PREOPERATIVE BETA‐BLOCKER USE REDUCES ATRIAL FIBRILLATION IN OFF‐PUMP CORONARY BYPASS SURGERY Effectiveness of Bi-atrial Pacing for Reducing Atrial Fibrillation after Coronary Artery Bypass Graft Surgery Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study† 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation Right atrial pacing for prevention of postoperative atrial fibrillation following coronary artery bypass grafting: a prospective observational trial. Surgical ablation of atrial fibrillation during mitral-valve surgery. Prevention of atrial fibrillation after cardiac valvular surgery by epicardial, biatrial synchronous pacing. Predictors of Atrial Fibrillation After Conventional and Beating Heart Coronary Surgery: A Prospective, Randomized Study A randomized clinical trial of early invasive intervention for atrial fibrillation (EARLY-AF) - methods and rationale. The role of ascorbic acid in the prevention of atrial fibrillation after elective on-pump myocardial revascularization surgery: a single-center experience--a pilot study. Left atrial radiofrequency ablation during cardiac surgery in patients with atrial fibrillation. Feasibility and efficacy of minimally invasive stand-alone surgical ablation of atrial fibrillation. A single-center experience Systematic Review Protocol: surgical ablation for atrial fibrillation during mitral valve surgery. Catheter ablation of atrial fibrillation in patients with atrial septal defect: long-term follow-up results Short-term sinus rhythm predicts long-term sinus rhythm and clinical improvement after intraoperative ablation of atrial fibrillation. Effective prevention of atrial fibrillation by continuous atrial overdrive pacing after coronary artery bypass surgery. Mitral valve surgery plus concomitant atrial fibrillation ablation is superior to mitral valve surgery alone with an intensive rhythm control strategy.
Background : Atrial fibrillation ( AF ) after coronary artery bypass graft surgery constitutes the most common sustained arrhythmia and results in many complications . The purpose of this study was to assess the effects of prophylactic use of beta‐blockers against atrial fibrillation in off‐pump surgery patients in the early postoperative period Atrial fibrillation ( AF )  is common after cardiac surgery and adds significant cost and morbidity . The use of prophylactic pacing strategies to prevent post-operative AF has been controversial . We previously performed a pilot study which suggested that the combination of beta-blockers and bi-atrial pacing ( BAP ) may reduce AF after cardiac surgery . We prospect ively r and omized 118 patients to continuous BAP for up to 96 hours post-operatively versus st and ard therapy .  All patients were treated with beta-blockers as tolerated . Patients were paced in the AAI mode at a rate of 100 pulses per minute . The primary endpoint of the study was the occurrence of sustained AF ( > 10 minutes).There was a significant reduction in the incidence of AF in the BAP group among patients undergoing coronary artery bypass graft surgery with or without aortic valve replacement ( 35 % vs. 19 % AF ; OR=0.38 , 95 % CI 0.15 , 0.93 ; p < 0.05 ) . Including patients undergoing isolated aortic valve surgery ( n=7 ) , there remained a strong trend toward a reduction of AF with pacing ( no atrial pacing [ NAP ] vs. BAP ; 35 % vs. 21 % AF ; OR=0.48 , 95 % CI 0.21 , 1.11 ; p=0.08 ) . Patients age 70 or greater benefited most from pacing ( NAP vs. BAP ; 55 vs. 25 % AF ; p<0.05 ) , while those less than 70 years of age did not ( 17 vs. 18 % p = NS ) . There was a significant reduction in the amount of time spent in the intensive care unit among patients receiving BAP ( 50±40 vs. 37±25[emsp4 ] h ; p<0.05).BAP together with beta-blockade after coronary artery bypass graft surgery reduces the incidence of post-operative atrial AF .  Elderly patients ( age 70 or greater ) appear to benefit most , and may be a group to whom this therapy should be targeted Aims Surgical ablation procedure can restore sinus rhythm ( SR ) in patients with atrial fibrillation ( AF ) undergoing cardiac surgery . However , it is not known whether it has any impact on long-term clinical outcomes . Methods and results This multicentre study r and omized 224 patients with AF scheduled for valve and /or coronary surgery : group A  ( left atrial surgical ablation , n = 117 ) vs. group B  ( no ablation , n = 107 ) . The primary efficacy outcome was the SR presence ( without any AF episode ) during a 24 h electrocardiogram ( ECG )  after 1 year . The primary safety outcome was the combined endpoint of death/myocardial infa rct ion/stroke/renal failure at 30 days . A Holter-ECG after 1 year revealed SR in 60.2 % of group A patients vs. 35.5 % in group B ( P = 0.002 ) . The combined safety endpoint at 30 days occurred in 10.3 % ( group A ) vs. 14.7 % ( group B , P = 0.411 ) . All-cause 1-year mortality was 16.2 % ( A ) vs. 17.4 % ( B , P = 0.800 ) . Stroke occurred in 2.7 % ( A ) vs. 4.3 % ( B ) patients ( P = 0.319 ) . No difference ( A vs. B ) in SR was found among patients with paroxysmal ( 61.9 vs. 58.3 % ) or persistent ( 72 vs. 50 % ) AF , but ablation significantly increased SR prevalence in patients with longst and ing persistent AF ( 53.2 vs. 13.9 % , P < 0.001 ) . Conclusion Surgical ablation improves the likelihood of SR presence post-operatively without increasing peri-operative complications . However , the higher prevalence of SR did not translate to improved clinical outcomes at 1 year . Further follow-ups ( e.g. 5-year ) are warranted to show any potential clinical benefit which might occur later During the past three decades , catheter and surgical ablation of  atrial fibrillation ( AF ) have evolved from investigational procedures to their current role as effective treatment options for patients with AF .  Surgical ablation of AF , using either st and ard , minimally invasive , or hybrid techniques , is available in most major hospitals throughout the world . Catheter ablation of AF is even more widely available , and is now the most commonly performed catheter ablation procedure . In 2007 , an initial Consensus Statement on Catheter and Surgical AF Ablation was developed as a joint effort of the Heart Rhythm Society ( HRS ) , the European Heart Rhythm Association ( EHRA ) , and the European Cardiac Arrhythmia Society (ECAS).1 The 2007 document was also developed in collaboration with the Society of Thoracic Surgeons ( STS ) and the American College of Cardiology ( ACC ) . This Consensus Statement on Catheter and Surgical AF Ablation was rewritten in 2012 to reflect the many advances in AF ablation that had occurred in the interim.2 The rate of advancement in the tools , techniques , and outcomes of AF ablation continue to increase as enormous research efforts are focused on the mechanisms , outcomes , and treatment of AF . For this reason , the HRS initiated an effort to rewrite and up date this Consensus Statement . Reflecting both the worldwide importance of AF , as well as the worldwide performance of AF ablation , this document is the result of a joint partnership between the HRS , EHRA , ECAS , the Asia Pacific Heart Rhythm Society ( APHRS ) , and the Latin American Society of Cardiac Stimulation and Electrophysiology ( Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia [ SOLAECE ] ) . The purpose of this 2017 Consensus Statement is to provide a state-of-the-art review of the field of catheter and surgical ablation of AF and to report the findings of a writing group , convened by these five international societies . The writing group is charged with defining the indications , techniques , and outcomes of AF ablation procedures . Included within this document are recommendations pertinent to the design of clinical trials in the field of AF ablation and the reporting of outcomes , including definitions relevant to this topic . The writing group is composed of 60 experts representing 11 organizations : HRS , EHRA , ECAS , APHRS , SOLAECE , STS , ACC , American Heart Association ( AHA ) , Canadian Heart Rhythm Society ( CHRS ) , Japanese Heart Rhythm Society ( JHRS ) , and Brazilian Society of Cardiac Arrhythmias ( Sociedade Brasileira de Arritmias Cardiacas [ SOBRAC ] ) . All the members of the writing group , as well as peer review ers of the document , have provided disclosure statements for all relationships that might be perceived as real or potential conflicts of interest . All author and peer review er disclosure information is provided in Appendix A and Appendix B. In writing a consensus document , it is recognized that consensus does not mean that there was complete agreement among all the writing group members . Surveys of the entire writing group were used to identify areas of consensus concerning performance of AF ablation procedures and to develop recommendations concerning the indications for catheter and surgical AF ablation . These recommendations were systematic ally balloted by the 60 writing group members and were approved by a minimum of 80 % of these members . The recommendations were also subject to a 1-month public comment period . Each partnering and collaborating organization then officially review ed , commented on , edited , and endorsed the final document and recommendations . The grading system for indication of class of evidence level was adapted based on that used by the ACC and the AHA.3,4 It is important to state , however , that this document is not a guideline . The indications for catheter and surgical ablation of AF , as well as recommendations for procedure performance , are presented with a Class and Level of Evidence ( LOE ) to be consistent with what the reader is familiar with seeing in guideline statements . A Class I recommendation means that the benefits of the AF ablation procedure markedly exceed the risks , and that AF ablation should be performed ; a Class IIa recommendation means that the benefits of an AF ablation procedure exceed the risks , and that it is reasonable to perform AF ablation ; a Class IIb recommendation means that the benefit of AF ablation is greater or equal to the risks , and that AF ablation may be considered ; and a Class III recommendation means that AF ablation is of no proven benefit and is not recommended . The writing group review ed and ranked evidence supporting current recommendations with the weight of evidence ranked as Level A if the data were derived from high- quality evidence from more than one r and omized clinical trial , meta-analyses of high- quality r and omized clinical trials , or one or more r and omized clinical trials corroborated by high- quality registry studies . The writing group ranked available evidence as Level B-R when there was moderate- quality evidence from one or more r and omized clinical trials , or meta-analyses of moderate- quality r and omized clinical trials . Level B-NR was used to denote moderate- quality evidence from one or more well- design ed , well-executed nonr and omized studies , observational studies , or registry studies . This design ation was also used to denote moderate- quality evidence from meta-analyses of such studies . Evidence was ranked as Level C-LD when the primary source of the recommendation was r and omized or nonr and omized observational or registry studies with limitations of design or execution , meta-analyses of such studies , or physiological or mechanistic studies of human subjects . Level C-EO was defined as expert opinion based on the clinical experience of the writing group . Despite a large number of authors , the participation of several societies and professional organizations , and the attempts of the group to reflect the current knowledge in the field adequately , this document is not intended as a guideline . Rather , the group would like to refer to the current guidelines on AF management for the purpose of guiding overall AF management strategies.5,6 This consensus document is specifically focused on catheter and surgical ablation of AF , and summarizes the opinion of the writing group members based on an extensive literature review as well as their own experience . It is directed to all health care professionals who are involved in the care of patients with AF , particularly those who are caring for patients who are undergoing , or are being considered for , catheter or surgical ablation procedures for AF , and those involved in research in the field of AF ablation . This statement is not intended to recommend or promote catheter or surgical ablation of AF . Rather , the ultimate judgment regarding care of a particular patient must be made by the health care provider and the patient in light of all the circumstances presented by that patient . The main objective of this document is to improve patient care by providing a foundation of knowledge for those involved with catheter ablation of AF . A second major objective is to provide recommendations for design ing clinical trials and reporting outcomes of clinical trials of AF ablation . It is recognized that this field continues to evolve rapidly . As this document was being prepared , further clinical trials of catheter and surgical ablation of AF were under way INTRODUCTION Atrial fibrillation ( AF ) is the most common complication after coronary artery bypass grafting ( CABG ) . Conventional clinical practice is to treat AF after its onset in the postoperative period . However effective prophylaxis can result in reduced morbidity and hospital stay . This prospect i ve study was design ed to assess the efficacy of right atrial pacing in the prevention of postoperative AF following CABG . METHODS All patients who had isolated first time CABG on cardiopulmonary bypass between January 2007 and June 2007 , operated by one surgeon were included in this study ( study group ) . During the same period , isolated CABG carried out by other surgeons in the same unit and not paced served as control ( control group ) . In the study group ( n=24 ) right atrial pacing was continued for 96h in the postoperative period . The end points of the study were occurrence of AF , death in postoperative period or discharge from hospital . RESULTS In the study group 5 patients could not be paced because of persistent tachycardia or failure of atrial electrodes . There was a statistically significant reduction in the incidence of postoperative atrial fibrillation from 31.1 % in control group to 5.2 % ( p-value 0.03 ) in patients who were paced . CONCLUSIONS The preliminary results of this study suggest that prophylactic right atrial pacing significantly reduced the incidence of AF following CABG . However these results need to be confirmed in a larger cohort of patients in a prospect i ve r and omised trial BACKGROUND Among patients undergoing mitral-valve surgery , 30 to 50 % present with atrial fibrillation , which is associated with reduced survival and increased risk of stroke .  Surgical ablation of atrial fibrillation has been widely adopted , but evidence regarding its safety and effectiveness is limited . METHODS We r and omly assigned 260 patients with persistent or long-st and ing persistent atrial fibrillation who required mitral-valve surgery  to undergo either surgical ablation ( ablation group ) or no ablation ( control group ) during the mitral-valve operation . Patients in the ablation group underwent further r and omization to pulmonary-vein isolation or a biatrial maze procedure . All patients underwent closure of the left atrial appendage . The primary end point was freedom from atrial fibrillation at both 6 months and 12 months ( as assessed by means of 3-day Holter monitoring ) . RESULTS More patients in the ablation group than in the control group were free from atrial fibrillation at both 6 and 12 months ( 63.2 % vs. 29.4 % , P<0.001 ) . There was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrial maze procedure ( 61.0 % and 66.0 % , respectively ; P=0.60 ) . One-year mortality was 6.8 % in the ablation group and 8.7 % in the control group ( hazard ratio with ablation , 0.76 ; 95 % confidence interval , 0.32 to 1.84 ; P=0.55 ) . Ablation was associated with more implantations of a permanent pacemaker than was no ablation ( 21.5 vs. 8.1 per 100 patient-years , P=0.01 ) . There were no significant between-group differences in major cardiac or cerebrovascular adverse events , overall serious adverse events , or hospital readmissions . CONCLUSIONS The addition of atrial fibrillation ablation to mitral-valve surgery significantly increased the rate of freedom from atrial fibrillation at 1 year among patients with persistent or long-st and ing persistent atrial fibrillation , but the risk of implantation of a permanent pacemaker was also increased . ( Funded by the National Institutes of Health and the Canadian Institutes of Health Research ; Clinical Trials.gov number , NCT00903370 . ) OBJECTIVE  Postoperative atrial fibrillation ( AF )  after cardiac surgery is a frequent complication after valvular surgery ( 30 - 60 % ) . The purpose of this prospect i ve , r and omized study was to determine if biatrial synchronous pacing reduces postoperative AF after cardiac valvular surgery as compared to conventional therapy . METHODS Eighty patients subjected to valvular surgery ( 52 men , age 66 + /- 10 years ) were r and omized to one of two groups : one group was treated with biatrial , synchronous pacing ( BAP ) for 72 h postoperatively ( n=40 ) the other group received no atrial pacing ( controls ; n=40 ) . All patients had one pair of epicardial wires attached to the right atrium . An additional electrode was placed to the left atrium in the BAP group . These patients were continuously paced at a rate of 10 beats per minute higher than the intrinsic rate starting immediately after surgery . All patients were monitored with full disclosure telemetry or Holter monitors to identify onset of AF . RESULTS Eighteen of the 40 patients in the control group ( 45 % ) developed AF within the first 3 days postoperatively as compared to eight patients ( 20 % ) in the BAP group ( P=0.02 ) . No complications occurred associated with the placement , maintenance and removal of the atrial pacing electrodes . CONCLUSIONS Temporary , biatrial synchronous pacing during the first 3 postoperative days is safe and has a significant rhythm-stabilizing effect in patients undergoing valvular cardiac surgery Background  Atrial fibrillation ( AF )  increases the morbidity of CABG . The pathophysiology is uncertain , and its prevention remains suboptimal . This prospect i ve , r and omized study was design ed to define the role of cardiopulmonary bypass ( CPB ) and cardioplegic arrest in the pathogenesis of this complication . Methods and Results Two hundred patients were prospect ively r and omized to ( 1 ) on-pump conventional surgery [ ( 100 patients , 79 men , mean age 63 ( 40 to 77 ) years ) ] with normothermic CPB and cardioplegic arrest of the heart or ( 2 ) off-pump surgery [ ( 100 patients , 82 men , mean age 63 ( 38 to 86 ) years ) ] on the beating heart .  Heart rate and rhythm were continuously monitored with an automated arrhythmia detector during the first 72 hours after surgery . Thereafter , routine clinical observation was performed and continuous monitoring restarted in the case of arrhythmia . The association of perioperative factors with AF was investigated by univariate analysis . Significant variables were then included into a stepwise logistic regression model to ascertain their independent influence on the occurrence of AF . There were no significant baseline differences between groups . Thirty-nine patients in the on-pump group and 8 patients in the off-pump group had postoperative sustained AF ( P = 0.001 ) . Univariate analysis showed that CPB inclusive of cardioplegic arrest , postoperative inotropic support , intubation time , chest infection , and hospital length of stay were predictors of AF ( all P < 0.05 ) . However , stepwise multivariate regression analysis identified CPB inclusive of cardioplegic arrest as the only independent predictor of postoperative AF ( OR 7.4 ; CI 3.4 to 17.9 ) . Conclusions CPB inclusive of cardioplegic arrest is the main independent predictor of postoperative AF in patients undergoing coronary revascularization BACKGROUND The ideal management of patients with newly diagnosed symptomatic atrial fibrillation ( AF ) remains unknown . Current practice guidelines recommend a trial of antiarrhythmic drugs ( AAD ) prior to considering an invasive ablation procedure . However , earlier ablation offers an opportunity to halt the progressive patho-anatomical changes associated with AF , as well as impart other important clinical benefits . OBJECTIVE The aim of this study is to determine the optimal initial management strategy for patients with newly diagnosed , symptomatic atrial fibrillation . METHODS / DESIGN The EARLY-AF study ( Clinical Trials.govNCT02825979 ) is a prospect i ve , open label , multicenter , r and omized trial with a blinded assessment of outcomes . A total of 298 patients will be r and omized in a 1:1 fashion to first-line AAD therapy , or first-line cryoballoon-based pulmonary vein isolation .  Patients with symptomatic treatment naïve AF will be included . Arrhythmia outcomes will be assessed by implantable cardiac monitor ( ICM ) . The primary outcome is time to first recurrence of AF , atrial flutter , or atrial tachycardia ( AF/AFL/AT ) between days 91 and 365 following AAD initiation or AF ablation . Secondary outcomes include arrhythmia burden , quality of life , and healthcare utilization . DISCUSSION The EARLY-AF study is a r and omized trial design ed to evaluate the optimal first management approach for patients with AF . We hypothesize that catheter ablation will be superior to drug therapy in prevention of AF recurrence Atrial fibrillation ( AF ) is a common arrhythmia that occurs postoperatively in cardiac surgery . There is evidence for the role of oxidative stress in the etiology of AF . In our study , we examined whether antioxidant ascorbic acid ( vitamin C ) , could help in the reduction of the incidence of postoperative AF . Patients who were scheduled to undergo elective isolated on-pump coronary artery bypass grafting ( CABG ) were included in our study . One hundred and seventy patients were r and omly divided in two groups : Group A ( n=85 ) received vitamin C preoperatively and postoperatively whereas Group B ( n=85 ) did not receive any ( control group ) . The incidence of AF was 44.7 % in the vitamin C group and 61.2 % in the control group ( P=0.041 ) . The hospitalization time , the intensive care unit stay and the time interval for the conversion of AF into sinus rhythm was significantly shorter in the vitamin C group . Patients that developed AF also had longer hospital length of stay ( 9.5±2.8 days vs. 6.7±1.9 , P=0.034 ) . Supplementation of vitamin C reduces the incidence of postCABG AF , and decreases the time needed for rhythm restoration and length of hospital stay INTRODUCTION Intraoperative left atrial radiofrequency ( RF ) ablation recently has been suggested as an effective surgical treatment for atrial fibrillation ( AF ) . The aim of this study was to verify the outcome of this technique in a controlled multicenter trial . METHODS AND RESULTS One hundred three consecutive patients ( 39 men and 65 women ; age 62 + /- 11 years ) affected by AF underwent cardiac surgery and RF ablation in the left atrium ( RF group ) . The control group consisted of 27 patients ( 6 men and 21 women ; age 64 + /- 7 years ) with AF who underwent cardiac surgery during the same period and refused RF ablation .  Mitral valve disease was present in 89 ( 86 % ) and 25 ( 92 % ) patients , respectively ( P = NS ) . RF endocardial ablation was performed in order to obtain isolation of both right and left pulmonary veins , a lesion connecting the previous lines , and a lesion connecting the line encircling the left veins to the mitral annulus . Upon discharge from the hospital , sinus rhythm was present in 65 patients ( 63 % ) versus 5 patients ( 18 % ) in the control group ( P < 0.0001 ) . Mean time of cardiopulmonary bypass was longer in the RF group ( 148 + /- 50 min vs 117 + /- 30 min , P = 0.013 ) . The complication rate was similar in both groups , but RF ablation-related complications occurred in 4 RF group patients ( 3.9 % ) . After a mean follow-up of 12.5 + /- 5 months ( range 4 - 24 ) , 83 ( 81 % ) of 102 RF group patients were in stable sinus rhythm versus 3 ( 11 % ) of 27 in the control group ( P < 0.0001 ) . The success rate was similar among the four surgical centers . Atrial contraction was present in 66 ( 79.5 % ) of 83 patients in the RF group in sinus rhythm . CONCLUSION Endocardial RF left atrial compartmentalization during cardiac surgery is effective in restoring sinus rhythm in many patients . This technique is easy to perform and reproducible . Rare RF ablation-related complications can occur . During follow-up , sinus rhythm persistence is good , and biatrial contraction is preserved in most patients Purpose Minimally invasive surgical ablation for atrial fibrillation ( AF ) has shown good results and low complications incidence . Our objective was to evaluate feasibility and efficacy of this technique in our center . Methods The procedure included pulmonary vein isolation , ganglionic plexi ablation , ligament of Marshall resection , and left atrial appendage exclusion through beating heart minimally invasive bilateral thoracotomies . Patients were monitored daily by telemedicine during the first 4 months and then by quarterly 24-h Holter monitoring or by implantable cardiac monitor . Ablation success was defined as freedom from any atrial tachyarrhythmia recurrence lasting more than 30 s and from antiarrhythmic drugs . All patients were followed up for a minimum of 12 months . Results Twenty-two consecutive patients with AF , paroxysmal in 27 % and persistent in 73 % , were treated . Mean age was 63 ± 10 years , 86 % were men . Seventy-three percent of patients had previously undergone to one or more catheter ablations . Median follow-up period was 22 months ( 25 ° –75 ° percentile , 20–27 ) . Patients free from any arrhythmia recurrence for at least 6 consecutive months discontinued antiarrhythmic therapy . Ablation was successful in 73 % of patients at 12 months . Freedom from AF recurrences independently from antiarrhythmic therapy status was 91 % at 12 months . Results were consistent in patients that reached 24 months follow-up . There were no deaths . Complications were : one conversion to sternotomy owing to thoracic adherences , one pacemaker implant , and one postoperative hemothorax requiring surgical revision . Conclusions Our results show that minimally invasive surgical ablation was feasible and gave satisfactory results at long-term term follow-up in patients with AF R and omized controlled trials comparing atrial fibrillation patients who underwent concomitant mitral valve surgery and surgical ablation , versus mitral valve surgery alone  , will be included . Six electronic data bases including MEDLINE , EMBASE , PubMed , Cochrane Central Register of Controlled Trials , Cochrane Data base of Systematic Review s , and Data base of Abstract s of Review s of Effectiveness will be search ed for original published studies . The reference lists of all retrieved articles will be review ed to further identify potentially relevant r and omized controlled studies . Experimental or observational studies will be included in the present review . Only studies in English will be included . Case reports , series with less than ten patients , abstract s , editorials , and expert opinions will be excluded . Two review ers will independently appraise the studies using a st and ard form , and extract data based on methodology , quality criteria , and outcome measures . All data will be extracted and tabulated from the relevant articles ’ texts , tables , and figures and checked by an additional review er . The studies will be assessed qualitatively using tools design ed to measure the risk of bias , as recommended by the Cochrane Collaboration ( Oxford , United Kingdom ) Introduction Atrial fibrillation ( AF ) is commonly found in patients with structural heart disease ( SHD ) , including atrial septal defect ( ASD ) . The feasibility and safety of ablation for AF in patients with unrepaired ASD is seldom reported . Objectives This study aims to evaluate and compare the long-term efficacy of  AF ablation  in patients with and without ASD . Methods From January 2008 to December 2012 , 18 consecutive patients were identified with medically refractory AF and an unrepaired ASD under catheter ablation .  For each ASD patient , four control subjects were matched from our data base . Results There were no significant differences between groups in terms of age , sex , type of AF , LA diameter , LVIDD , and EF . The mean procedural and fluoroscopy times were not different between the groups ( p = NS ) . After a median follow-up of 20 months , the patients in the ASD group had 44.4 % AF recurrence after a single procedure compared with 34.7 % in the control group ( p = 0.11 ) . The mean LA diameter in non-recurrent patients was smaller than in recurrent patients ( p = 0.03 ) . In univariate Cox proportional hazards analyses , the factor found to have a significant association with arrhythmia recurrences was left atrial diameter ( hazard ratio 1.059 , 95 % confidence interval 1.002 to 1.120 , p = 0.03 ) . Conclusions These results indicate that in patients with AF and an ASD amenable to percutaneous closure , a staged approach with radiofrequency ablation of AF preceding closure is a rational strategy AIMS Our aim was to compare the long-term effects on rhythm and quality of life ( QoL ) after left atrial epicardial radiofrequency ( RF ) ablation vs. no ablation in patients undergoing cardiac surgery . METHODS AND RESULTS Thirty-nine patients with ECG documented atrial fibrillation ( AF ) scheduled for coronary artery bypass grafting ( CABG ) with or without concomitant valve surgery were consecutively elected for epicardial RF ablation .  Thirty-nine age- and gender-matched patients scheduled for CABG with or without concomitant valve surgery only and with documented AF served as controls . The follow-up after ablation was 32 + /- 11 months . The percentage of patients in sinus rhythm ( SR ) at long-term follow-up was 62 vs. 33 % ( P = 0.03 ) after ablation and no ablation , respectively . SR at 3 months was highly predictive of that at 32 months ( sensitivity 95 % , positive predictive value 86 % ) . Long-term SR was associated with better QoL , fewer symptoms , higher ejection fraction , and smaller left and right atria than AF . CONCLUSION SR at 3 months was highly predictive of long-term SR that was associated with clinical improvement when compared with patients still in AF . AF at 3 months did not preclude a later stabilization to SR OBJECTIVES The present study was aim ed to evaluate the efficacy of a specific algorithm with continuous atrial dynamic overdrive pacing to prevent atrial fibrillation ( AF ) after coronary artery bypass graft ( CABG ) surgery . BACKGROUND Atrial fibrillation occurs in 30 % to 40 % of patients after cardiac surgery with a peak incidence on the second day . It still represents a challenge for postoperative prevention and treatment and may have medical and cost implication s. METHODS Ninety-six consecutive patients undergoing CABG for severe coronary artery disease and in sinus rhythm without antiarrhythmic therapy on the second postoperative day were r and omized to have or not 24 h of atrial pacing through temporary epicardial wires using a permanent dynamic overdrive algorithm .  Holter ECGs recorded the same day in both groups were analyzed to detect AF occurrence . RESULTS No difference was observed in baseline data between the two study groups , particularly for age , male gender , history of AF , ventricular function , severity of coronary artery disease , preoperative beta-adrenergic blocking agent therapy or P-wave duration . The incidence of AF was significantly lower ( p = 0.036 ) in the paced group ( 10 % ) compared with control subjects ( 27 % ) . Multivariate analysis showed AF incidence to increase with age ( p = 0.051 ) but not in patients with pacing ( p = 0.078 ) . It decreased with a better left ventricular ejection fraction only in conjunction with atrial pacing ( p = 0.018 ) . CONCLUSIONS We conclude that continuous atrial pacing with an algorithm for dynamic overdrive reduces significantly incidence of AF the second day after CABG surgery , particularly in patients with preserved left ventricular function OBJECTIVE Prospect i ve r and omised study comparing patients with atrial fibrillation ( AF ) of more than 6 months duration after mitral valve surgery plus biatrial modified radiofrequency Maze procedure using Medtronic Cardioblate System ( Cardioblate group , n=24 ) vs mitral valve surgery plus intensive rhythm control strategy ( control group , n=25 ) . METHODS Patients were blinded to r and omisation . Preoperatively , at discharge , and at 3-month and 1-year follow-up ,  echocardiography , quality of life assessment s and ECGs  were done . In both groups , sinus rhythm ( SR ) restoration was attempted by intra- and postoperative DC cardioversion and class III antiarrhythmic medication . All patients received warfarin . Amiodarone and warfarin was considered for discontinuation after 3 months in SR , 24-h Holter or event monitor excluding AF . RESULTS Both groups underwent mitral valve replacement or repair ( Cardioblate vs control : 16:8 vs 10:15 ) , had similar gender ( male : 33 % vs 56 % ) , age ( 66+/-8 years vs 68+/-9 years ) , additional aortic valve replacement ( 7 vs 6 patients ) , tricuspid annuloplasty ( 13 vs 13 patients ) , and CABG ( 10 vs 16 patients ) . There was 0 % operative mortality , 0 % postoperative cerebrovascular accidents , but 2 late deaths in the control group . At discharge , 3- and 12-month follow-up , more patients in the Cardioblate group returned to normal SR compared to control ( 29 % , 57 % and 75 % vs 20 % , 43 % and 39 % ; p=0.030 ) . Return of functional atrial contraction in patients in SR at 1 year was comparable between groups ( 63 % vs 89 % , NS ) , and more likely in non-rheumatic pathology and preoperative AF of shorter duration . The effectiveness of atrial contraction was 36+/-14 % vs 43+/-18 % of transmitral flow and there was no difference between groups .  Amiodarone treatment decreased more in Cardioblate group over time ( 92 % , 55 % and 29 % vs 52 % , 52 % and 21 % ; p=0.003 ) , whereas warfarin decrease was comparable ( 100 % , 100 % and 71 % vs 100 % , 95 % and 82 % ; NS ) . CONCLUSIONS Radiofrequency Maze ablation additional to mitral valve surgery result ed in a higher SR conversion rate ( 75 % ) , despite control group treatment with intensive rhythm control strategy having a higher SR conversion rate ( 39 % ) compared to literature ( approximately 25 % ) . Maze ablation result ed in normalisation of atrial function in 63 % of patients converted to SR
Results The consensus panel agreed on the following statements in patients with AF undergoing cardiac surgery concomitant surgical ablation : 1 .
Improves the achievement of sinus rhythm at discharge and 1 year ( level A ) ; this effect is sustained up to 5 years ( level B ) .
2 .
3 .
Does not increase the risk of perioperative mortality ( level A ) , stroke ( level A ) , myocardial infa rct ion ( level B ) , cardiac tamponade ( level A ) , reoperative bleeding ( level A ) , esophageal injury ( level B ) , low cardiac output ( level A ) , intraaortic balloon ( level B ) , congestive heart failure ( level B ) , ejection fraction ( EF ; level B ) , pleural effusion ( level A ) , pneumonia ( level A ) , renal dysfunction ( level B ) , and mediastinitis ( level A ) .
The incidence of esophageal injury remains to be low ( level B ) .
4 .
Does not reduce mortality at 1 year ( level A ) .
5 .
6 .
Increases cardiopulmonary bypass and cross-clamp times ( level A ) , with no difference in intensive care unit and hospital length of stay ( level A ) .
Conclusions Given these evidence -based statements , the consensus panel stated that , in patients with persistent and permanent AF undergoing cardiac surgery , concomitant surgical ablation is recommended to increase incidence of sinus rhythm at short- and long-term follow-up ( class 1 , level A ) ; to reduce the risk of stroke and thromboembolic events ( class 2a , level B ) ; to improve EF ( class 2a , level A ) ; and to exercise tolerance ( class 2a , level A ) and long-term survival ( class 2a , level B )
Objective This purpose of this consensus conference was to determine whether surgical atrial fibrillation ( AF ) ablation during cardiac surgery improves clinical and re source outcomes compared with cardiac surgery alone in adults undergoing cardiac surgery for valve or coronary artery bypass grafting .