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  •    Add-on arrhythmia surgery does not add to sinus rhythm conversion or the quality-of-life after open heart surgery
    Sunthosh Parvathaneni MD, University Hospitals Case Medical Center, Case Western Reserve University, Harrington-McLaughlin Heart & Vascular Institute, Cleveland, Ohio.

    Atrial Fibrillation (AF), chronic or paroxysmal, is an entity that creates significant morbidity, through stroke, and mortality as well as a diminished quality of life. The desirable therapeutic goal is to induce sinus rhythm and therefore avoiding long-term anticoagulation, reducing thromboembolic risk, enhancing cardiac performance, survival, and perhaps even health related quality of life (which can be assessed on 4 domains: physical condition, psychological well-being, social activities, and activity of daily living).  Over the years, definitive treatment options were developed, such as pulmonary vein isolation (PVI), wide area circumferential ablation (WACA), and limited left atrial ablation techniques. 

    In patients receiving valvular or coronary surgery, the prevalence of AF is about 5-40% and successful add-on arrhythmia surgery can be of great benefit. Even though improved quality of life is one of the aims of invasive arrhythmia management, reports on successful treatment is limited to small nonrandomized trials.  Van Breugel et al. 2010, however, conducted a multicenter randomized trial comparing the effect of add-on epicardial pulmonary vein isolation (EPVI) and standard surgery on the maintenance of sinus rhythm and health related quality of life in patients with paroxysmal, permanent, and persistent AF.

    The authors evaluated 150 patients who underwent a prospective, randomized clinical multicenter trial, specifically assessing rhythm outcome, morbidity and mortality in the two treatment strategies, add-on EPVI (epicardial off-pump beating heart ablation) or “surgery as usual,” for patients with AF undergoing valvular and/or coronary surgery.  Patients and all involved medical personnel were blinded to group assignment. To be enrolled in the trial, all patients required a history of AF, either paroxysmal or persistent, for a minimum of 3 months prior to scheduled surgery. Patients that had underlying conduction disease such as Sick Sinus Syndrome or had a contraindication to anticoagulation were excluded.  Health related quality of life, through EuroQoL (EQ-5D), RAND 36 Item Health Survey (SF-36), Multidimensional Fatigue Inventory (MFI-20) questionnaires, and maintenance of sinus rhythm was assessed at 1 year post-intervention in intervals of 3, 6, and 12 months via ECG and at 12 months a 24 holter monitor was prescribed. All atrial arrhythmias during this period were treated by the patient’s personal Cardiologist through rate control and cardioversion.  The Cardiologist, of course, was blinded to which arm the patient belonged.

    At the 12 month follow up, 62 patients remained free of AF without a significant difference between the two treatment arms, add-on EPVI and “surgery as usual” (p = 0.28).  Furthermore, 69.8% of patients with PAF converted to sinus rhythm whereas only 28.2% and 44.4% converted to sinus rhythm in patients with permanent and persistent AF.  In terms of health related quality of life, cardiac surgery overall resulted in improvement.  Not surprisingly, the EQ-5D showed an increase in pain for both treatment arms (p < 0.001 and p = 0.006).

    In summary, health related quality of life improved in patients with AF after cardiac surgery, irrespective of add-on arrhythmia surgery. This likely reflects the fact that the preoperative impaired quality of life in this patient population was due to the underlying pathological heart disease rather than AF. This study also reinforces the fact that patient selection is very important in identifying patients who would benefit from AF ablation.

    References:

    1. Van Breugel HN, Nieman FH, Accord RE, Van Mastrigt GA, Nijs JF, Severens JL, Vrakking R; Maessen JG: A prospective randomized multicenter comparison on health-related quality of life: The value of add-on arrhythmia surgery in patients with paroxysmal, permanent or persistent atrial fibrillation undergoing valvular and/or coronary bypass surgery. J Cardiovasc Electrophysiol 2010; 21: 511-520.

    2. Pappone C, Rosanio S, Augello G, Gallus G, Vicedomini G, Mazzzone P, Gulletta S, Gugliotta F, Pappone A, Santinelli V, Tortoriello V, Sala S, Zangrillo A, Crescenzi G, Benussi S; Alfieri O: Mortality, morbidity, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation: Outcomes from a controlled nonrandomized long-term study. J Am Coll Cardiol 2003; 42: 185-197.

    3. Luderitz B, Jung W: Quality of life in atrial fibrillation. J Interv Card Electrophysiol 2000; 4(suppl 1): 201-209.

    4. Brooks R: Quality of life measures. Crit Care Med 1996; 24: 1769.

    5. Smets EM, Garssen B, Bonke B, De Haes JC: The multidimensional fatigue inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res 1995; 39: 315-325.

    6. McHorney CA, Ware JE, Raczek AE: The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care 1993; 31: 247-263.

    7. Suwalski P, Suwalski G, Doll N, Majstrak F, Kurowski A, Suwalski KB: Epicardial beating heart “off-pump” ablation of atrial fibrillation in non-mitral valve patients using new irrigated bipolar radiofrequency technology. Ann Thorac Surg 2006; 82: 1876-1879.


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