Cor Vasa 2017, 59(4):e367-e375 | DOI: 10.1016/j.crvasa.2017.06.016

Arrhythmia recurrence in patients following cardiac surgery with concomitant therapy of atrial fibrillation - experience of our cardiac center

Marek Janotka^*, Jan Škoda, Jan Petrů, Lucie Šedivá, Milan Chovanec, Štěpán Černý, Petr Pavel, Martin Michel, Ivo Skalský, Miroslava Benešová, Petr Neužil

Kardiocentrum, Nemocnice Na Homolce, Praha, Česká republika

Introduction: Surgical treatment of atrial fibrillation (AF) is a common and time-proven treatment method for this type of arrhythmias both as a separate procedure and as a procedure related to cardiac surgery for another indication (concomitant procedure). Patients experience arrhythmia recurrence despite highly efficient surgical treatment. These arrhythmias are often resistant to pharmacological treatment (due to an extensive fibrous substrate); therefore, electroanatomical mapping accompanying catheter ablation is significantly more effective. The arrhythmogenic fibrous substrate is a result of both a primary cardiac disease (an underlying disease causing atrial dilation) and surgical intervention (incision, cannula insertion sites, MAZE lines with a renewed spread of electrical signal in these blocks).
Method and patients: Electroanatomical mapping and ablation were performed in 92 patients with arrhythmia recurrence following concomitant surgical treatment for AF between January 2010 and November 2015. The Cox-MAZE procedure was performed using a disposable cryoablation catheter. The heart rhythm in patients following radiofrequency ablation procedure was monitored in half-year intervals (24-hour Holter ECG, 7-day loop recorder, in some patients also by means of implanted pacemakers or implantable loop recorders). The average left atrial size (PLAX) was 50 mm, 59% of patients underwent mitral valve surgery, 54% of patients had tricuspid valve surgery, 16% were operated for congenital developmental disorders, in 17% of patients, repeated cardiac surgery was performed. The above-mentioned facts show that these are patients with an extensive arrhythmogenic substrate.

Results: The Cox-MAZE procedure resulted in an extensive fibrous arrhythmogenic substrate in the atrium (arrhythmia recurrence following the MAZE procedure is more often regular atrial tachycardias while AF is predominant among arrhythmias for which the MAZE procedure was indicated). All patients had a follow-up visit after 12 months, 80% of patients presented for a follow-up visit after 24 months. Early recurrence after ablation (within 3 months following the procedure) was found in 21% of patients. Early recurrence after ablation was statistically significantly related to arrhythmia recurrence within 12 months (p = 0.003) and arrhythmia recurrence within 24 months (p = 0.003). 73% of patients had no recurrent AF or atrial tachycardia (AT) after 12 months and 53% after 24 months. A total of 146 arrhythmias were ablated, i.e. one third of patients had more than one arrhythmia. These were persistent AF found in 24% of patients, paroxysmal AF seen in 13% of patients and regular AT detected in 53% of patients. More than one half of regular AT originated in LA (as perimitral atrial flutter in most cases). Remaining arrhythmias originated from the right atrium (as typical atrial flutter in half of the cases). 57% of patients had a renewed spread of signal in the mitral isthmus (ablation of the coronary sinus was necessary in one third of patients). No domination in the number of reconnections was found for any of the pulmonary veins. The finding of a significantly reduced signal amplitude in the entire LA was associated with a higher risk of acute ablation failure (p = 0.001). Acute ablation failure was associated with a higher risk of arrhythmia recurrence after 12 months (p = 0.07). There was a trend of a higher AT incidence originating from the RA in patients who underwent surgery for a congenital heart defect (p = 0.06). The diagnosis of arterial hypertension was associated with a higher risk of arrhythmia recurrence (p = 0.13). The finding of persistent AF on ECG (compared to other findings, i.e. paroxysmal AF and regular AT) before ablation did not increase the risk of recurrence after ablation.

Conclusion: In patients after cardiac surgery, catheterization performed to treat arrhythmia recurrence is an effective method of subsequent treatment, despite an extensive arrhythmogenic substrate. A rather large number of AT cases originate from the right atrium, in particular in patients after surgery for congenital heart defects. Patients with a significantly reduced signal in the larger part of the atrium due to an extensive arrhythmogenic substrate present the most complicated cases.

Keywords: Arrhythmogenic substrate; Atrial fibrillation; Atrial tachycardia; Concomitant; Electroanatomic mapping; MAZE; Radiofrequency ablation

Received: March 5, 2017; Revised: June 27, 2017; Accepted: June 29, 2017; Published: August 1, 2017  Show citation