Purse-String Pv Box Isolation: A Less Invasive Modified Maze Procedure For Non-Mitral Atrial Fibrillation

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1 Purse-String Pv Box Isolation: A Less Invasive Modified Maze Procedure For Non-Mitral Atrial Fibrillation T. Taguchi, K. Imai, M. Watanabe, H. Kodama, K. Katayama, S. Takahashi, T. Kurosaki, T. Sueda Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima, Japan Introduction: We have developed purse-string pulmonary box isolation (ppbvi) for atrial fibrillation (AF) without mitral valve disease (MVD). Methods: Nine non-mvd paroxysmal AF (paf) cases (3 ASD, 3 AVR 1 TVR and 2 OPCAB) were received ppvbi. Box ablation line was created by using bipolar radiofrequency device with bilateral epicardial PV isolation line and upper and lower connecting line (Fig.), without incision of left atrial wall using purse-string technique. All patients were received continuous monitor ECG (in hospital) and Holter ECG of every 6 month (after discharge). Results: At discharge, freedom from AF was 89%. In the patients of AF free at discharge, 100% of patients were free from paf at averaged more than 12 months follow-up. Conclusions: ppvbi can be a less invasive and effective procedure for non-mvd paf.

2 Oesophageal Injury After Convergent Procedure For Treatment Of Atrial Fibrillation M. Jan, M. Cvijić, R. Juvan, T.P. Kalin ek, K. Rupar, B. Geršak Cardiovascular Surgery Department, University Medical Center Ljubljana, Ljubljana, Slovenia Introduction: Convergent procedure (CP) includes high energy left atrial (LA) radiofrequency ablation (RFA) which may result in oesophageal injury due to tissue overheating. Our aim was to assess postprocedural oesophageal injury. Methods: A retrospective study included 61 patients [age years, 48 (78.7%) male] that underwent CP for treatment of atrial fibrillation. Procedure included epicardial LA RFA combined with endocardial catheter RFA for pulmonary vein isolation. Precautions were taken to avoid oesophageal overheating (infusion of cooled saline into the pericardial space during epicardial ablations, monitoring of oesophageal temperature). All patients had endoscopy of the oesophagus 2 days after CP. Patients were followed for 3 to 62 months. Results: 5 patients (8%) had redness of the mucosa in the part of the oesophagus that was adjacent to the posterior wall of the LA, in 4 of those patients repeat endoscopy showed complete healing of the injuries. Patients had no complications related to oesophageal injury during the time of follow up. Conclusions: Rate of postprocedural oesophageal injury after convergent procedure was low. Only transient redness of the oesophageal mucosa was seen, which did not result in serious complications.

3 Comparison Of Short-Term Outcome Of Convergent Procedure And Catheter Ablation For Treatment Of Patients With Paroxysmal Atrial Fibrillation M. Jan, M. Cvijić, K. Rupar, B. Geršak Cardiovascular Surgery Department, University Medical Center Ljubljana, Ljubljana, Slovenia Introduction: Catheter ablation (CA) is increasingly used as an effective treatment for the paroxysmal atrial fibrillation (PAF). Our aim was to compare short term (6 months) outcome of convergent procedure (CP) and CA. Methods: A single center, prospective, randomized study comparing outcomes after CP and CA for the treatment of PAF was initiated. Twenty-eight patients (aged 60±8.6 years; 75% (21) males; average PAF duration 4.9±4.1 years) were enrolled in this study (14 CP and 14 CA). Patients were implanted with loop recorders. Rhythm status was evaluated 6 months after the procedure; patients with atrial fibrillation (AF) burden less than 0.3% were considered to be free of AF. Results: There were no significant differences in baseline characteristics for both groups. Six months post procedure more patients from the CP group were free of AF (CP group vs. CA group; 85.7% (12) vs. 57.1% (8); p=0.03). Conclusions: After short-term follow-up more patients treated for paroxysmal AF were free of AF after convergent procedure compared to catheter ablation.

4 Hybrid Two-Step Approach In Treatment Of Patients With Coronary Artery Disease And Atrial Fibrillation A. Kovalev, S. Kovalev, L. Bokeria, A. Filatov, D. Gryaznov 1 Laboratory of intraoperative diagnosis and treatment of arrhythmias, Bakoulev Center for Cardiovascular Surgery, Moscow, Russian Federation. 2 Interregional Cardiac surgery department, Voronezh state hospital #1, Voronezh, Russian Federation The aim of the study was to compare the efficacy of simultaneous CABG and MAZE procedure and hybrid two-step approach with endocardial box lesion ablation Methods: The two-center clinical cohort study was held in and includes 96 patients with CAD and persistent AF. All patients underwent CABG procedure. The first group (58 patient) also passed through simultaneous MAZE-4 procedure. In the second group (38) endocardial ablation with the help of electroanatomical mapping of CFAE areas was held not later than 3 months after CABG. Follow-up was 2 years. All patients were on AAT for 3-6 months after the procedure. Results: Hospital efficacy in group 1 was 81% (47 patients), in group 2 78,9% (30 patients). In the end of study efficacy was 77,6% and 71% respectively (p=0,658); cumulative HR was 0,99 (0,64;2,05) and 1,2 (0,77;2,73); NYHA I-II was in 70,7% and 68,4%; freedom from TIA was 94,8% (OR 4,5 (0,6;34,51)) and 86,8% (OR 7,14 (0,83;73,64)). Total mortality was 1,04%. Conclusions: Hybrid two-step approach is AS effective as MAZE-4 in patients with CAD and CABG procedure.

5 Improved Procedural Efficacy Of Pulmonary Vein Isolation Using The Novel Second-Generation Cryoballoon. M. Maines, D. Catanzariti, C. Angheben, M. Del Greco Department of Cardiology, Santa Maria del Carmine Hospital, Rovereto, Italy Purpose: The cryoballoon technology has the potential to isolate a pulmonary vein (PV) with a single energy application. However, using the first-generation cryoballoon (CB1) repeated freezing is often necessary. The novel second-generation cryoballoon (CB2) features a widened zone of optimal cooling comprising the whole frontal hemisphere. The aim of this study was to investigate the impact of the novel CB2 on procedural efficacy of cryoballoon PV isolation (CB-PVI). Methods and Results: CB-PVI using a single big balloon (28 mm) and an endoluminal mapping catheter (Achive-Medtronic) was performed in 46 consecutive patients with paroxysmal or short-term persistent atrial fibrillation: 23 with the CB1 (300 seconds application time) and 23 with the CB2 ( seconds application time). When compared to the CB1, using the CB2 increased single-shot PVI rate from 56% to 85% (P < 0.01) and decreased procedure duration (190 ± 26 vs 139 ± 32 minutes; P < 0.01), and fluoroscopy exposure time (35.7 ± 8.3 vs 23.4 ± 5.4 min; P = 0.01). Time to PVI was shorter in the CB2 group (68 ± 28 vs. 49 ± 26 second). The need of pull-down maneuver also evaluated with intracardiac echo decreased from 16% in the CB1 to 4% in the CB2. Conclusions: the CB2 significantly improved procedural efficacy compared to the CB1.

6 Seven Years Of Cryo-Ballon Catheter Ablation. Follow-Up Analysis, Results, Recurrences, Complications And Side Effects In Patients Treated For Paroxysmal Atrial Fibrillation, With A Prospective Protocol Guided By Complete Bidirectional Left Atrium-Pulmonary Veins Disconnection After Adenosine As Main Target End Point. A Single Center Report. J.M. Paylos, C. Ferrero, L. Azcona, A. Morales, M.A. Vargas, L. Lacal, C.M. Cilleros, T.G. Delange Arrhythmia Unit and Electrophysiology Lab. Moncloa University Hospital. European University of Madrid, Madrid, Spain Introduction: Cryo-balloon catheter ablation technique (CB) has demonstrated been useful to treat patients with Paroxysmal Atrial Fibrillation (PAF). We analyzed our seven years follow-up experience of our patients, initially treated with CB for PAF, with demonstration of complete bidirectional electrical isolation (CBEI) of the pulmonary veins (PV) from the left atrium (LA) after Adenosine as the main target end point to achieve, in all cases. Methods: Since Nov to May-2015, a cohort of 104 patients (pts.) (81 Male and 23 Female, mean age 53 ± 13 and 62 ± 9 years, respectively), with not structural heart disease, were treated for PAF with CB. Years evolution of Arrhythmia: 5 ± 5. Number of episodes / year: 62 ± 69. Follow-up time: 1347 ± 623 days. All previously treated with antiarrhythmic: ßß (85%), class III (2%), 1C class (89%) ßß + 1C (76%). Morphological and structural data are shown in Table. Results: A total of 394 PV and 22 common trunks (CT) were treated only with CB and CBEI demonstrated in 353 (89.5%). Acute reconduction post CB showed 41 PV (10.4%): 14 residual conduction (GAP), 12 extrapulmonary muscular connections (EMC) and 15 dormant tissue unmasked by Adenosine, all eliminated with RF. Side effects and complications: Aphonia: 6 pts (5.7%). Phrenic paresia: 7 (6.7%). Phrenic palsy: 2 (1.9%). Pulmonary infiltrates: 5 (4.8%). Dyspepsia: 2 (1.9%). Bronchospasm: 2 (1.9%). Intra-nodal reentry: 2 (1.9%). In-hospital arrhythmia: 1 (0.9%). In 45 ± 21 months follow-up, 91 pts (87.5%) remain asymptomatic, in sinus rhythm, free of medication. Thirteen pts. (12.5%) had clinical recurrence: 11 M mean age 52 ± 8 years and 2 F 63 ± 13 years. Early recurrences occurred when medication stopped after three months blanking-period in 9 male. Late recurrences presented two male at 24 and 27 months and 2 female at 7 and 40 months respectively. All recurrences were REDO, and PV-LA reconduction demonstrated in all cases. From these 13 REDO cases, 6 showed reconduction in the basal procedure, in a different segment location unrelated with the acute GAP. In a follow up of 30 ± 17 months, all 13 REDO pts remained in sinus rhythm without medication. Conclusions: CB technique alone is very effective for the definitive treatment of PAF, with 87.5% of Pts, remaining in sinus rhythm, free of arrhythmia, without medication, in a very long-term follow-up, when this CBEI protocol in a prospective manner is applied, being this serie the largest follow-up described, so far. LA Diameter (mm) LA/AREA (cm²) AP:37±6 (21-50) 22±4 (15-26) LAT: 47±7 (35-61) SI: 54±7 (40-75) PV (mm) CT LVEF AP:18±5 (8-32) SI: 20±4 (10-28) AP: 26±6 (18-35) SI: 26±5 (17-31) 67±5% (59-79)

7 Cryo-Balloon Catheter Ablation Efficacy Restoring And Maintaining Sinus-Rhythm In Patients Treated For Persistent Long Standing Atrial Fibrillation After Acute Complete Electrical Isolation Of The Pulmonary Veins J.M. Paylos, C. Ferrero, L. Azcona, A. Morales, M. A. Vargas, L. Lacal, V. Gomez-Tello Arrhythmia Unit and Electrophysiology Lab. Moncloa Hospital. European University of Madrid. Madrid, Spain Introduction: Cryo-balloon catheter ablation (CB) has proven effective in the definitive treatment of paroxysmal atrial fibrillation However, the isolated efficacy of CB restoring and maintaining sinus rhythm in patients with persistent long standing atrial fibrillation (AF) is less knowed in a medium -long terms follow-up. We analyzed the acute results and the medium-long term follow-up of our patients suffering AF and initially treated with CB. Methods: A total of 35 patients (28 male (80%) and 7 female (17%), mean age 59 ±11 and 64±5 years respectively with AF were treated with CB. The mean time duration of stable arrhythmia was 4±3 years (2-11). PV/LA morphological and structural data are shown in table 1. Results: Are showed in table 2. Conclusions: CB technique is useful to treat persistent long standing Atrial Fibrillation with 46% success rate maintaining sinus rhythm without medication at 2,5 years, increasing by 23% to 69% when antiarrhythmic drugs are added. Patients without Structural Heart Disease along with those who sinus rhythm was restored during CB showed the best results. Table 1: Morphological and structural LA/PV and LV data. Without structural heart disease. (28 patients) (7 patients) Diameters (mm) AP 40±4 (33-49) SI 24±5 (42-70) LAT 47±7 (41-66) LA PV LCT LVEF Diameters (mm) 20±5 (14-28) 21±4 (9-32) 28±2 (25-29) 31±3 (30-35) 68%±6 AP 43±5 (34-48) LA/Area (cm²) 24±5 (14-36) SI 60±4 (55-65) LAT 50±7 (43-60) LA PV LCT LVEF 18±5 (14-28) 22±5 (16-32) 27 63%±5 30 LA/Area (cm²) 28±3 (24-33) Table 2: Results Follow-up mean period duration: 2.5 years (9-80 month) Arrhythmia Recurrence Maintenance of Sinus Rhythm 11 Patients (31%) 24 Patients (69%) 7 (Structural Heart Disease) 4 (No Structural Heart Disease) 8 (23%) with medication 16 (46%) without drugs 7 SR restored during CB