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. 2022 Sep 21:12:137-146.
doi: 10.1016/j.xjon.2022.08.014. eCollection 2022 Dec.

Hybrid ablation of persistent and long-standing persistent atrial fibrillation with depressed ejection fraction: A single-center observational study

Armin Kiankhooy  1 , Carolyn Pierce  1 , Shelby Burk  1 , Andrew Phillips  2 , Susan Eisenberg  3 , Gansevoort Dunnington  1
Affiliations

Hybrid ablation of persistent and long-standing persistent atrial fibrillation with depressed ejection fraction: A single-center observational study

Armin Kiankhooy et al. JTCVS Open. .

Abstract

Objective: The relationship between atrial fibrillation (AF) and heart failure with depressed ejection fraction (EF) is complex. AF-related tachycardia-mediated cardiomyopathy (TMC) can lead to worsening EF and clinical heart failure. We sought to determine whether a hybrid team ablation approach (HA) can be performed safely and restore normal sinus rhythm in patients with TMC and heart failure and to delineate the effect on heart failure.

Methods: We retrospectively analyzed patients with nonparoxysmal (ie, persistent and long-standing persistent) AF-related TMC with depressed left ventricular EF (LVEF ≤40%) and heart failure (New York Heart Association [NYHA] class ≥2) who underwent HA between 2013 and 2018 and had at least 1 year of follow-up. Pre-HA and post-HA echocardiograms were compared for LVEF and left atrial (LA) size. Rhythm success was defined as <30 seconds in AF/atrial flutter/atrial tachycardia without class I or III antiarrhythmic drugs. Results are expressed as mean ± SD and 95% confidence interval (CI) of the mean.

Results: Forty patients met the criteria for inclusion in our analysis. The mean patient age was 67 ± 9.4 years. The majority of patients had long-standing persistent AF (26 of 40; 65%), and the remainder had persistent AF (14 of 40; 35%). All patients had NYHA class II or worse heart failure (NYHA class II, 36 of 40 [90%]; NYHA class III, 4 of 40 [10%]). The mean time in AF pre-HA was 5.6 ± 6.7 years. All patients received both HA stages. No deaths or strokes occurred within 30 days. Three new permanent pacemakers (7.5%) were placed. Rhythm success was achieved in >60% of patients during a mean 3.5 ± 1.9 years of follow-up. LVEF improved significantly by 12.0% ± 12.5% (95% CI, 7.85%-16.0%; P < .0001), and mean LA size decreased significantly by 0.40 cm ± 0.85 cm (95% CI, 0.69-0.12 cm; P < .01), with a mean of 3.0 ± 1.5 years between pre-HA and post-HA echocardiography. NYHA class improved significantly after HA (mean pre-HA NYHA class, 2.1 ± 0.3 [95% CI, 2.0-2.2]; mean post-HA NYHA class, 1.5 ± 0.6 [95% CI, 1.3-1.7]; P < .0001).

Conclusions: Thoracoscopic HA of AF in selected patients with TMC heart failure is safe and can result in rhythm success with structural heart changes, including improvements in LVEF and LA size.

Keywords: AAD, antiarrhythmic drug; AF, atrial fibrillation; AFL, atrial flutter; AT, atrial tachycardia; CA, catheter ablation; HA, hybrid ablation; LA, left atrium/atrial; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; PV, pulmonary vein; TMC, tachycardia-mediated cardiomyopathy; arrythmia surgery; heart failure; hybrid ablation; left ventricular ejection fraction; tachycardia-mediated cardiomyopathy.

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Figures

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Graphical abstract
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Hybrid ablation of atrial fibrillation with depressed ejection fraction can lead to significant improvement in ejection fraction.
Figure 1
Figure 1
Rhythm results with hybrid ablation in patients with heart failure at 1-, 2-, and 3-year follow-ups: <30 seconds of atrial fibrillation (AF)/atrial flutter (AFL)/atrial tachycardia (AT) (dark green), electrocardiography (ECG) in normal sinus rhythm (NSR) off antiarrhythmic drugs (AADs) (light green), 0% AF burden but >30 seconds of AT (blue), ECG in NSR with AAD (orange), paroxysmal AF (black and white pattern), continuous AF/AFL/AT (black), and reintervention with direct-current cardioversion (DCCV) or catheter ablation (CA) (white). DCCV, Direct-current cardioversion; CA, catheter ablation; AF, atrial fibrillation; AFL, atrial flutter; AT, atrial tachycardia; NSR, normal sinus rhythm; AAD, antiarrhythmic drugs; EKG, electrocardiogram; CAM, continuous ambulatory monitor.
Figure 2
Figure 2
Kaplan–Meier freedom from atrial fibrillation (AF) recurrence (red) with 95% confidence intervals. Freedom from AF recurrence is defined as <30 seconds of AF, atrial flutter, or atrial tachycardia. AF, Atrial fibrillation.
Figure 3
Figure 3
Left ventricular ejection fraction (LVEF) in patients with tachycardia-mediated cardiomyopathy (TMC) and heart failure pre- and post-hybrid ablation (HA) of atrial fibrillation (AF). EF, Ejection fraction.
Figure 4
Figure 4
Left atrial (LA) size (cm) in patients with tachycardia-mediated cardiomyopathy and heart failure pre- and post-hybrid ablation of atrial fibrillation. LA, Left atrial.
Figure 5
Figure 5
New York Heart Association (NYHA) classification improvement after hybrid ablation (HA). NYHA, New York Heart Association; HA, hybrid ablation.
Figure E1
Figure E1
Diagram of hybrid ablation. Red lines represent lesions created during first-stage epicardial ablation (bilateral pulmonary vein [PV] isolation, interconnecting lines [roof and floor]—left atrial [LA] “box,” LA appendage to left superior PV [coumadin ridge], and mitral isthmus). Green lines represent lesions created during the second-stage endocardial ablation (completion of the mitral isthmus, cava-tricuspid isthmus, and any additional ablation needed to complete the posterior wall and PV isolation). Ganglionic plexi are also ablated during the epicardial ablation. LA, Left atrial; SVC, superior vena cava; IVC, inferior vena cava.
Figure E2
Figure E2
Rhythm results with hybrid ablation in patients with tachycardia-mediated cardiomyopathy (TMC) and TMC-ischemia (TMC-I): <30 seconds of atrial fibrillation (AF)/atrial flutter (AFL)/atrial tachycardia (AT) (dark green), electrocardiography (ECG) in normal sinus rhythm (NSR) off antiarrhythmic drugs (AADs; light green), 0% AF burden but >30 seconds AT (blue), ECG in NSR with AAD (orange), paroxysmal AF (black and white pattern), continuous AF/AFL/AT (black), and reintervention with direct-current cardioversion (DCCV) or catheter ablation (CA; asterisks). Red boxes show patient numbers. CAM, continous ambulatory monitor; AF, atrial fibrillation; AFL, atrial flutter; AT, atrial tachycardia; AAD, antiarrhythmic drugs; EKG, electrocardiogram; NSR, normal sinus rhythm; DCCV, Direct-current cardioversion; CA, catheter ablation; TMC, tachycardia-mediated cardiomyopathy; LVEF, left ventricular ejection fraction.
Figure E3
Figure E3
Simple logistic regression analysis of time in atrial fibrillation (AF) (A) and left atrial (LA) size (B) to predict rhythm success at 1 year. AF, Atrial fibrillation; AFIB, atrial fibrillation; LA, left atrial.
Figure E4
Figure E4
Structural heart changes of hybrid ablation in patients with tachycardia-mediated cardiomyopathy (TMC) and TMC with ischemia (TMC-I). LVEF, Left ventricular ejection fraction; LA, left atrial; TMC, tachycardia-mediated cardiomyopathy.
Figure E5
Figure E5
Patient Flow Diagram. LVEF, Left ventricular ejection fraction; ECHO, echocardiogram; F/u, follow up; NYHA, New York Heart Association.
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