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Total endoscopic ablation of patients with long-standing persistent atrial fibrillation: a randomized controlled study
Örebro University, School of Medical Sciences. Department of Cardiology, Örebro University, Örebro, Sweden.
Department of Cardiothoracic and Vascular Surgery, Örebro University, Örebro, Sweden.
Department of Cardiology, Örebro University, Örebro, Sweden; Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Arrhythmia Centre, South General Hospital, Stockholm, Sweden.
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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. Vol. 23, no 2, p. 292-298
Keywords [en]
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: urn:nbn:se:oru:diva-50200DOI: 10.1093/icvts/ivw088ISI: 000383248800021PubMedID: 27068249Scopus ID: 2-s2.0-84981165123OAI: oai:DiVA.org:oru-50200DiVA, id: diva2:946147
Note

Funding Agency:

Research Committee of Örebro University Hospital

Available from: 2016-07-04 Created: 2016-05-04 Last updated: 2018-04-25Bibliographically approved
In thesis
1. Atrial fibrillation: endoscopic ablation and postoperative studies
Open this publication in new window or tab >>Atrial fibrillation: endoscopic ablation and postoperative studies
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
Atrial fibrillation, Bypass surgery, Cerebral ischemia, Follow-up studies, Survival, Anticoagulation, Ablation, Endoscopy, Randomized trial, Implantable loop recorder
National Category
General Practice
Identifiers
urn:nbn:se:oru:diva-61949 (URN)978-91-7529-220-5 (ISBN)
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

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Fengsrud, EspenAhlsson, Anders

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