-up studies; Survival
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
urn:nbn:se:oru:diva-35559 (URN)10.1016/j.ejcts.2009.12.033 (DOI)000279086500020 ()20138531 (PubMedID)2-s2.0-77952584268 (Scopus ID)
Available from: 2014-06-27 Created: 2014-06-27 Last updated: 2017-12-12Bibliographically approved
2. Pre- and postoperative atrial fibrillation in CABG patients have similar prognostic impact
Open this publication in new window or tab >>Pre- and postoperative atrial fibrillation in CABG patients have similar prognostic impact
2017 (English)In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 51, no 1, p. 21-27Article in journal (Refereed) Published
Abstract [en]

Objectives: To study pre- and postoperative atrial fibrillation and its long-term effects in a cohort of aortocoronary bypass surgery patients.

Design: Altogether 615 patients undergoing aortocoronary bypass graft surgery in 1999-2000 were studied. Forty-four (7%) had preoperative atrial fibrillation. Postoperative atrial fibrillation occurred in 165/615 patients (27%) while 406/615 patients (66%) had no atrial fibrillation. After a median follow-up of 15 years, symptoms and medication in survivors were recorded, and cause of death in the deceased was obtained.

Results: Death due to cerebral ischaemia was most common in the pre- and postoperative atrial fibrillation groups (7% and 5%, respectively, v. 2% among those without atrial fibrillation, p = 0.038), as were death due to heart failure (18% and 14%, v. 7%, p = 0.007) and sudden death (9% and 5%, v. 2%, p = 0.029). The presence of pre- or postoperative atrial fibrillation was an independent risk factor for late mortality (hazard ratios 1.47 (1.02-2.12) and 1.28 (1.01-1.63), respectively).

Conclusions: Patients with pre- or postoperative atrial fibrillation undergoing aortocoronary bypass surgery have increased long-term mortality and risk of cerebral ischemic and cardiovascular death compared with patients in sinus rhythm.

Place, publisher, year, edition, pages
Taylor & Francis, 2017
Keywords
Atrial fibrillation, bypass surgery, cerebral ischaemia, anticoagulation, survival
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:oru:diva-52180 (URN)10.1080/14017431.2016.1234065 (DOI)000392468400004 ()27615545 (PubMedID)2-s2.0-84988640946 (Scopus ID)
Note

Funding Agency:

Research Committee, Orebro University Hospital  136/04

Available from: 2016-09-21 Created: 2016-09-14 Last updated: 2017-12-12Bibliographically approved
3. Total endoscopic ablation of atrial fibrillation
Open this publication in new window or tab >>Total endoscopic ablation of atrial fibrillation
2015 (English)In: Multimedia manual of cardiothoracic surgery : MMCTS / European Association for Cardio-Thoracic Surgery, ISSN 1813-9175Article in journal (Refereed) Published
Abstract [en]

Total endoscopic ablation of atrial fibrillation is a treatment option in symptomatic patients after unsuccessful catheter ablation or when catheter ablation is considered inappropriate. We describe a technique of endoscopic ablation of the left atrium using temperature-controlled unipolar or bipolar radiofrequency. A left atrial box lesion encircling the pulmonary veins is created using three ports in the right hemithorax. The technical aspects and preliminary results of the procedure are discussed.

Place, publisher, year, edition, pages
Oxford University Press, 2015
Keywords
Ablation; Atrial fibrillation; Endoscopy; Radiofrequency energy
National Category
Surgery
Research subject
Surgery esp. Thoracic and Cardivascular Surgery
Identifiers
urn:nbn:se:oru:diva-50201 (URN)10.1093/mmcts/mmv010 (DOI)26079408 (PubMedID)2-s2.0-84944929578 (Scopus ID)
Available from: 2016-07-04 Created: 2016-05-04 Last updated: 2018-07-03Bibliographically approved
4. Total endoscopic ablation of patients with long-standing persistent atrial fibrillation: a randomized controlled study
Open this publication in new window or tab >>Total endoscopic ablation of patients with long-standing persistent atrial fibrillation: a randomized controlled study
Show others...
2016 (English)In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 23, no 2, p. 292-298Article in journal (Refereed) Published
Abstract [en]

Objectives: Total endoscopic ablation of atrial fibrillation is an alternative to catheter ablation, but its clinical role needs further evaluation. The aim of this study was to compare total endoscopic ablation with rate control in patients with long-standing persistent atrial fibrillation and to examine the effect of endoscopic ablation on heart rhythm, symptoms, physical working capacity and myocardial function during 1 year of follow-up.

Methods: In a prospective controlled study, 36 patients aged >50 years with symptomatic long-standing persistent atrial fibrillation were randomized to either total endoscopic ablation (n = 17, after two drop-outs before ablation n = 15) or rate control therapy (n = 19). In the ablation group, a box lesion encircling the pulmonary veins was performed, using temperature-controlled radiofrequency energy. Loop recorders were implanted in all patients. Echocardiography and quality-of-life assessment were performed at 6 and 12 months, and physical working capacity assessment at 6 months.

Results: There was no mortality or thromboembolic event. In the control group, all patients were in permanent atrial fibrillation during 12 months of follow-up. In the ablation group, the proportion of patients in sinus rhythm without antiarrhythmic drugs was 12/15 (80%) at 12 months. The median freedom of atrial fibrillation at 3-12 months was 95% in the ablation group and the proportion of patients with an atrial fibrillation burden of <5% at 3-12 months was 8/15 (53%). The left ventricular ejection fraction increased during follow-up in the ablation group compared with the control group (from 53.7 ± 8.6 to 58.8 ± 6.5%, P = 0.003), combined with a reduction in the left atrial area (from 29.2 ± 5.5 to 27.2 ± 6.3 cm(2), P = 0.002). The physical working capacity increased in the ablation group compared with the control group (from 94 ± 21.4 to 102.9 ± 14.4%, P = 0.011). The subjective physical and mental capacity scale also improved during follow-up in the ablation group, but not in the control group (P =0.003 and 0.018, respectively).

Conclusions: Total endoscopic ablation in patients with long-standing persistent atrial fibrillation significantly reduced atrial fibrillation burden 12 months after intervention compared with controls. The left ventricular function, physical working capacity and subjective physical and mental health were improved. These results need to be confirmed in larger randomized trials.

Place, publisher, year, edition, pages
Oxford, United Kingdom: Oxford University Press, 2016
Keywords
Atrial fibrillation, ablation, endoscopy, randomized trial, implantable loop recorder
National Category
Surgery Cardiac and Cardiovascular Systems
Research subject
Surgery esp. Thoracic and Cardivascular Surgery; Cardiology
Identifiers
urn:nbn:se:oru:diva-50200 (URN)10.1093/icvts/ivw088 (DOI)000383248800021 ()27068249 (PubMedID)2-s2.0-84981165123 (Scopus ID)
Note

Funding Agency:

Research Committee of Örebro University Hospital

Available from: 2016-07-04 Created: 2016-05-04 Last updated: 2018-04-25Bibliographically approved

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