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Surgical ablation for the treatment of atrial fibrillation in different patient populations: A study of clinical outcomes including rhythm, quality of life, atrial function and safety
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Cardiology-Arrhythmia.ORCID iD: 0000-0003-3950-1171
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Patients with atrial fibrillation (AF) have markedly reduced quality of life (QoL) and catheter ablation has become a useful tool in the rhythm control therapy. However, because of the poor outcome for patients with persistent AF, new surgical ablation strategies for rhythm control are emerging.

The aims of this thesis were to evaluate QoL, the main indication for rhythm control, after three different types of surgical ablation for AF, two stand-alone epicardial AF ablation procedures and one concomitant procedure during mitral valve surgery (MVS), and to perform a long-term follow-up of one of the techniques with regard to rhythm outcome, left atrial function, exercise capacity and safety.

As the first center in the Nordic countries to adopt the video-assisted epicardial pulmonary vein isolation and ganglionated plexi ablation combined with left atrial appendage excision (LAA), the  freedom from AF at one year follow-up was found to be 71% and associated with improved exercise capacity, QoL and symptoms as well as preserved left atrial function and size. The most common complication was bleeding events (14%). After 10 years, the improved symptoms and QoL remained, reaching comparable levels of the general Swedish population, despite a marked decline in the rate of freedom from AF (36%). 4 strokes appeared during follow-up despite LAA excision in 3 of these patients.

In order to improve the rhythm outcome for patients with longstanding persistent AF a box-lesion was added to the procedure. At one year follow-up, both symptoms and QoL improved and was indistinguishable from those in the Swedish general population.

Finally, concomitant AF ablation during MVS did not improve QoL compared to MVS alone in a double blinded randomized controlled trial. Moreover, no difference was seen between patients in AF or sinus rhythm at one year follow-up, irrespective of the allocated therapy, indicating that their preoperative symptoms were mainly related to their valve disease.

In conclusion, the stand-alone procedures using surgical ablation was found to be effective but at the expense of procedural complications. In contrast, the concomitant surgical AF ablation did not improve QoL, a finding that raises concerns regarding current recommendations for this procedure. 

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. , p. 111
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1418
Keywords [en]
Atrial fibrillation, surgical ablation, quality of life, vagal denervation, ganglionated plexi, left atrial function, epicardial, minimally invasive, left atrial ablation
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
URN: urn:nbn:se:uu:diva-338097ISBN: 978-91-513-0207-2 (print)OAI: oai:DiVA.org:uu-338097DiVA, id: diva2:1173871
Public defence
2018-03-02, Enghoffsalen, Akademiska Sjukhuset, ingång 50, bv, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2018-02-12 Created: 2018-01-14 Last updated: 2018-02-14Bibliographically approved
List of papers
1. Epicardial off-pump pulmonary vein isolation and vagal denervation improve long-term outcome and quality of life in patients with atrial fibrillation
Open this publication in new window or tab >>Epicardial off-pump pulmonary vein isolation and vagal denervation improve long-term outcome and quality of life in patients with atrial fibrillation
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2009 (English)In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 137, no 5, p. 1265-1271Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: The limited information available on thoracoscopic pulmonary vein isolation combined with ganglionated plexi ablation and the lack of studies regarding its effect on quality of life and physical capacity urged us to study its acute and long-term results in patients with atrial fibrillation. METHODS: Forty-three patients (mean age 57.1 years) with symptomatic atrial fibrillation referred for thoracoscopic off-pump epicardial pulmonary vein isolation and ganglionated plexi ablation using radiofrequency energy were included. RESULTS: The physical capacity improved significantly at 6-month follow-up compared with baseline (mean +/- standard deviation, 165.2 +/- 65 Watt versus 155.9 +/- 57 Watt, P = .02). Quality of life (Short Form-36 health survey) significantly improved 12 months after surgery compared with baseline in all subscales except for bodily pain. The symptom severity questionnaire score decreased significantly from mean 15.2 +/- 4.0 points to 10.7 +/- 4.8 points (P = .02). Overall, 25 of 33 patients (76%) followed up for 12 months had no symptomatic atrial fibrillation recurrences or atrial fibrillation episodes on 24-hour Holter recordings. The corresponding figures were 79% (19/24) for patients with paroxysmal atrial fibrillation, 100% (2/2) for persistent atrial fibrillation, and 57% (4/7) for permanent atrial fibrillation. The most common complication was bleeding events (9%) during pulmonary vein dissection. CONCLUSIONS: Epicardial off-pump pulmonary vein isolation combined with ganglionated plexi ablation improved quality of life, symptoms, and exercise capacity and therefore may be considered for patients with atrial fibrillation who fail endocardial pulmonary vein ablation or as a first-line procedure if left atrial appendage exclusion is warranted.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-103119 (URN)10.1016/j.jtcvs.2008.12.017 (DOI)000265299000034 ()19380002 (PubMedID)
Available from: 2009-05-14 Created: 2009-05-14 Last updated: 2018-01-14Bibliographically approved
2. Left atrial function after epicardial pulmonary vein isolation in patients with atrial fibrillation
Open this publication in new window or tab >>Left atrial function after epicardial pulmonary vein isolation in patients with atrial fibrillation
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2017 (English)In: Journal of interventional cardiac electrophysiology (Print), ISSN 1383-875X, E-ISSN 1572-8595, Vol. 50, no 2, p. 195-201Article in journal (Refereed) Published
Keywords
left atrial function; epicardial; atrial fibrillation; left atrial size; minimally invasive; pulmonary vein isolation; vagal denervation; ganglionated plexi
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
urn:nbn:se:uu:diva-338090 (URN)10.1007/s10840-017-0290-2 (DOI)000416448400007 ()29127542 (PubMedID)
Funder
Swedish Research Council, 2014-36708-117759-70Swedish Heart Lung Foundation, 20150751
Available from: 2018-01-07 Created: 2018-01-07 Last updated: 2018-03-19Bibliographically approved
3. Quality of life is not improved after mitral valve surgery combined with epicardial left atrial cryoablation as compared with mitral valve surgery alone: a substudy of the double blind randomized SWEDish Multicentre Atrial Fibrillation study (SWEDMAF)
Open this publication in new window or tab >>Quality of life is not improved after mitral valve surgery combined with epicardial left atrial cryoablation as compared with mitral valve surgery alone: a substudy of the double blind randomized SWEDish Multicentre Atrial Fibrillation study (SWEDMAF)
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2017 (English)In: Europace, ISSN 1099-5129, E-ISSN 1532-2092Article in journal (Refereed) Epub ahead of print
Keywords
concomitant surgical ablation; mitral valve surgery; atrial fibrillation; quality of life; ablation;
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
urn:nbn:se:uu:diva-338091 (URN)10.1093/europace/eux253 (DOI)
Available from: 2018-01-07 Created: 2018-01-07 Last updated: 2018-02-14Bibliographically approved
4. 10 years follow-up of video-assisted epicardial pulmonary vein isolation and vagal denervation in patients with atrial fibrillation
Open this publication in new window or tab >>10 years follow-up of video-assisted epicardial pulmonary vein isolation and vagal denervation in patients with atrial fibrillation
(English)In: Article in journal (Other academic) Submitted
Keywords
Atrial fibrillation; epicardial; pulmonary vein isolation; qualiy of life; minimally invasive; vagal denervation; ganglionated plexi
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
urn:nbn:se:uu:diva-338092 (URN)
Available from: 2018-01-07 Created: 2018-01-07 Last updated: 2018-02-14
5. A Prospective Study of the Effects of Thoracoscopic Epicardial Left Atrial Ablation on Symptoms and Quality of Life: A comparison with the normal Swedish population and other severe disease states
Open this publication in new window or tab >>A Prospective Study of the Effects of Thoracoscopic Epicardial Left Atrial Ablation on Symptoms and Quality of Life: A comparison with the normal Swedish population and other severe disease states
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(English)Manuscript (preprint) (Other academic)
Keywords
Atrial fibrillation; quality of life; thoracoscopic; epicardial; left atrial ablation;
National Category
Cardiac and Cardiovascular Systems
Research subject
Cardiology
Identifiers
urn:nbn:se:uu:diva-338093 (URN)
Available from: 2018-01-07 Created: 2018-01-07 Last updated: 2018-01-15

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