Single center experience and approach evolution of multidisciplinary therapy for atrial fibrillation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

QING Hongkun ¹ , LIU Jian ¹ , XIE Bin ¹ , ZHANG Yuyuan ¹ , FANG Liangzheng ¹ , LIU Fangzhou ² , XUE Yumei ² , ZHAN Xianzhang ² , FANG Xianhong ² , WU Shulin ² ,  GUO Huiming ¹

1. Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, P.R.China;
2. Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, P.R.China;

Corresponding author：

GUO Huiming, Email: guohuiming@163.com

Keywords：

Atrial fibrillation; stand-alone surgical ablation; mini maze procedure; hybrid procedure

DOI：

10.7507/1007-4848.201802004

Video：

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Objective To investigate the preliminary experience, the evolution of surgical approach of multidisciplinary therapy for atrial fibrillation and the advantages and disadvantages of each procedure. Methods We retrospectively analyzed the clinical data of 69 patients with stand-alone surgical ablation with or without transcatheter radiofrequency ablation for atrial fibrillation in our center from January 2015 to May 2017. There were 50 males and 19 females at average age of 57.2 years. The patients were divided into three groups according to the surgical approach including a median sternotomy group (n=9), a left unilateral thoracoscopy group (n=7) and a bilateral thoracoscopy group (n=53). One (11.1%) patient, 3 (42.9%) patients and 26 (49.1%) patients received transcatheter mapping and radiofrequency ablation after surgical ablation in each group, respectively. Results The mean follow-up time in the median sternotomy group was 10.2 months. All 9 patients maintained sinus rhythm. The mean follow-up time of the left unilateral thoracoscopy group was 7.4 months. Five (71.4%) patients maintained sinus rhythm. While the mean follow-up time of the bilateral thoracoscopy group was 5.0 months. Forty-seven (88.7%) patients maintained sinus rhythm. There was no perioperative death, or death, stroke, major bleeding nor pulmonary vein stenosis during follow-up. Conclusion The classic Cox-Maze Ⅳ procedure with high success rate is still the basic operation for the surgical treatment of atrial fibrillation, while the thoracoscopic mini maze procedure has the advantages of minimally invasiveness, repeatibility, and can achieve similar results as Cox-Maze Ⅳ procedure when combined with transcatheter radiofrequency ablation. Multidisciplinary therapy could be the best solution for non-paroxysmal atrial fibrillation.

Citation： QING Hongkun, LIU Jian, XIE Bin, ZHANG Yuyuan, FANG Liangzheng, LIU Fangzhou, XUE Yumei, ZHAN Xianzhang, FANG Xianhong, WU Shulin, GUO Huiming. Single center experience and approach evolution of multidisciplinary therapy for atrial fibrillation. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2018, 25(10): 849-854. doi: 10.7507/1007-4848.201802004 Copy

1.	Cox JL, Schuessler RB, D'Agostino HJ, et al. The surgical treatment of atrial fibrillation.Ⅲ. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg, 1991, 101(4): 569-83.
2.	Garcia-Villarreal OA, Fernández-Ceseña E, Vega-Hernández R. Cox maze Ⅲ procedure: The best alternative in surgery for atrial fibrillation. J Thorac Cardiovasc Surg, 2014, 148(1): 368-369.
3.	Johansson Bi, Väärt O, Edvardsson N, et al. Low mortality and low rate of perceived and documented arrhythmias after Cox Maze Ⅲ surgery for atrial fibrillation. Pacing Clin Electrophysiol, 2014, 37(2): 147-156.
4.	Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm, 2012, 9(4): 632-696.e21.
5.	Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace, 2006, 8(9): 651-745.
6.	January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation, 2014, 130(23): e199-e267.
7.	Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J, 2016, 37(38): 2893-2962.
8.	Shi J, Bai Z, Zhang B, et al. A modified Cox maze Ⅳ procedure: a simpler technique for the surgical treatment of atrial fibrillation. Interact Cardiovasc Thorac Surg, 2016, 23(6): 856-860.
9.	曹向戎, 孙广龙, 张富恩, 等. 双侧腋下小切口肺静脉隔离术治疗孤立性心房颤动. 临床外科杂志, 2014, 22(4): 293-295.
10.	Wolf RK, Schneeberger EW, Osterday R, et al. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg, 2005, 130(3): 797-802.
11.	马南, 姜兆磊, 尹航, 等. 单中心连续 353 例梅氏微创消融术经验和 2 年随访结果. 中华胸心血管外科杂志, 2015, 31(11): 670-673.
12.	Damiano RJ, Schwartz FH, Bailey MS, et al. The Cox maze Ⅳ procedure: Predictors of late recurrence. J Thorac Cardiovasc Surg, 2011, 141(1): 113-121.
13.	Henn MC, Lancaster TS, Miller JR, et al. Late outcomes after the Cox maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg, 2015, 150(5): 1168-1178.e2.
14.	Lawrance CP, Henn MC, Damiano RJ. Concomitant Cox-Maze IV techniques during mitral valve surgery. Ann Cardiothorac Surg, 2015, 4(5): 483-486.
15.	Lawrance CP, Henn MC, Miller JR, et al. Comparison of the stand-alone Cox-Maze IV procedure to the concomitant Cox-Maze IV and mitral valve procedure for atrial fibrillation. Ann Cardiothorac Surg, 2014, 3(1): 55-61.
16.	Philpott JM, Zemlin CW, Cox JL, et al. The ABLATE Trial: safety and efficacy of Cox Maze-Ⅳ using a bipolar radiofrequency ablation system. Ann Thorac Surg, 2015, 100(5): 1541-1548.
17.	Saint LL, Bailey MS, Prasad S, et al. Cox-Maze Ⅳ results for patients with lone atrial fibrillation versus concomitant mitral disease. Ann Thorac Surg, 2012, 93(3): 789-795.
18.	Weimar T, Schena S, Bailey MS, et al. The Cox-Maze procedure for lone atrial fibrillation: A single-center experience over 2 decades. Circ Arrhythm Electrophysiol, 2012, 5(1): 8-14.
19.	Boersma LVA, Castella M, van Boven W, et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): A 2-center randomized clinical trial. Circulation, 2012, 125(1): 23-30.
20.	Edgerton JR, Brinkman WT, Weaver T,et al. Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach. J Thorac Cardiovasc Surg, 2010, 140(4): 823-828.
21.	Edgerton JR, Jackman WM, Mack MJ. A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set. Ann Thorac Surg, 2009, 88(5): 1655-1657.
22.	Krul SP, Driessen AH, van Boven WJ, et al. Thoracoscopic video-assisted pulmonary vein antrum isolation, ganglionated plexus ablation, and periprocedural confirmation of ablation lesions: first results of a hybrid surgical-electrophysiological approach for atrial fibrillation. Circ Arrhythm Electrophysiol, 2011, 4(3): 262-270.
23.	Yilmaz A, Geuzebroek GSC, Van Putte BP, et al. Completely thoracoscopic pulmonary vein isolation with ganglionic plexus ablation and left atrial appendage amputation for treatment of atrial fibrillation. Eur J Cardiothorac Surg, 2010, 38(3): 356-360.
24.	Yilmaz A, Van Putte BP, Van Boven WJ. Completely thoracoscopic bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg, 2008, 136(2): 521-522.

1. Cox JL, Schuessler RB, D'Agostino HJ, et al. The surgical treatment of atrial fibrillation.Ⅲ. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg, 1991, 101(4): 569-83.
2. Garcia-Villarreal OA, Fernández-Ceseña E, Vega-Hernández R. Cox maze Ⅲ procedure: The best alternative in surgery for atrial fibrillation. J Thorac Cardiovasc Surg, 2014, 148(1): 368-369.
3. Johansson Bi, Väärt O, Edvardsson N, et al. Low mortality and low rate of perceived and documented arrhythmias after Cox Maze Ⅲ surgery for atrial fibrillation. Pacing Clin Electrophysiol, 2014, 37(2): 147-156.
4. Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm, 2012, 9(4): 632-696.e21.
5. Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: full text: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) Developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Europace, 2006, 8(9): 651-745.
6. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation, 2014, 130(23): e199-e267.
7. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J, 2016, 37(38): 2893-2962.
8. Shi J, Bai Z, Zhang B, et al. A modified Cox maze Ⅳ procedure: a simpler technique for the surgical treatment of atrial fibrillation. Interact Cardiovasc Thorac Surg, 2016, 23(6): 856-860.
9. 曹向戎, 孙广龙, 张富恩, 等. 双侧腋下小切口肺静脉隔离术治疗孤立性心房颤动. 临床外科杂志, 2014, 22(4): 293-295.
10. Wolf RK, Schneeberger EW, Osterday R, et al. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg, 2005, 130(3): 797-802.
11. 马南, 姜兆磊, 尹航, 等. 单中心连续 353 例梅氏微创消融术经验和 2 年随访结果. 中华胸心血管外科杂志, 2015, 31(11): 670-673.
12. Damiano RJ, Schwartz FH, Bailey MS, et al. The Cox maze Ⅳ procedure: Predictors of late recurrence. J Thorac Cardiovasc Surg, 2011, 141(1): 113-121.
13. Henn MC, Lancaster TS, Miller JR, et al. Late outcomes after the Cox maze IV procedure for atrial fibrillation. J Thorac Cardiovasc Surg, 2015, 150(5): 1168-1178.e2.
14. Lawrance CP, Henn MC, Damiano RJ. Concomitant Cox-Maze IV techniques during mitral valve surgery. Ann Cardiothorac Surg, 2015, 4(5): 483-486.
15. Lawrance CP, Henn MC, Miller JR, et al. Comparison of the stand-alone Cox-Maze IV procedure to the concomitant Cox-Maze IV and mitral valve procedure for atrial fibrillation. Ann Cardiothorac Surg, 2014, 3(1): 55-61.
16. Philpott JM, Zemlin CW, Cox JL, et al. The ABLATE Trial: safety and efficacy of Cox Maze-Ⅳ using a bipolar radiofrequency ablation system. Ann Thorac Surg, 2015, 100(5): 1541-1548.
17. Saint LL, Bailey MS, Prasad S, et al. Cox-Maze Ⅳ results for patients with lone atrial fibrillation versus concomitant mitral disease. Ann Thorac Surg, 2012, 93(3): 789-795.
18. Weimar T, Schena S, Bailey MS, et al. The Cox-Maze procedure for lone atrial fibrillation: A single-center experience over 2 decades. Circ Arrhythm Electrophysiol, 2012, 5(1): 8-14.
19. Boersma LVA, Castella M, van Boven W, et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): A 2-center randomized clinical trial. Circulation, 2012, 125(1): 23-30.
20. Edgerton JR, Brinkman WT, Weaver T,et al. Pulmonary vein isolation and autonomic denervation for the management of paroxysmal atrial fibrillation by a minimally invasive surgical approach. J Thorac Cardiovasc Surg, 2010, 140(4): 823-828.
21. Edgerton JR, Jackman WM, Mack MJ. A new epicardial lesion set for minimal access left atrial maze: the Dallas lesion set. Ann Thorac Surg, 2009, 88(5): 1655-1657.
22. Krul SP, Driessen AH, van Boven WJ, et al. Thoracoscopic video-assisted pulmonary vein antrum isolation, ganglionated plexus ablation, and periprocedural confirmation of ablation lesions: first results of a hybrid surgical-electrophysiological approach for atrial fibrillation. Circ Arrhythm Electrophysiol, 2011, 4(3): 262-270.
23. Yilmaz A, Geuzebroek GSC, Van Putte BP, et al. Completely thoracoscopic pulmonary vein isolation with ganglionic plexus ablation and left atrial appendage amputation for treatment of atrial fibrillation. Eur J Cardiothorac Surg, 2010, 38(3): 356-360.
24. Yilmaz A, Van Putte BP, Van Boven WJ. Completely thoracoscopic bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg, 2008, 136(2): 521-522.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Single center experience and approach evolution of multidisciplinary therapy for atrial fibrillation

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