J Korean Med Sci.  2023 Oct;38(39):e320. 10.3346/jkms.2023.38.e320.

Totally Thoracoscopic Ablation in Patients With Recurrent Atrial Fibrillation After Catheter Ablation

• Lim SK
• Chung S
• Park I
• Chi SA
• Kim K
• Park KM
• Park SJ
• Kim JY
• Kim JS
• On YK
• Jeong DS

• KMID: 2546924
• DOI: http://doi.org/10.3346/jkms.2023.38.e320

Abstract

Background
The objective of this study was to evaluate the efficacy and safety of totally thoracoscopic ablation (TTA) in patients with recurrent atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA).
Methods
From February 2012 to May 2020, 460 patients who underwent TTA were classified into two groups: CA (presence of RFCA history, n = 74) and nCA groups (absence of RFCA history, n = 386). Inverse probability of treatment weighting (IPTW) analyses were used to adjust for confounders. The primary endpoint was freedom from the composite of AF, typical atrial flutter, atypical atrial flutter and any atrial tachyarrhythmia, lasting more than 30 seconds during the follow-up. All patients were followed up at 3, 6, and 12 months via electrocardiogram and 24-hour Holter monitoring.
Results
Bilateral pulmonary vein isolation (PVI) was conducted in all patients and the conduction block tests were confirmed. In the CA group, difficult PVI occasionally occurred due to structural changes, such as pericardial adhesion and fibrosis of the pulmonary venous structure, caused by a previous catheter ablation. Early complications such as stroke and pacemaker insertion were not different between the two groups. The normal sinus rhythm was maintained in 70.1% (317/460) patients after a median follow-up period of 38.1 months. The IPTW-weighted Kaplan-Meier curves revealed that freedom from AF events at 5 years was 68.4% (95% confidence interval, 62.8–74.5) in the nCA group and 31.2% (95% confidence interval, 16.9–57.5) in the CA group (P < 0.001). In IPTW-weighted Cox regression, preoperative left atrial diameter, persistent or long-standing AF, the presence of congestive heart failure and catheter ablation history were associated with AF events.
Conclusion
Patients in the CA group showed a higher recurrence rate of AF than those in the nCA group, while TTA was safely performed in both the groups.

Keyword

Atrial Fibrillation; Radiofrequency Catheter Ablation; Totally Thoracoscopic Ablation; Pulmonary Vein Isolation; Pulmonary Venous Structure Fibrosis

Figure

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  Fig. 1 Flow diagram of patients in this study.IPTW = inverse probability of treatment weighting, TTA = totally thoracoscopic ablation, PVI = pulmonary vein isolation, LAA = left atrial appendage, CA = presence of catheter ablation, nCA = absence of previous catheter ablation, RFCA = radiofrequency catheter ablation.

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  Fig. 2 Inverse probability of treatment weighting -weighted Kaplan-Meier curves of freedom from AF events between the nCA group (red line) and the CA group (blue line) after matching.CA = presence of catheter ablation, nCA = absence of previous catheter ablation, AF = atrial fibrillation.

Reference

1. Park HC, Park JK, Choi SI, Kim SG, Kim MK, Choi BY, et al. Prevalence of atrial fibrillation and relation to echocardiographic parameters in a healthy asymptomatic rural Korean population. J Korean Med Sci. 2015; 30(8):1078–1084. PMID: 26240485.

2. Park YM, Roh SY, Lee DI, Shim J, Choi JI, Park SW, et al. The effects of single nucleotide polymorphisms in Korean patients with early-onset atrial fibrillation after catheter ablation. J Korean Med Sci. 2020; 35(49):e411. PMID: 33350184.

3. Brooks AG, Stiles MK, Laborderie J, Lau DH, Kuklik P, Shipp NJ, et al. Outcomes of long-standing persistent atrial fibrillation ablation: a systematic review. Heart Rhythm. 2010; 7(6):835–846. PMID: 20206320.

4. Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M, et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial. Circulation. 2012; 125(1):23–30. PMID: 22082673.

5. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016; 18(11):1609–1678. PMID: 27567465.

6. Phan K, Phan S, Thiagalingam A, Medi C, Yan TD. Thoracoscopic surgical ablation versus catheter ablation for atrial fibrillation. Eur J Cardiothorac Surg. 2016; 49(4):1044–1051. PMID: 26003961.

7. Vos LM, Bentala M, Geuzebroek GS, Molhoek SG, van Putte BP. Long-term outcome after totally thoracoscopic ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2020; 31(1):40–45. PMID: 31691391.

8. Lim SK, Kim JY, On YK, Jeong DS. Mid-term results of totally thoracoscopic ablation in patients with recurrent atrial fibrillation after catheter ablation. Korean J Thorac Cardiovasc Surg. 2020; 53(5):270–276. PMID: 32919447.

9. Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017; 14(10):e275–e444. PMID: 28506916.

10. On YK, Park KM, Jeong DS, Park PW, Lee YT, Park SJ, et al. Electrophysiologic results after thoracoscopic ablation for chronic atrial fibrillation. Ann Thorac Surg. 2015; 100(5):1595–1602. PMID: 26215779.

11. Huang X, Chen Y, Huang Z, He L, Liu S, Deng X, et al. Catheter radiofrequency ablation for arrhythmias under the guidance of the Carto 3 three-dimensional mapping system in an operating room without digital subtraction angiography. Medicine (Baltimore). 2018; 97(25):e11044. PMID: 29923993.

12. Vos LM, Kotecha D, Geuzebroek GS, Hofman FN, van Boven WJ, Kelder J, et al. Totally thoracoscopic ablation for atrial fibrillation: a systematic safety analysis. Europace. 2018; 20(11):1790–1797. PMID: 29361045.

13. Kim HJ, Kim JS, Kim TS. Epicardial thoracoscopic ablation versus endocardial catheter ablation for management of atrial fibrillation: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2016; 22(6):729–737. PMID: 26912577.

14. Pokushalov E, Romanov A, Elesin D, Bogachev-Prokophiev A, Losik D, Bairamova S, et al. Catheter versus surgical ablation of atrial fibrillation after a failed initial pulmonary vein isolation procedure: a randomized controlled trial. J Cardiovasc Electrophysiol. 2013; 24(12):1338–1343. PMID: 24016147.

15. Di Biase L, Natale A, Romero J. Thrombogenic and arrhythmogenic roles of the left atrial appendage in atrial fibrillation. Circulation. 2018; 138(18):2036–2050. PMID: 30372144.

16. Driessen AH, Berger WR, Krul SP, van den Berg NW, Neefs J, Piersma FR, et al. Ganglion plexus ablation in advanced atrial fibrillation: the AFACT study. J Am Coll Cardiol. 2016; 68(11):1155–1165. PMID: 27609676.

17. Kwon HJ, Jeong DS, Park SJ, Park KM, Kim JS, On YK. Long-term outcome of totally thoracoscopic surgical ablation in atrial fibrillation: a single-center experience. Int J Cardiol Heart Vasc. 2021; 36:100861. PMID: 34485680.

18. La Meir M, Gelsomino S, Lucà F, Pison L, Parise O, Colella A, et al. Minimally invasive surgical treatment of lone atrial fibrillation: early results of hybrid versus standard minimally invasive approach employing radiofrequency sources. Int J Cardiol. 2013; 167(4):1469–1475. PMID: 22560495.

19. Pison L, La Meir M, van Opstal J, Blaauw Y, Maessen J, Crijns HJ. Hybrid thoracoscopic surgical and transvenous catheter ablation of atrial fibrillation. J Am Coll Cardiol. 2012; 60(1):54–61. PMID: 22742400.

20. Kim JY, Jeong DS, Kwon HJ, Park SJ, Park KM, Kim JS, et al. Effectiveness of the early staged hybrid approach for treatment of symptomatic atrial fibrillation: the electrophysiology study could be deferred? J Korean Med Sci. 2021; 36(43):e276. PMID: 34751009.

21. Fender EA, Widmer RJ, Hodge DO, Cooper GM, Monahan KH, Peterson LA, et al. Severe pulmonary vein stenosis resulting from ablation for atrial fibrillation: presentation, management, and clinical outcomes. Circulation. 2016; 134(23):1812–1821. PMID: 27793993.

22. Samuel M, Khairy P, Mongeon FP, Andrade JG, Gomes S, Galvan Z, et al. Pulmonary vein stenosis after atrial fibrillation ablation: insights from the ADVICE trial. Can J Cardiol. 2020; 36(12):1965–1974. PMID: 33157186.

23. Packer M. Effect of catheter ablation on pre-existing abnormalities of left atrial systolic, diastolic, and neurohormonal functions in patients with chronic heart failure and atrial fibrillation. Eur Heart J. 2019; 40(23):1873–1879. PMID: 31081029.

24. Rostock T, Steven D, Hoffmann B, Servatius H, Drewitz I, Sydow K, et al. Chronic atrial fibrillation is a biatrial arrhythmia: data from catheter ablation of chronic atrial fibrillation aiming arrhythmia termination using a sequential ablation approach. Circ Arrhythm Electrophysiol. 2008; 1(5):344–353. PMID: 19808429.

25. Shah AJ, Jadidi A, Liu X, Miyazaki S, Forclaz A, Nault I, et al. Atrial tachycardias arising from ablation of atrial fibrillation: a proarrhythmic bump or an antiarrhythmic turn? Cardiol Res Pract. 2010; 2010:950763. PMID: 20379387.

26. Chelu MG, King JB, Kholmovski EG, Ma J, Gal P, Marashly Q, et al. Atrial fibrosis by late gadolinium enhancement magnetic resonance imaging and catheter ablation of atrial fibrillation: 5-year follow-up data. J Am Heart Assoc. 2018; 7(23):e006313. PMID: 30511895.

27. Ma N, Lu R, Zhao D, Jiang Z, Tang M, Bao C, et al. Left atrial appendage fibrosis and 3-year clinical outcomes in atrial fibrillation after endoscopic ablation: a histologic analysis. Ann Thorac Surg. 2020; 109(1):69–76. PMID: 31302082.

28. Oakes RS, Badger TJ, Kholmovski EG, Akoum N, Burgon NS, Fish EN, et al. Detection and quantification of left atrial structural remodeling with delayed-enhancement magnetic resonance imaging in patients with atrial fibrillation. Circulation. 2009; 119(13):1758–1767. PMID: 19307477.

29. Wong KC, Paisey JR, Sopher M, Balasubramaniam R, Jones M, Qureshi N, et al. No benefit of complex fractionated atrial electrogram ablation in addition to circumferential pulmonary vein ablation and linear ablation: benefit of complex ablation study. Circ Arrhythm Electrophysiol. 2015; 8(6):1316–1324. PMID: 26283145.