Targeting Bachmann’s bundle in hybrid ablation for long-standing persistent atrial fibrillation: a proof of concept study

Martino, Giuseppe; Nasso, Giuseppe; Gasperetti, Alessio; Moscarelli, Marco; Mancusi, Carmine; Rattá, G.; Calvanese, Claudia; Mitacchione, Gianfranco; Bonifazi, Raffaele; Bari, Nicola Di; Vassallo, Enrico; Schiavone, Marco; Gaudino, Mario; Forleo, Giovanni B.; Saglio, Giuseppe

doi:10.1007/s10840-021-00971-7

Cited by 10 publications

(12 citation statements)

References 21 publications

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“…Such results may influence the selection of patients who are eligible for AFSA and may suggest an early timing indication for surgery (ML-LAD ≤ 6 cm), with associated concomitant LAA exclusion. It will be of primary importance to focus further attention on different aspects in the literature: (1) extensive literature review and prospective studies to identify the main predictors of the efficacy of atrial fibrillation ablation; (2) possible alternative sites that may improve the outcome of this technique, such as ablation of Bachmann's bundle [42]; (3) a comparison of the energies and strategies used.…”

Section: Discussionmentioning

confidence: 99%

Left Atrial Appendage Exclusion in Atrial Fibrillation Radiofrequency Ablation during Mitral Valve Surgery: A Single-Center Experience

Lavalle

Straito

Chourda

et al. 2021

Cardiology Research and Practice

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Background. Atrial fibrillation surgical radiofrequency ablation (AFSA) during mitral valve surgery (MVS) has almost completely superseded the Cox-Maze procedure for the treatment of atrial fibrillation. Methods. We retrospectively analyzed 100 patients who underwent MVS + AFSA in our institution from January 2008 to June 2017. We compared the effectiveness of AFSA in patients who underwent LAA exclusion to those who did not. Moreover, we analyzed the role of preoperative AF duration (≤ or >1 year) and medial-lateral left atrial dimensions (ML-LAD) (≤ or >6 cm). The efficacy endpoint was freedom from AF at discharge and at 2-year follow-up. The safety endpoints were need of a permanent pacemaker (PMK), surgical re-exploration, occurrence of stroke, and left circumflex artery or esophageal lesions. Results. Overall, the rate of AF freedom was 69% at discharge and 80% at 2-year follow-up. LAA exclusion did not influence AF freedom at 2-year follow-up, and 84.6% of patients who underwent LAA exclusion were in the sinus rythm (SR) at 2 year compared to 75% of those who did not receive LAA exclusion free from AF as well ( p = 0.230 ). AF duration ≤1 or >1 year did not influence sinus rhythm (SR) maintenance (85.7% vs. 75.8%; p = 0.224 ), and in these two groups, LAA exclusion did not change the efficacy of AFSA. ML-LAD ≤ 6 cm was associated with better results in terms of SR maintenance. A statistically significant association between LAA exclusion and SR maintenance at 2-year follow-up ( p = 0.017 ) was found among patients with ML-LAD ≤ 6 cm. Complications included 7 cases of PMK implantation, 2 cases of surgical re-exploration, and 1 case of stroke. No circumflex artery or esophageal lesions occurred after surgical procedures. Conclusions. In our experience, AFSA during isolated MVS resulted in good outcomes in terms of SR maintenance and incidence of complications. AF duration ≤ 1 year did not influence results, while patients with ML-LAD ≤ 6 cm had significantly better results regarding SR at follow-up. In patients with ML-LAD ≤ 6 cm, LAA exclusion significantly increased the success rate of SR maintenance at 2-year follow-up.

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Section: Discussionmentioning

confidence: 99%

Left Atrial Appendage Exclusion in Atrial Fibrillation Radiofrequency Ablation during Mitral Valve Surgery: A Single-Center Experience

Lavalle

Straito

Chourda

et al. 2021

Cardiology Research and Practice

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“…As previously described (7), hybrid patients underwent a staged endocardial ablation within 6 weeks after the surgical procedure with the aim at verifying or ablating: (i) the surgical lines and completing isolation of the box lesion if needed, (ii) additional right and left atrial substrate modi cation, and (iii) other triggers of AF.…”

Section: Methodsmentioning

confidence: 99%

“…RF was applied using an open irrigated tip catheter with power output up on the posterior wall and in the remaining atrial sites. Entrance block was de ned by complete elimination or dissociation of PV potentials, determined by the circular mapping catheter positioned in the PVs and posterior wall (7). Endocardial ablation was rst directed to possible gaps in the surgical lesions.…”

Section: Methodsmentioning

confidence: 99%

“…Recently, it has been shown that electrical isolation of the left atrial posterior wall, particularly when targeting the Bachmann's bundle (BB), may play a key role in ensuring procedural success (7). BB may be involved in the pathogenesis of AF by sustaining a number of unstable reentrant circuits, and BB isolation has been hypothesized to prevent induction of stable AF (7)(8)(9)(10). As indicated by current guidelines, the achievement of complete ablation is of great relevance.…”

Section: Introductionmentioning

confidence: 99%

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Catheter, Surgical, or Hybrid Procedure: What Future for Atrial Fibrillation Ablation?

Nasso¹,

Lorusso

Moscarelli³

et al. 2021

Preprint

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Background - The debate on the best treatment strategy for AF has expanded following the introduction of the so-called “hybrid procedure” that combines minimally invasive epicardial ablation with endocardial catheter ablation. However, the advantage of the hybrid approach over conventional epicardial ablation remains to be established.Methods -From June 2008 to December 2020, 609 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency (RF) device was used, whereas from 2011 to 2020 a bipolar RF device was used. In addition, between September 2016 and April 2017, 60 patients underwent endocardial completion of epicardial linear ablation. In 30 of these latter patients, surgical isolation of the Bachmann’s bundle (BB) was also performed. Starting from 2021, surviving patients at follow-up were asked to undergo ECG evaluation and left ventricular function assessment and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF. Results - The ablation procedure was completed in all patients. Upon discharge, 30 (4.9%) patients showed recurrence of AF, whereas the remaining patients (95.1%) were in sinus rhythm. All patients in whom a hybrid approach was used either with or without BB ablation were discharged in sinus rhythm. After a mean follow-up of 74 months, 122 (20%) patients developed recurrent AF, including 19.9% in whom a unipolar RF device was used, 21% in whom a bipolar RF device was used, 23% who had undergone a hybrid procedure without BB ablation and 3.3% who had undergone a hybrid procedure. On multivariate analysis, reduced left ventricular ejection fraction, worsening of EHRA symptom class, and cognitive impairment or depression during follow-up were found to be significantly associated with AF recurrence. Conclusions - Surgical AF ablation through a right minithoracotomy is safe and may allow the creation of additional linear lesions, particularly in the BB. The placement of adjunctive linear lesions in the setting of a hybrid procedure is more effective in reducing the risk for AF recurrence than isolated surgical ablation or hybrid ablation without the addition of further linear lesions, with no incremental risk to the patient.

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“…This leads to the second consideration, the e cacy of the proposed treatment. Part of the answer to this problem is an evolution of our AF ablation strategy with the addition of a "hybrid" approach and ablation of the roof of the left atrium (8).…”

Section: E Cacymentioning

confidence: 99%

The Fate of Patients After Failed Epicardial Ablation of Atrial Fibrillation

Nasso¹,

Lorusso

Motekallemi

et al. 2021

Preprint

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Background – Much debate is still going on about the best ablation strategy – via endocardial or epicardial approach – in patients with atrial fibrillation (AF), and evidence gaps exist in current guidelines in this area. More specifically, there are no clear long-term outcome data after failed surgical AF ablation.Methods – Since June 2008, 549 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency device was used (151 patients), whereas from 2011 to 2020 a bipolar radiofrequency device was used (398 patients). Patients were scheduled for surgery on the basis of the following criteria: recurrent episodes of paroxysmal or persistent lone AF refractory to maximally tolerated antiarrhythmic drug dosing and at least one failed cardioversion attempt. Besides the recommended follow-up by the local cardiologist, starting from 2021, surviving patients were asked to undergo assessment of left ventricular function and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF.Results – At a mean follow-up of 77 months, the rate of AF recurrence was 20.7% (n=114). On multivariate analysis, impaired left ventricular ejection fraction (58 patients, 51%, p=0.002), worsening of European Heart Rhythm Association (EHRA) symptom class (37 patients, 32%, p=0.003) and cognitive decline or depression (23 patients, 20%, p=0.023) during follow-up were found to be significantly associated with AF recurrence.Conclusions – Surgical AF ablation through a right minithoracotomy is safe, but a better outcome could be achieved using a hybrid approach. Patients after initial failed surgical AF ablation show worsening of cardiac function, clinical status and quality of life at follow-up compared to patients with successful AF ablation.

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Targeting Bachmann’s bundle in hybrid ablation for long-standing persistent atrial fibrillation: a proof of concept study

Cited by 10 publications

References 21 publications

Left Atrial Appendage Exclusion in Atrial Fibrillation Radiofrequency Ablation during Mitral Valve Surgery: A Single-Center Experience

Left Atrial Appendage Exclusion in Atrial Fibrillation Radiofrequency Ablation during Mitral Valve Surgery: A Single-Center Experience

Catheter, Surgical, or Hybrid Procedure: What Future for Atrial Fibrillation Ablation?

The Fate of Patients After Failed Epicardial Ablation of Atrial Fibrillation

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