Catheter ablation of atrial arrhythmias in patients after thoracoscopic ablation of persistent atrial fibrillation

Aim. To determine the mechanisms of development and approaches to interventional treatment of postoperative atrial tachycardia in patients after thoracoscopic ablation (TA) of atrial fibrillation (AF).

Material and methods. The results of thoracoscopic ablation of AF in 46 patients were analyzed, of which 19,5% (n=9) had atrial tachycardia after the procedure. Radiofrequency ablation (RFA) was conducted in these patients after a 3-month blanking period. Regardless of tachycardia type, the threedimensional reconstruction including high-density right and left atrial (LA) voltage mapping was performed in order to visualize the lesions, pulmonary veins and LA posterior wall isolations. After RFA and sinus rhythm restoration, re-mapping was performed to assess conduction block and absence of electrical activity in the lesion zones.

Results. Complete pulmonary vein (PV) isolation was verified in 55,5% of patients (n=5). In 44,4% (n=4), there were residual PV fractionated potentials without conduction with LA. In 22,2% of subjects (n=2), we identified typical atrial flutter (AFL), which was terminated by RFA in cavotricuspid isthmus (CTI). There were 77,7% (n=7) of patients who were diagnosed with atypical LA flutter; 66,6% (n=6) of them had conduction reconnection at the thoracoscopic box-lesion line. Perimitral AFL with slow conduction zone which was located on the anterior wall of LA was verified in 11,1% of patients (n=1). The effective RFA was performed in these areas.

Two main factors affecting failed ablation were LA volume and body mass index (BMI). In patients with arrhythmias after TA, LA volume was 180,2±35,6 ml vs 158,34±38,5 ml in patients with sinus rhythm. BMI was 30,8±3,1 kg/m2 and 28,9±3,9 kg/m2, respectively. The mean follow-up was 9,8±2,7 months. All patients after catheter ablation maintained a stable sinus rhythm.

Conclusion. Atrial tachycardia after TA is caused by the gaps in box-lesion lines. The main predictors of gaps are high values of LA volume and BMI. The high-density mapping increases the effectiveness of RFA. Combination of epicardial and endocardial accesses is the most effective approach to treatment of patients with persistent AF.

1. Kirchhof P, Benussi S, Kotecha D, at al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal. 2016;37(38):2893-962. doi:101093/eurheartj/ehw210.

2. Castella M, Kotecha D, van Laar Ch, et al Thoracoscopic vs. catheter ablation for atrialfibrillation: long-termfollow-up of the FAST randomized trial. Europace. 2019;00:1-8. doi:10.1093/europace/euy325.

3. Verma A, Jiang CY, Betts TR, et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med. 2015;372:1812-22. doi:10.1056/NEJMoa1408288.

4. La Meir M, Gelsomino S, Luca F, et al. Minimal invasive surgery for atrial fibrillation: an updated review. Europace. 2013;15:170-82. doi:10.1093/europace/eus216.

5. Wolf RK, Schneeberger EW, Osterday R, et al. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg. 2005;130:797-802. doi:10.1016/j.jtcvs.2005.03.041.

6. Probst J, Jideus L, Blomstrom P, et al. Thoracoscopic epicardial left atrial ablation in symptomatic patients with atrial fibrillation. Europace. 2016;18(10):1538-44. doi:10.1093/europace/euv438.

7. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014;130:2071-104. doi:10.1161/CIR.0000000000000040.

8. Cox JL, Malaisrie SCh, Kislitsina ON, et al. The electrophysiologic basis for lesions of the contemporary Maze operation. J Thorac Cardiovasc Surg. 2019;157:584-90. doi:10.1016/j.jtcvs.2018.08.007.

9. Altman RK, Proietti R, Barrett CD, et al. Management of refractory atrial fibrillation postsurgical ablation. Ann Cardiothorac Surg. 2014;3:91-7. doi:10.3978/j.issn.2225-319X.201312.08.

10. McElderry HT, McGiffin DC, Plumb VJ, at al. Proarrhythmic aspects of atrial fibrillation surgery: mechanisms of postoperative macroreentrant tachycardias. Circulation. 2008;117:155-62. doi:10.1161/CIRCULATIONAHA.107.688358.

11. Bockeria LA, Revishvily ASh, Artyukhina EA. Clinical case of atrial tachycardias removal following “labyrinth-3” surgery using nonfluoroscopic mapping system. Annals of Arrhythmology. 2009;(2):74-80. (In Russ.)

12. Artyukhina EA, Dedukh EV, Yashkov MV. Stage surgical and catheter approach to the treatment of long-persistent atrial fibrillation. Russian Journal of Cardiology. 2019;(7):96-8. (In Russ.) doi:1015829/1560-4071-2019-7-96-98.

13. Liu X, Dong J, Mavrakis HE, et al. Mechanisms of arrhythmia recurrence after video-assisted thoracoscopic surgery for the treatment of atrial fibrillation: insights from electrophysiological mapping and ablation. J Cardiovasc Electrophysiol. 2009;20(12):1313-20. doi:10.1111/j.1540-8167.2009.01627.

14. Gwag HB, Jeong DS, Hwang JK, et al. Characteristics of Symptomatic Recurrent Tachyarrhythmia after Thoracoscopic Ablation for Persistent Atrial Fibrillation. Pacing and Clinical Electrophysiology. 2019;42(6):686-93. doi:10.1111/pace.13667.

15. Beukema RJ, Adiyaman A, Smit JJ, et al. Catheter ablation of symptomatic postoperative atrial arrhythmias after epicardial surgical disconnection of the pulmonary veins and left atrial appendage ligation in patients with atrial fibrillation. Eur J Cardiothorac Surg. 2016;49:265-71. doi:10.1093/ejcts/ezv047.