IntroductionAtrial fibrillation (AF) increases long-term mortality and stroke rate in patients having coronary artery bypass grafting (CABG). Because oral anticoagulation (OAC) is associated with both a significant incidence of discontinuation and well known complication rates, left atrial appendage occlusion might be beneficial for stroke prevention. This study presents the first clinical and practical comparison of two epicardial left appendage occluders (LAAO) accruing experience in application during off-pump coronary revascularisation in patients with persistent AF.Material and methodsFifteen consecutive patients with persistent AF were assigned to intraoperative LAA occlusion with either TigerPaw System II (n = 8) or AtriClip (n = 7) device during off-pump CABG and concomitant left atrial epicardial ablation. Both systems were analysed in terms of ease and safety of application along with intraoperative LAA occlusion success.ResultsSurgical risk was increased in the study population (mean EuroScore II: 3.2 ± 0.3%). In all patients in the AtriClip group successful off-pump LAA occlusion confirmed by intraoperative transoesophageal echocardiography was achieved. The TigerPaw application was quicker and easier, but in 2 patients it was unsuccessful. During the hospital stay there were no bleeding or thromboembolic events recorded.ConclusionsIn a pilot cohort epicardial LAAO during off-pump CABG in patients with persistent AF was performed safely and successfully with an AtriClip device. The TigerPaw System requires technological improvement. It might be useful to adapt the use of the type of occluding device to the LAA morphologic type and target revascularisation vessels to avoid the additional use of a heart positioner or obviate coronary compression.
IntroductionLeft atrial ganglionated plexi ablation is an adjuvant technique used to
increase the success rate of surgical ablation of atrial fibrillation.
Ganglionated plexi ablation requires previous detection. We aimed to assess
determinants of successful ganglionated plexi detection and to correlate
range of ganglionated plexi ablation with risk of early atrial fibrillation
recurrence.MethodsThe study involved 34 consecutive patients referred for surgical coronary
revascularization with concomitant atrial fibrillation ablation.
Ganglionated plexi detection was done by inducing vagal reflexes in the area
of the pulmonary veins and left atrial fat pads.ResultsDetection of GP was successful in 85% of the patients. There was no
difference in preoperative characteristics nor in atrial fibrillation type
between patients in whom ganglionated plexi detection was successful and
others. The number of detected ganglionated plexi correlated significantly
only with preoperative resting heart rate. Significant negative correlation
was found in patients with preoperative heart rate>75 beat/min in terms
of total number of detected ganglionated plexi (P=0.04).
Average number of detected ganglionated plexi was significantly higher in
patients with in-hospital atrial fibrillation recurrence requiring
electrical cardioversion (3.8±3) in comparison to rest of the study
population (2±1.3; P=0.02). In patients in whom 4 or
more ganglionated plexi were detected, significantly increased risk of
in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI
1.5-164; P=0.003).ConclusionLeft atrial ganglionated plexi detection was unsuccessful in a considerable
percentage of patients. Preoperative heart rate significantly influenced
positive ganglionated plexi detection and number of ablated ganglia. Higher
number of detected ganglionated plexi was related with early recurrence of
atrial fibrillation.
The early success of epicardial LAA occlusion is not dependent on LAA morphologic type or occluder used. A minimal remnant LAA stump not exceeding 1 cm in length without distal blood flow was observed in one-third of the cases.
This report documents the safety and feasibility of right atrial exposure using a suction-based cardiac positioner to complete ablation for AF concomitant with off-pump coronary revascularization. This technique may be widely adopted to create stable haemodynamic conditions and optimal visualization of the right pulmonary veins.
Multiple applications of bipolar radiofrequency energy during off-pump epicardial pulmonary vein isolation did not lead to PVS. Creating bidirectional conduction block using multiple energy applications through created lesions is feasible in all patients using the ablation protocol described.
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