scholarly journals Efficacy of the Stand-Alone Cox-Maze IV Procedure in Patients with Longstanding Persistent Atrial Fibrillation

2021 ◽  
Author(s):  
Martha McGilvray ◽  
Nadia Bakir ◽  
Meghan Kelly ◽  
Samuel Perez ◽  
Laurie Sinn ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Persistent Atrial Fibrillation ◽  
Implantable Loop Recorder ◽  
Atrial Tachyarrhythmia ◽  
Loop Recorder ◽  
Factors Associated ◽  
Holter Monitor ◽  
Long Duration ◽  
Prolonged Monitoring

Introduction: Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and results in significant morbidity and mortality. The Cox-Maze IV procedure (CMP-IV) has been shown to have excellent efficacy in returning patients to sinus rhythm, but there have been few reports of late follow-up in sizable cohorts of patients with longstanding persistent AF, the most difficult type of AF to treat. Methods & Results: Between May 2003 and March 2020, 174 consecutive patients underwent a stand-alone CMP-IV for longstanding persistent AF. Rhythm outcome was assessed postoperatively for up to 10 years, primarily via prolonged monitoring (Holter monitor, pacemaker interrogation, or implantable loop recorder). Fine-Gray regression was used to investigate factors associated with atrial tachyarrhythmia (ATA) recurrence, with death as a competing risk. Median duration of preoperative AF was 7.8 years (interquartile range [IQR] 4.0-12.0 years), with 71% (124/174) having failed at least one prior catheter-based ablation. There were no 30-day mortalities. Freedom from ATAs was 94% (120/128), 83% (53/64), and 88% (35/40) at 1, 5, and 7 years, respectively. On regression analysis, preoperative AF duration and early postoperative ATAs were associated with late ATAs recurrence. Conclusion: Despite the majority of patients having a long-duration of preoperative AF and having failed at least one catheter-based ablation, the stand-alone CMP-IV had excellent late efficacy in patients with longstanding persistent AF, with low morbidity and no mortality. We recommend consideration of stand-alone CMP-IV for patients with longstanding persistent AF who have failed or are poor candidates for catheter ablation.

P1913Implantable Loop Recorder Detected Pattern of Atrial Fibrillation Recurrence Following Cryoballoon Pulmonary Vein Isolation in Patients with Persistent Atrial Fibrillation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
D Musat ◽  
N Milstein ◽  
R Shaw ◽  
A Bhatt ◽  
M Preminger ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Pulmonary Vein Isolation ◽  
Persistent Atrial Fibrillation ◽  
Limited Data ◽  
Loop Recorder ◽  
Long Term Follow Up ◽  
Af Recurrence

Abstract Background Cryoballoon (CB) pulmonary vein isolation (PVI) is increasingly being used in patients (pts) with persistent atrial fibrillation (AF). However, there are limited data about the pattern of atrial fibrillation (AF) recurrence in these pts. Objective To assess, using an implantable loop recorder (ILR), the patterns of AF recurrence following CB PVI in pts with persistent atrial fibrillation. Methods We enrolled consecutive pts with persistent AF ablation undergoing their first CB ablation. Other cavotricuspid isthmus ablation when indicated, no other ablation was performed. A Reveal LINQ ILR (Medtronic) was implanted <3 months following ablation; all pts had a minimum of 1-year follow-up. The recurrence of any atrial arrhythmia was determined and adjudicated; 4 distinct AF patterns were characterized (Figure). Results We studied 64 pts (66±9 years; 50 [78%] male; CHA2DS2-VASc 2.6±1.9) with persistent AF; 52 (81%) pts were on an antiarrhythmic drug (AAD) peri-ablation. During 803±361 days of follow-up, 33 (52%) pts had their 1st AF recurrence 91–365 days post-ablation and another 17 (27%) pts had their 1st AF recurrence >365 days post-ablation. No AF was seen in 14 (31%) pts. Most pts (33 of 50, 66%) with AF recurrence presented with 1 of 3 distinct patterns of paroxysmal AF (Figure), which ranged from 22 min to 124 hours. In 2/3 of these pts, all AF recurrences lasted <24 hours. Only 17 (34%) pts recurred with persistent AF. Conclusion Following single CB PVI, most pts with persistent AF remained free of persistent AF during long-term follow-up. Most pts with recurrent AF have 1 of 3 distinct patterns with episodes commonly last <24 hours. These data suggest that CB PVI ablation may halt AF progression in pts initially presenting with persistent AF.

scholarly journals Thoracoscopic surgical ablation versus catheter ablation as first-line treatment for long-standing persistent atrial fibrillation: the CASA-AF RCT

2021 ◽  
Vol 8 (18) ◽  
pp. 1-122
Author(s):  
Shouvik Haldar ◽  
Habib R Khan ◽  
Vennela Boyalla ◽  
Ines Kralj-Hans ◽  
Simon Jones ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Antiarrhythmic Drugs ◽  
Persistent Atrial Fibrillation ◽  
Loop Recorder ◽  
Surgical Ablation ◽  
Single Procedure

Background Standalone thoracoscopic surgical ablation may be more effective than catheter ablation in patients with long-standing persistent atrial fibrillation. Objectives To determine whether or not surgical ablation is clinically superior to catheter ablation as the first-line treatment strategy in long-standing persistent atrial fibrillation. Design This was a prospective, multicentre, randomised control trial. Setting Four NHS tertiary centres in England. Participants Adults with long-standing persistent atrial fibrillation, who had European Heart Rhythm Association symptom scores > 2 and who were naive to previous catheter ablation or thoracic/cardiac surgery. Interventions Minimally invasive thoracoscopic surgical ablation and conventional catheter ablation (control intervention). Main outcome measures The primary outcome was freedom from atrial fibrillation/tachycardia ≥ 30 seconds after a single procedure without antiarrhythmic drugs (class 1C/3) at 1 year, excluding a 3-month blanking period. The secondary outcomes include the intervention-related major complication rate; clinical success (≥ 75% reduction in arrhythmia burden); and changes in symptoms, quality of life and cost-effectiveness. Methods Patients (n = 120) were randomised to surgical ablation (n = 60) or catheter ablation (n = 60). An implanted loop recorder provided continuous cardiac monitoring following ablation. Follow-up visits were at 3, 6, 9 and 12 months. Loop recorder data were reviewed monthly by a physiologist who was blinded to the randomisation outcome. Results The study treatment was received by 55 patients in the surgical ablation arm and 60 patients in the catheter ablation arm; five patients withdrew from surgical ablation before treatment. Data from randomised and treated patients were analysed as per intention to treat. Patients had a mean age of 62.3 (standard deviation 9.6) years, were predominantly male (74%), had a mean left atrial diameter of 44.6 mm (standard deviation 6 mm) and were in continuous atrial fibrillation for 22 months (range 16–31 months). At 12 months, 26% of patients in the surgical ablation arm (14/54) and 28% of patients in the catheter ablation arm (17/60) were free from atrial arrhythmias after a single procedure without antiarrhythmic drugs (odds ratio 1.13, 95% confidence interval 0.46 to 2.83; p = 0.84). An arrhythmia burden reduction of ≥ 75% was seen in 36 out of 54 (67%) patients in the surgical ablation arm, compared with 46 out of 60 (77%) patients in the catheter ablation arm (odds ratio 1.64, 95% confidence interval 0.67 to 4.08; p = 0.3). Procedure-related serious complications within 30 days of the intervention occurred in 15% (8/55) of patients in the surgical ablation arm (including one death) compared with 10% (6/60) of patients in the catheter ablation arm (p = 0.46). Surgical ablation was associated with significantly higher costs (£23,221 vs. £18,186; p = 0.02) and fewer quality-adjusted life-years than catheter ablation (0.76 vs. 0.83; p = 0.02). Limitations This study was conducted in four highly specialised cardiology centres that have substantial experience in both treatment modalities; therefore, the results may not be widely generalisable. The study was not powered to detect small differences in efficacy. Conclusions We found no evidence to suggest that standalone thoracoscopic surgical ablation outcomes were superior to catheter ablation outcomes in achieving freedom from atrial arrhythmia after a single procedure without antiarrhythmic drugs. Moreover, surgical ablation is associated with a longer hospital stay, smaller improvements in quality of life and higher health-care costs than catheter ablation (standard care therapy). Future work Evaluation of the impact of ablation treatments on sinus rhythm maintenance and quality of life with extended follow-up to 3 years. Model-based economic analysis to estimate long-term benefits, harms and costs of surgical and catheter ablation compared with antiarrhythmic drug therapy in long-standing persistent atrial fibrillation patients. Trial registration Current Controlled Trials ISRCTN18250790 and ClinicalTrials.gov NCT02755688. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council (MRC) and National Institute for Health Research (NIHR) partnership. This study was supported by the UK Clinical Research Collaboration-registered King’s Clinical Trials Unit at King’s Health Partners, which is part funded by the NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King’s College London and the NIHR Evaluation, Trials and Studies Coordinating Centre. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 8, No. 18. See the NIHR Journals Library website for further project information.

Abstract 18233: Implantable Loop Recorder Monitoring is Useful in Detecting a High Incidence of Previously Unrecognized Atrial Fibrillation in Hemodialysis Patients. Preliminary Data From the Monitoring in Dialysis (MiD) Study

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Bruce A Koplan ◽  
Selcuk A Tombul ◽  
James A Tumlin ◽  
David M Charytan
Keyword(s):  
Atrial Fibrillation ◽  
Risk Reduction ◽  
Stroke Risk ◽  
Study Entry ◽  
Population Increase ◽  
Prior History ◽  
Implantable Loop Recorder ◽  
Loop Recorder ◽  
High Incidence

Introduction: Patients with end stage renal disease have a high incidence of stroke and studies have shown that even short durations of atrial fibrillation (AFib) in this population increase stroke risk. Hypothesis: Implantable loop recorder monitoring will provide useful information to guide stroke risk reduction by detecting and quantifying AFib in hemodialysis (HD) pts. Methods: MiD is a prospective multi-center study to characterize arrhythmias in maintenance HD pts with an implantable loop recorder (ILR) over a 12mo period. The ILR device used detects AFib episodes based on incoherence in adjacent R-R intervals, with previous validation against simultaneous Holter monitoring showing 92% sensitivity and 80% positive predictive value for AFib episodes lasting ≥6 minutes. Results: Follow-up is available for 45 pts [mean follow-up 6.4mo (0.6-12.0mo), mean age 56yrs (27-76yrs), 36% female]. 1294 AFib episodes ≥6 minutes were detected in 19/45 pts (42%), occurring at a mean rate of 13.7 (95% CI 6.1-30.9) events per patient month in these 19 pts. Minimum total duration of AFib in these 19 pts was 20 minutes with 13/19 pts (68%) having > 100 minutes and 8/19 pts (42%) having >20 hours of ILR-detected Afib during follow-up. Only 5/19 pts (26%) with Afib episodes ≥6 minutes had any prior history of Afib and 13/19 pts (68%) were not on anticoagulation (AC) at study entry. There were also 2 pts with Afib episodes ≥6 minutes with a prior CVA or TIA who had not previously been diagnosed with Afib and were not on AC at study entry. All 19 pts (100%) with Afib episodes ≥6 minutes had CHADS 2 scores ≥1 and 15/19 pts (79%) had CHADS 2 scores ≥2, including 12/13 pts (92%) not on AC. ILR surveillance thus identified 12/45 pts (27%) in the cohort who were not on AC at enrollment with the potential to derive significant stroke risk reduction with AC. Conclusions: Afib is common and often undiagnosed in HD pts with 42% of MiD patients having at least one sustained episode (≥6 minutes) and only 11% of these patients having any prior history. ILR surveillance has value in identifying patients at risk for stroke in whom anticoagulation may be beneficial. With improvement in ILR technology with respect to size and wireless capability, clinicians should have a low tolerance to evaluate HD patients for Afib.

scholarly journals Patients with recurrent syncope and implantable loop recorder exhibit better survival than the control group without implantable loop recorder

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
C Perings ◽  
C Wolff ◽  
A Wilk ◽  
A Witthohn ◽  
R Voss ◽  
...  
Keyword(s):  
Life Expectancy ◽  
Control Group ◽  
Funding Source ◽  
Implantable Loop Recorder ◽  
Loop Recorder ◽  
Cardiac Device ◽  
Unexplained Syncope ◽  
Care Costs

Abstract Introduction In 30% of patients with syncope, the underlying cause remains unexplained after clinical investigations. Unexplained syncope tends to recur, significantly impacting patients' quality of life of patients and mortality. Thus, there is a need for timely and more accurate diagnosis to initiate treatment. Dedicated care pathways are recommended by ESC guidelines. Purpose Patients with recurrent syncope were followed over time and patient outcomes with ILR were compared to patients with the same syncope burden, age, gender and mortality risk score who did not receive an ILR. Method A representative database of 4.9 million patients insured by German company statuary health insurances (BKK) was analysed over a time period of 10 years, 2007–17. Patients with recurrent syncope (two times ICD-10 GM diagnosis codes R55), age between 45–84 and no diagnosis code for the syncope were included in the analysis and followed for at least 2 years. Patients with ILR were matched to patients without ILR based on age, gender and Charlson Comorbidity index (CCI) using mahalanobis distances. The index event was the device implant in the ILR group and the second syncope event in the control group. Life expectancy, syncope hospitalisations, fall related injuries, health care costs, diagnoses and treatment rates were compared between the groups. Results A total of 412 patients with ILR for recurrent unexplained syncope were matched to the control group. Overall mean age was 68, mean was CCI 2.7, 42% were females. The risk of death was 2.35 times higher in the control group during follow up as shown in Figure 1 (p-value logrank test &lt;0.0001). Cardiovascular related diagnosis and treatment rates were higher in the ILR group with 69% of patients having a cardiology diagnosis compared to 41% in the control group. Over a quarter (27%) of ILR patients received an implantable cardiac device compared to 5% in the control group. Ablation rates were 7% in the ILR group compared to 0% in the control group. Median health care costs were € 3,847 higher in the ILR group including the costs of the ILR implant, follow up and higher rates of cardiac treatments. These extra costs appear moderate given the substantially higher mortality risk in the control group. Conclusion This study of patients with recurrent unexplained syncope shows a remarkable difference in life expectancy in patients with ILR compared to a matched control group. Two large claim data analysis have recently shown higher rates of cardiovascular death as well as all-cause mortality in patients with unexplained syncope. A more vigilant cardiac workup might be needed to identify a possible underlying cardiac condition. Higher rates of cardiac device therapy in the ILR group were likely to play an important role for their better life expectancy. Cardiac therapies such as pacemakers, defibrillators and ablation have also been shown to significantly improve patients' quality of life. Life Expectancy Comparison Funding Acknowledgement Type of funding source: Private company. Main funding source(s): The data analysis was funded by Medtronic

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