JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
The epicardial approach was able to be performed within 24 hours in 85% of patients. Left atrial appendage closure with the Atriclip was performed in 37/40 (92.5%). There were no procedural complications within 30 days and no patients required conversion to an open surgical procedure for completion of the procedure. Implantable cardiac monitoring (ICM) was in place (either with a newly placed ILR or prior implanted permanent pacemaker or defibrillator) in all patients at procedure completion. Oral antiarrhythmic agents were discontinued following an approximate three month blanking period after the procedure.
Follow Up Data
Data Point
Value
Duration of Follow Up ILR or PPM/ICD Implanted
12 Months = 100%
100.0%
Next Day Epicardial Approach 85%
LAA Clip Delivered
92.5%
Complications
Intra-procedural complications = 0% Convert to Open = 0% Post-op complications = 2.5% (1 patient)
Table 2. Follow Up Data ICD: Internal cardiac defibrillator ILR: Implantable loop recorder LAA: Left atrial appendage PPM: Pacemaker
Findings Follow up for 12 months was performed in all 40 patients.
At one year follow up all 40 patients with previously diagnosed persistent and long-standing persistent atrial fibrillation were documented to be in sinus rhythm. While atrial arrhythmias were seen, these were paroxysmal in nature. Freedom from recurrence of any atrial arrhythmia was seen in 35/40 patients (87.5%) outside the 3 month blanking window. Freedom from recurrence of atrial arrhythmias trended higher in patients with documented persistent atrial fibrillation vs. long standing atrial fibrillation prior to the procedure, although this difference did not reach statistical significance. Despite this finding, maintenance of sinus rhythm on follow-up was documented in all patients (Table 3).
Follow Up After hospital discharge, the patients were monitored in office on a routine basis every three months for the first year and every four to six months thereafter for recurrence of atrial arrhythmia after ablation. Atrial arrhythmias occurring during the first three months, considered a blanking period, were not included. Oral antiarrhythmics were discontinued after this three-month blanking period. 16 Follow up with arrhythmia monitoring was continued for a minimum of 12 months. End Points The primary end-point was freedom from any atrial arrhythmia > 30 seconds, more than 91 days from the epicardial procedural date as defined in the guidelines at 12 month follow-up. 17 Analysis Statistical analysis was completed using SPSS Statistics version 21.0 (IBM; Armonk, NY). Descriptive statistics include means and standard deviations for continuous variables and frequencies and percentages for categorical variables. A failure was defined according to Heart Rhythm Society Guidelines as any episode of AF, atrial flutter or atrial tachycardia (the latter two are considered identical for purpose of outcomes) lasting more than 30 seconds detected after the 3-month post-procedural blanking period by EKG or continuous implanted monitor. Outcomes were further compared between patients with LSPeAF versus PeAF using a Log-Rank comparison with statistical significance below a p-value of < 0.05.
Post Procedural Data
Data Point
Value
AT/AF Recurrence
12.5%
Sustained Atrial Arrhythmia within Blanking Window Average Time to AAD Discontinuation (Months)
3.28 ± 2.0
25.0%
Patients Required DCCV
5.0%
Patients Requiring Redo Procedure
0.0%
Table 3. Post Procedural Data AAD: Antiarrhythmic drug AF: Atrial fibrillation AT: Organized atrial rhythm DCCV: DC cardioversion
RESULTS
DISCUSSION
Patient Characteristics Forty patients underwent the procedure between June 2012 and December 2014. Thirty-one patients were classified as persistent (PeAF) while nine met criteria for long-standing persistent (LSPeAF). The median atrial fibrillation duration was 6.0 ± 4.5 years. The patients mean age was 61.7 ± 7.9 years with 70% being male. Baseline patient characteristics demonstrated in table 1.
While endocardial catheter ablation has been well established in the management of paroxysmal atrial fibrillation, its success in persistent atrial fibrillation has been limited. This is likely due to a dynamic continuum of structural, electrical and contractile remodeling. 18 Better understanding of underlying pathophysiology has led to a better understandingof anatomical targets and advancements in technology have improved the available tools for performing minimally invasive procedures. We can now apply effective epicardial and endocardial lesions
74 J La State Med Soc VOL 169 MAY/JUNE 2017
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