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Permanent chronic atrial fibrillation: is pulmonary vein isolation alone enough?
Wilfried Wisser1, Gernot Seebacher, Tatjana Fleck
1Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria. wilfried.wisser@meduniwien.ac.at
Insights
The left atrial endocardial maze procedure is more effective than pulmonary vein isolation alone for treating permanent chronic atrial fibrillation. This surgical ablation technique offers superior long-term freedom from atrial fibrillation.
Area of Science:
- Cardiology
- Cardiac Surgery
- Electrophysiology
Background:
- Evaluating the efficacy of epicardial pulmonary vein isolation versus left atrial endocardial maze for permanent chronic atrial fibrillation.
- Assessing surgical ablation techniques in treating complex cardiac arrhythmias.
Purpose of the Study:
- To compare the effectiveness of left atrial endocardial maze with pulmonary vein isolation for permanent chronic atrial fibrillation.
- To determine the optimal surgical strategy for long-term management of chronic atrial fibrillation.
Main Methods:
- Retrospective analysis of 72 patients undergoing left atrial maze procedures (January 2003-December 2005).
- Group I: Endocardial ablation (n=29) using unipolar irrigated RF. Group II: Epicardial pulmonary vein isolation (n=43) using bipolar irrigated RF.
- Concomitant valve and/or coronary procedures performed. Follow-up included ECG and echocardiography at 6 and 12 months.
Main Results:
- Mean follow-up was 19.5 months. No procedure-related mortality.
- Freedom from atrial fibrillation at follow-up was 85.7% for endocardial maze (Group I) vs. 58.5% for pulmonary vein isolation (Group II) (p=0.016).
- Pacemaker implantation rates were similar between groups (10.3% Group I vs. 11.6% Group II).
Conclusions:
- Pulmonary vein isolation alone is insufficient for treating permanent chronic atrial fibrillation.
- Left atrial endocardial maze, including connections to the mitral annulus and/or pulmonary veins, is essential for chronic permanent atrial fibrillation.
- Surgical maze procedures demonstrate superior efficacy in achieving long-term sinus rhythm.
Background:
The efficacy of mere pulmonary vein isolation epicardially for the treatment of permanent chronic atrial fibrillation, in comparison with the left atrial endocardial maze procedure was evaluated.
Methods:
Retrospective data collection and analysis toward the outcome of 72 consecutive patients who underwent left atrial maze procedures between January 2003 and December 2005 was performed. Surgical ablation was performed concomitantly with valve and (or) coronary procedures. Group I (n = 29) received an endocardial left atrial ablation using unipolar saline irrigated radiofrequency (Medtronic Cardioblate surgical ablation pen; Medtronic Inc, Minneapolis, MN). Group II (n = 43) received epicardial isolation of the pulmonary veins using bipolar saline irrigated radiofrequency (Medtronic Cardioblate). Follow-up included 24h electrocardiogram and echocardiography 6 and 12 months postoperatively.
Results:
Mean follow-up was 19.5 +/- 1.0 months (17.7 +/- 19.5 months group I vs 20.6 +/- 1.1 months group II). Both groups were comparable with regard to duration of preoperative atrial fibrillation, European system for cardiac operative risk evaluation, left ventricular ejection fraction, aortic cross-clamp time, bypass time, intensive care unit and hospital stay (p > 0.05). No maze procedure-related mortality was observed. In group I, three patients required postoperative pacemaker implantation due to atrioventricular (AV) bloc, bradycardia, and sick sinus syndrome, respectively. In group II, five patients required postoperative pacemaker implantation (three AV bloc and two bradycardia). Freedom from atrial fibrillation at last follow-up was 85.7% and 58.5% in groups I and II, respectively (p = 0.016).
Conclusions:
Pulmonary vein isolation alone seems to be insufficient in treating permanent chronic atrial fibrillation. In case of chronic permanent atrial fibrillation, left atrial endocardial maze, providing the connection lines to the mitral annulus and (or) between the pulmonary veins, seems to be mandatory.
