The Same is Not the Same: Device Effect during Bipolar Radiofrequency Ablation of Atrial Fibrillation

Abstract

Background Different ablation devices deliver the same type of energy but use individual control mechanisms to estimate efficacy. We compared patient outcome after the application of radiofrequency ablation systems, using temperature- or resistance-control in paroxysmal and persistent atrial fibrillation (AF).

Methods This is an unselected all-comers study. Patients underwent standardized left atrial (paroxysmal atrial fibrillation, [PAF] n = 31) or biatrial ablation (persistent atrial fibrillation [persAF] n = 61) with bipolar RF from October 2010 to June 2013. Patients with left atrial dilatation (up to 57 mm), reduced left ventricular (LV) function, and elderly were included. We used resistance-controlled (RC) or temperature-controlled (TC) devices. We amputated atrial appendices and checked intraoperatively for completeness of pulmonary vein exit block. All patients received implantable loop recorders. Follow-up interval was every 6 months. Antiarrhythmic medical treatment endured up to month 6.

Results We reached 100% freedom from atrial fibrillation (FAF) in PAF. In perAF 19% of the RC but 82% of the TC patients reached FAF (12 months; p < 0.05). TC patients exhibited higher creatine kinase-muscle/brain (CK-MB) peak values. In persAF, CK-MB-levels correlated to FAF. No and no mortality (30 days) was evident. Twelve-month mortality did not correlate to AF type, AF duration, LV dimension, or function and age. Prolonged need of oral anticoagulants was 90.1% (RC) and 4.5% (TC).

Conclusion In patients with persAF undergoing RF ablation, TC reached higher FAF than RC. Medical devices are not “the same” regarding effectiveness even if used according to manufacturer's instructions. Thus, putative application of “the same” energy is not always “the same” efficacy.

Keywords

atrial fibrillation - surgery - techniques

Publication History

Received: 29 January 2019

Accepted: 12 August 2019

Article published online:
11 October 2019

• References

• 1 Wolf PA, Mitchell JB, Baker CS, Kannel WB, D'Agostino RB. Impact of atrial fibrillation on mortality, stroke, and medical costs. Arch Intern Med 1998; 158 (03) 229-234
• 2 Sundt III TM, Camillo CJ, Cox JL. The maze procedure for cure of atrial fibrillation. Cardiol Clin 1997; 15 (04) 739-748
• 3 Doll N, Aupperle H, Borger M, Czesla M, Mohr FW. [Efficacy and safety of various energy sources and application techniques for the surgical treatment of atrial fibrillation]. Herzschrittmacherther Elektrophysiol 2007; 18 (02) 83-91
• 4 Stulak JM, Suri RM, Burkhart HM. et al. Surgical ablation for atrial fibrillation for two decades: are the results of new techniques equivalent to the Cox maze III procedure?. J Thorac Cardiovasc Surg 2014; 147 (05) 1478-1486
• 5 Gaynor SL, Schuessler RB, Bailey MS. et al. Surgical treatment of atrial fibrillation: predictors of late recurrence. J Thorac Cardiovasc Surg 2005; 129 (01) 104-111
• 6 McCarthy PM, Kruse J, Shalli S. et al. Where does atrial fibrillation surgery fail? Implications for increasing effectiveness of ablation. J Thorac Cardiovasc Surg 2010; 139 (04) 860-867
• 7 Lee R, McCarthy PM. Surgical ablation for atrial fibrillation: not all energy sources are created equal. J Am Coll Cardiol 2011; 58 (02) 200-201 , author reply 201
• 8 Lawrance CP, Henn MC, Damiano Jr RJ. Surgical ablation for atrial fibrillation: techniques, indications, and results. Curr Opin Cardiol 2015; 30 (01) 58-64
• 9 Gillinov AM, Bhavani S, Blackstone EH. et al. Surgery for permanent atrial fibrillation: impact of patient factors and lesion set. Ann Thorac Surg 2006; 82 (02) 502-513 , discussion 513–514
• 10 Melby SJ, Schuessler RB, Damiano Jr RJ. Ablation technology for the surgical treatment of atrial fibrillation. ASAIO J 2013; 59 (05) 461-468
• 11 Wood MA, Ellenbogen AL, Pathak V, Ellenbogen KA, Kasarajan V. Efficacy of a cooled bipolar epicardial radiofrequency ablation probe for creating transmural myocardial lesions. J Thorac Cardiovasc Surg 2010; 139 (02) 453-458
• 12 Martínez-Comendador J, Castaño M, Mosquera I. et al. Cryoablation of atrial fibrillation in cardiac surgery: outcomes and myocardial injury biomarkers. J Cardiothorac Vasc Anesth 2011; 25 (06) 1030-1035
• 13 Calkins H, Kuck KH, Cappato R. et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 2012; 14 (04) 528-606
• 14 Miyairi T, Nakao M, Kigawa I. et al. A closed biatrial procedure using bipolar radiofrequency ablation. J Thorac Cardiovasc Surg 2006; 132 (01) 168-169
• 15 Cox JL. A brief overview of surgery for atrial fibrillation. Ann Cardiothorac Surg 2014; 3 (01) 80-88
• 16 Goette J, Weimar T, Vosseler M. et al. Freezing equals freezing? Performance of two cryoablation devices in concomitant mitral valve repair. Thorac Cardiovasc Surg 2016; 64 (08) 672-678
• 17 Ad N, Henry L, Hunt S. The impact of surgical ablation in patients with low ejection fraction, heart failure, and atrial fibrillation. Eur J Cardiothorac Surg 2011; 40 (01) 70-76
• 18 Gillinov M, Soltesz E. Surgical treatment of atrial fibrillation: today's questions and answers. Semin Thorac Cardiovasc Surg 2013; 25 (03) 197-205
• 19 Nattel S, Harada M. Atrial remodeling and atrial fibrillation: recent advances and translational perspectives. J Am Coll Cardiol 2014; 63 (22) 2335-2345
• 20 Ad N, Henry L, Hunt S, Barnett S, Stone L. The Cox-Maze III procedure success rate: comparison by electrocardiogram, 24-hour Holter monitoring and long-term monitoring. Ann Thorac Surg 2009; 88 (01) 101-105
• 21 Kazui T, Henn MC, Watanabe Y. et al. The impact of 6 weeks of atrial fibrillation on left atrial and ventricular structure and function. J Thorac Cardiovasc Surg 2015; 150 (06) 1602-1608
• 22 Staszewsky L, Masson S, Barlera S. et al; on the behalf of the GISSI-AF Investigators. Cardiac remodeling, circulating biomarkers and clinical events in patients with a history of atrial fibrillation. Data from the GISSI-AF Trial. Cardiovasc Drugs Ther 2015; 29 (06) 551-561
• 23 El Arid JM, Sénage T, Toquet C. et al. Human comparative experimental study of surgical treatment of atrial fibrillation by epicardial techniques. J Cardiothorac Surg 2013; 8: 140
• 24 Ad N. MicroRNAs and post-operative atrial fibrillation: a step in the understanding of the mechanism and identifying reliable biomarkers. Eur J Cardiothorac Surg 2017; 51 (01) 78-79
• 25 Damiano Jr RJ, Lawrance CP, Saint LL. et al. Detection of atrial fibrillation after surgical ablation: conventional versus continuous monitoring. Ann Thorac Surg 2016; 101 (01) 42-47 , discussion 47–48
• 26 Hanke T, Charitos EI, Stierle U. et al. Twenty-four-hour Holter monitor follow-up does not provide accurate heart rhythm status after surgical atrial fibrillation ablation therapy: up to 12 months experience with a novel permanently implantable heart rhythm monitor device. Circulation 2009; 120 (11, Suppl): S177-S184
• 27 Björkenheim A, Brandes A, Chemnitz A, Magnuson A, Edvardsson N, Poçi D. Rhythm control and its relation to symptoms during the first two years after radiofrequency ablation for atrial fibrillation. Pacing Clin Electrophysiol 2016; 39 (09) 914-925
• 28 Essebag V, Baldessin F, Reynolds MR. et al. Non-inducibility post-pulmonary vein isolation achieving exit block predicts freedom from atrial fibrillation. Eur Heart J 2005; 26 (23) 2550-2555
• 29 Manani KA, Christensen K, Peters NS. Myocardial architecture and patient variability in clinical patterns of atrial fibrillation. Phys Rev E 2016; 94 (04) 042401
• 30 Swanson DK, Smith WJ, Ibrahim T, Wechsler AS. Tissue temperature feedback control of power: the key to successful ablation. Innovations (Phila) 2011; 6 (04) 276-282