Benefit Of Ablation Of First Diagnosed Atrial Fibrillation In Patients Submitted To Coronary Artery Bypass Grafting
semanticscholar(2013)
摘要
Introduction: In patients with long-term history of paroxysmal atrial fibrillation (AF) a decision can be made to go for concomitant coronary artery bypass grafting (CABG) and epicardial AF ablation procedures. Whether patients with recent onset of PAF might benefit of epicardial AF ablation concomitant to CABG is not known. Aim of this prospective, randomized, single-center pilot study is the comparison of patients with first diagnosed AF submitted to CABG and treated with and without epicardial pulmonary vein isolation (PVI). Methods: Patients with first diagnosed paroxysmal AF and indication for CABG were enrolled in this prospective randomized pilot study. The primary endpoint was AF free survival (AF burden <0.5%) between two groups at 18 months follow up. The secondary end-points were: the percentage of AF burden defined through continuous monitoring using an implantable loop recorder, thromboembolic events and procedural complications. All patients were implanted with a subcutaneous cardiac monitor to track the cardiac rhythm and measure the AF burden. Results: This study enrolled 43 patients (mean age 59±7 years, 74% males), followed up for 18 months after CABG. The patients were randomly allocated to two groups, CABG alone (n=21) and CABG with concomitant PVI (n=22). At the 18 month follow-up after surgery, 19 (86%) patients in the CABG+PVI group were AF-free (i.e. AF%<0.5%) vs 9 (43%) in the CABG only group (Log-Rank test, p=0.007). At the end of follow-up, the mean AF burden in the CABG and CABG+PVI group was 7.8±5.1% and 1.6±1.8%, respectively (P<0.001). Four (26%) of the 15 patients with AF recurrences were completely asymptomatic. Conclusion: Patients with recent-onset atrial fibrillation submitted to CABG may benefit of concomitant ablation of the arrhythmia for preventing recurrences. www.jafib.com October, 2013 | Special Issue Surgery For Cardiac Arrhythmias The Hybrid Approach For The Treatment Of Atrial Fibrillation In PTS With Giant Left Atriums And Ischemic Or Valvular Cardiomyopathy: Safe And Efficacious S. Gundry, W. Ehrman, H. Bhatka The International Heart and Lung Institute, Departments of Surgery and Cardiology,Desert Regional Medical Center, Palm Springs, CA, USA Abstract Introduction: We studied whether a combined surgical radiofrequency LA box lesion set, performed prior to cardiopulmonary bypass, coupled with post-operative EP study and additional catheter based lesion sets, would be safe and efficacious in high-risk surgical pts with AF, cardiomyopathy, and giant LA’s. AF ablation is deemed too risky in these pts, but restoration of NSR may be critical to short and long-term survival. Epicardial Ablation pre-bypass, followed by catheter ablation post op (Hybrid Approach), would eliminate the additional ischemia and bypass time, yet restore NSR if effective. Methods: Twelve (12) pts, aged 58-84, with EF’s =30% (range 10-30%), with LA size 6.5-8.5 cm by TEE, have been studied. All pts underwent revascularization with 3-5 CABG’s/pt.; 10/12 (83%) had concomitant MV repair and TV repair; two/12 (16%) had AV replacement as well. All pts had PV isolation by a LA box lesion created epicardially using the Estech (San Ramon, CA) Cobra Adhere XL or the Fusion Varipolar Devices pre bypass. All pts had exit and entrance block. All left the OR in either NSR, or atrial paced or DDD paced rhythms. Results: Ten/12 pts (83%) developed AF or Aflutter post-op. Four/10 (40%) were studied acutely and found to have RA flutter, which was ablated. One/11 required a second intervention for a left sided RA. Six/10 (60%) either converted or were cardioverted. Four/12 (33%) required permanent pacemaker implant for bradycardia. There were no deaths. At followup, 2/12 (16%) have persistent A Flutter with rate control. Conclusions: We conclude that the Hybrid approach to the treatment of AF in pts with giant LA’s and cardiomyopathy using an Epicardial LA Box lesion set, performed off pump with Bipolar and Unipolar Radiofrequency Ablation prior to cardiac surgery, is safe and efficacious in these high risk pts; restoring sinus rhythm in 84% at up to 2 year followup.Introduction: We studied whether a combined surgical radiofrequency LA box lesion set, performed prior to cardiopulmonary bypass, coupled with post-operative EP study and additional catheter based lesion sets, would be safe and efficacious in high-risk surgical pts with AF, cardiomyopathy, and giant LA’s. AF ablation is deemed too risky in these pts, but restoration of NSR may be critical to short and long-term survival. Epicardial Ablation pre-bypass, followed by catheter ablation post op (Hybrid Approach), would eliminate the additional ischemia and bypass time, yet restore NSR if effective. Methods: Twelve (12) pts, aged 58-84, with EF’s =30% (range 10-30%), with LA size 6.5-8.5 cm by TEE, have been studied. All pts underwent revascularization with 3-5 CABG’s/pt.; 10/12 (83%) had concomitant MV repair and TV repair; two/12 (16%) had AV replacement as well. All pts had PV isolation by a LA box lesion created epicardially using the Estech (San Ramon, CA) Cobra Adhere XL or the Fusion Varipolar Devices pre bypass. All pts had exit and entrance block. All left the OR in either NSR, or atrial paced or DDD paced rhythms. Results: Ten/12 pts (83%) developed AF or Aflutter post-op. Four/10 (40%) were studied acutely and found to have RA flutter, which was ablated. One/11 required a second intervention for a left sided RA. Six/10 (60%) either converted or were cardioverted. Four/12 (33%) required permanent pacemaker implant for bradycardia. There were no deaths. At followup, 2/12 (16%) have persistent A Flutter with rate control. Conclusions: We conclude that the Hybrid approach to the treatment of AF in pts with giant LA’s and cardiomyopathy using an Epicardial LA Box lesion set, performed off pump with Bipolar and Unipolar Radiofrequency Ablation prior to cardiac surgery, is safe and efficacious in these high risk pts; restoring sinus rhythm in 84% at up to 2 year followup. www.jafib.com October, 2013 | Special Issue Cardiac Resynchronization Therapy. Surgically Implanted Epicardial Left Ventricular Lead Compared With Coronary Sinus Lead Stimulation N. Martinenghi, N. Galizio, M. Mysuta, J.L. Gonzalez, F. Robles, A. Palazzo, G. X. Vallejo Deeb, G. Carnero, H. Fraguas Department of Cardiac Electrophysiology. University Hospital Favaloro Foundation Ciudad Autónoma de Buenos Aires, Argentina Abstract Introduction: Epicardial left ventricle lead (ELVL) is an alternative when a coronary sinus lead (CSL) implantation failed. The aim of the study was to assess the outcome of both approaches. Methods: A prospective analysis was performed in 97 pts with idiopathic dilated or ischemic cardiomyopathy who fulfilled CRT-D indications. Group A: 22 pts underwent surgical implantation of ELVL. Group B: 75 pts received CSL implantation. Mean follow up: 21 months (2-69). Pts were considered responders if there was a LVEF improvement ≥5% and/or a reduction of ≥1 NYHA functional class. Responder rate, mean LVEF improvement and end diastolic left ventricle diameter (EDLVD) were assessed. Results: Baseline characteristics were similar in both groups. Responder rate was 86% vs 70.6% (ns), mean LVEF improvement was 11.5±10% vs 10.7±10% (ns) and EDLVD reduction was 11±13% vs 5.6±12.8% (ns) among group A and B respectively. Conclusions: In our study population ELVL implantation was an effective approach in performing an appropriate CRT. The rate of responders was high and there was no significant difference in terms of LVEF improvement and EDLVD reduction.Introduction: Epicardial left ventricle lead (ELVL) is an alternative when a coronary sinus lead (CSL) implantation failed. The aim of the study was to assess the outcome of both approaches. Methods: A prospective analysis was performed in 97 pts with idiopathic dilated or ischemic cardiomyopathy who fulfilled CRT-D indications. Group A: 22 pts underwent surgical implantation of ELVL. Group B: 75 pts received CSL implantation. Mean follow up: 21 months (2-69). Pts were considered responders if there was a LVEF improvement ≥5% and/or a reduction of ≥1 NYHA functional class. Responder rate, mean LVEF improvement and end diastolic left ventricle diameter (EDLVD) were assessed. Results: Baseline characteristics were similar in both groups. Responder rate was 86% vs 70.6% (ns), mean LVEF improvement was 11.5±10% vs 10.7±10% (ns) and EDLVD reduction was 11±13% vs 5.6±12.8% (ns) among group A and B respectively. Conclusions: In our study population ELVL implantation was an effective approach in performing an appropriate CRT. The rate of responders was high and there was no significant difference in terms of LVEF improvement and EDLVD reduction. www.jafib.com October, 2013 | Special Issue Long-Term Results After Cardiac Resynchronization Therapy With Or Without Surgical Revascularization In Patients With Ischemic Heart Failure And Left Ventricle Dyssynchrony D. Losik, A. Strelnikov, S. Bayramova, A. Romanov, E. Pokushalov, A. Chernyavskiy, D. Prokhorova, V. Shabanov, I. Stenin, A. Karaskov Arrhythmia Department and EP Laboratory, State Research Institute of Circulation Pathology, Novosibirsk, Russia Abstract Introduction: We have tested the hypothesis whether epicardial cardiac resynchronization therapy (CRT) concomitantly with surgical revascularization is superior to CRT and medical therapy in patients with ischemic heart failure, LVEF<35% and LV dyssynchrony, who were eligible to coronary artery bypass grafting or medical therapy. Methods: A Ninety seven consecutive patients with severe ischemic heart failure were randomly assigned to endocardial CRT implantation plus medical therapy (n=48) or epicardial CRT implantation plus CABG (n=49). The primary end point was reduction in left ventricle systolic volume (LVESV) by 15% mesured by echocardiography. The major secondary endpoint included the all cause death. The patients were fo
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