Which Method to Use for Surgical Ablation of Atrial Fibrillation Performed Concomitantly with Mitral Valve Surgery: Radiofrequency Ablation <i>versus</i> Cryoablation

Vural, Ünsal; Balcı, Ahmet Yavuz; Ağlar, Ahmet Arif; Kızılay, Mehmet

doi:10.21470/1678-9741-2018-0130

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Brazilian Journal of Cardiovascular Surgery

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ORIGINAL ARTICLE • Braz. J. Cardiovasc. Surg. 33 (6) • Nov-Dec 2018 • https://doi.org/10.21470/1678-9741-2018-0130 copy

Which Method to Use for Surgical Ablation of Atrial Fibrillation Performed Concomitantly with Mitral Valve Surgery: Radiofrequency Ablation versus Cryoablation

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

The effects of energy source on the maintenance of sinus rhythm and the contribution of demographic characteristics to the case selection in patients submitted to ablation performed concurrently with mitral valve surgery were analyzed.

Methods:

Cryothermal (n=42; 43.8%) and radiofrequency (n=54; 56.3%) energy were employed in 96 patients submitted to mitral valve replacement and Cox maze IV procedure. Patients were called for control visits between 15 days and 12 months after discharge. The causal relationship between recurrence of atrial fibrillation and factors such as left atrial diameter, C-reactive protein, hypertension, left ventricular ejection fraction, chronic obstructive pulmonary disease, and body mass index was determined.

Results:

Maintenance rates of the sinus rhythm with radiofrequency and cryoablation were 97.6% and 96.3%, respectively, in the first postoperative month, whereas at the 12^th postoperative month were 88.1% and 83.3%. No significant difference was found between groups in relation to the energy source. Sensitivity and specificity for left atrial diameter with a cut-off value of 50.5 mm were 85.7% and 70.7%, respectively. Sensitivity and specificity for C-reactive protein with a cut-off value of 12 mg/dL on the 15^th postoperative day were 83.3% and 88.9%, respectively. The effect of body mass index on atrial fibrillation recurrence was 3.2 times. Sensitivity and specificity for left ventricular ejection fraction 37% cut-off value were 96.3% and 11.4%, respectively. Atrial fibrillation in hypertensive cases was 5.3 times more. In patients with chronic obstructive pulmonary disease, recurrence of atrial fibrillation was 40%. The causal relation between recurrence of atrial fibrillation and the studied factors was established.

Conclusion:

Demographic characteristics have a significant impact on ablation efficiency, while the type of energy source does not.

Keywords:
Mitral Valve/surgery; Cryosurgery; Catheter Ablation; Ablation; Ablation Techniques

Abbreviations, acronyms & symbols
AF	= Atrial fibrillation	ECG	= Electrocardiogram
ACC	= American College of Cardiology	EHRA	= European Heart Rhythm Association
AHA	= American Heart Association	ESC	= European Society of Cardiology
BMI	= Body mass index	HRS	= Heart Rhythm Society
COPD	= Chronic obstructive pulmonary disease	LVEF	= Left ventricular ejection fraction
CrA	= Cryothermal ablation	RFA	= Radiofrequency ablation
CRP	= C-reactive protein	ROC	= Receiver operating characteristic
ECAS	= European Cardiac Arrhythmia Society

		Ablation type
		RFA (n=54)		CrA (n=42)
		Mean	SD	Mean	SD	P-value
Age (years)		48	9	53	9	0.016^a a =independent t-test;
Left atrium diameter (mm)		48.98	5.45	49.05	5.72	0.954^a a =independent t-test;
Intensive Care Unit (days)		1	1	1	__	0.145^a a =independent t-test;
Hospitalization (days)		6	1	6	1	0.509^a a =independent t-test;
Aortic cross-clamping time (min)		63	12	68	11	0.035^a a =independent t-test;
Total cardiopulmonary bypass time (min)		66	10	83	10	0.001^a a =independent t-test;
Left ventricular ejection fraction (%)		48.78	6.52	50.07	6.13	0.325^a a =independent t-test;
Preoperative CRP (mg/dL)		4.6	1.6	4.5	1.5	0.864^a a =independent t-test;
		n	%	n	%
Body mass index (kg/m²)	<25	25	54.3	21	45.7	0.395^a a =independent t-test;
	25-29	20	55.6	16	44.4
	30-35	6	54.5	5	45.5
	>35	3	100	__	__
Gender	Female	24	48	26	52	0.089^b b =Chi-square test; Fisher's exact test, continuity correction test.
Gender	Male	30	65.2	16	34.8
Surgical procedure	MVR	29	65.9	15	34.1	0.079^b b =Chi-square test; Fisher's exact test, continuity correction test.
Surgical procedure	MVR+TDVGA	25	48.1	27	51.9
Previous stroke	Unavailable	52	55.9	41	44.1	0.712^b b =Chi-square test; Fisher's exact test, continuity correction test.
Previous stroke	Available	2	66.7	1	33.3
Postoperative pacemaker	Unavailable	53	55.8	42	44.2	0.375^b b =Chi-square test; Fisher's exact test, continuity correction test.
Postoperative pacemaker	Available	1	100	__	__
Chronic obstructive pulmonary disease	Unavailable	47	54.7	39	45.3	0.356^b b =Chi-square test; Fisher's exact test, continuity correction test.
Chronic obstructive pulmonary disease	Available	7	70	3	30
New York Heart Association functional class	I	10	41.7	14	58.3	0.13^a a =independent t-test;
	II	30	60	20	40
	III	14	63.6	8	36.4
	IV	__	__	__	__
Hypertension	Unavailable	45	55.6	36	44.4	0.75^b b =Chi-square test; Fisher's exact test, continuity correction test.
Hypertension	Available	9	60	6	40

		AF status
		Unavailable		Available		P-value
		Mean	SD	Mean	SD	P-value
Age (years)		50	9	50	10	0.921^a a =independent t test;
Left atrium diameter (mm)		48.1	5.11	54.36	5.06	0.001^a a =independent t test;
Intensive Care Unit (days)		1	1	1	1	0.685^a a =independent t test;
Hospitalization (days)		6	1	6	1	0.843^a a =independent t test;
Aortic cross-clamping time (min)		64	11	68	14	0.236^a a =independent t test;
Cardiopulmonary bypass time (min)		75	13	68	16	0.08^a a =independent t test;
Left ventricular ejection fraction (%)		50.44	5.85	42.93	5.46	0.001^a a =independent t test;
		n	%	n	%
Body mass index (kg/m²)	<25	46	100	__	__	0.001^a a =independent t test;
	25-29	27	75	9	25
	30-35	9	81.8	2	18.2
	>35	__	__	3	100
Gender	Woman	43	86	7	14	0.872^b b =Chi-square, Fisher's exact test, continuity correction test
Gender	Man	39	84.8	7	15.2
Surgical procedure	MVR	35	79.5	9	20.5	0.137^b b =Chi-square, Fisher's exact test, continuity correction test
Surgical procedure	MVR+TDVGA	47	90.4	5	9.6
Previous stroke	Unavailable	79	84.9	14	15.1	0.472^b b =Chi-square, Fisher's exact test, continuity correction test
Previous stroke	Available	3	100	__	__
Postoperative pacemaker	Unavailable	81	85.3	14	14.7	0.682^b b =Chi-square, Fisher's exact test, continuity correction test
Postoperative pacemaker	Available	1	100	__	__
Chronic obstructive pulmonary disease	Unavailable	76	88.4	10	11.6	0.016^b b =Chi-square, Fisher's exact test, continuity correction test
Chronic obstructive pulmonary disease	Available	6	60	4	40
New York Heart Association functional class	I	23	95.8	1	4.2	0.343^a a =independent t test;
	II	40	80	10	20
	III	19	86.4	3	13.6
	IV	__	__	__	__
Hypertension	Unavailable	74	91.4	7	8.6	0.001^b b =Chi-square, Fisher's exact test, continuity correction test
Hypertension	Available	8	53.3	7	46.7
Ablation type	RFA	45	83.3	9	16.7	0.517^b b =Chi-square, Fisher's exact test, continuity correction test
Ablation type	CrA	37	88.1	5	11.9
CRP¹ b =Chi-square, Fisher's exact test, continuity correction test (mg/dL)	Postoperative	65.2	26.4	84.5	7.5	0.266^a a =independent t test;
	15^th postoperative day	9.3	6.9	16.4	8.9	0.003^a a =independent t test;
	1^st postoperative month	2.7	1.2	5.1	1.0	0.001^a a =independent t test;

Authors’ roles & responsibilities
ÜV	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published
AYB	Final approval of the version to be published
AAA	Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published
MK	Drafting the work or revising it critically for important intellectual content; final approval of the version to be published

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[1] Correspondence Address: Ünsal Vural, Selimiye Mh. Tibbiye Cd. No:13, 34668 - Uskudar, Istanbul, Turkey. E-mail: unsalvural@gmail.com