Edited by: Matt Wright, King's College London, United Kingdom
Reviewed by: Malcolm Finlay, Barts Heart Centre, United Kingdom; Alberto Guido Pozzoli, Ospedale Regionale di Lugano, Switzerland
This article was submitted to Cardiac Rhythmology, a section of the journal Frontiers in Cardiovascular Medicine
†These authors have contributed equally to this work
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Atrial fibrillation (AF) occurs frequently after mitral valve (MV) surgery. This study aims to evaluate the efficacy and long-term clinical outcomes after the first AF ablation in patients with prior MV surgery.
Sixty consecutive patients with a history of MV surgery without MAZE referred to three European centers for a first AF ablation between 2007 and 2017 (group 1) were retrospectively enrolled. They were matched (propensity score match) with 60 patients referred for AF ablation without prior MV surgery (group 2).
After the index ablation, 19 patients (31.7%) from group 1 and 24 (40%) from group 2 had no recurrence of atrial arrhythmias (ATa) (
Long-term freedom of atrial arrhythmias after atrial fibrillation catheter ablation is achievable and safe in patients with a history of mitral valve surgery. In AF patients without a history of mitral valve surgery, repeated procedures are needed to maintain sinus rhythm.
Atrial tachyarrhythmias (ATa) are a common cause of morbidity in patients with mitral valve disease. Left atrial volume and pressure loading in the setting of stenotic and regurgitant mitral valvular disease results in atrial electrical and structural remodeling predisposing to atrial arrhythmogenesis (
To the best of our knowledge, little data exist on long-term efficacy, beyond 2 years, of AF catheter ablation after MV surgery. The aim of this study is, therefore, to evaluate long-term safety and efficacy outcomes of catheter ablation in this cohort.
An electronic medical database of three Europeans was screened for patients with a history of successful surgical correction of mitral stenosis or regurgitation and without concomitant MAZE surgery, referred for a first AF ablation from January 2008 to December 2017 across three European centers, were screened for inclusion (group 1). Patients with no or mild residual mitral regurgitation and with both paroxysmal and persistent AF were included. Those with a history of prior surgical or percutaneous ATa ablation or congenital cardiomyopathy were excluded. After collecting patients' written informed consent, a detailed case report form including clinical and procedural characteristics and follow-up was filled and incorporated into a common database shared by the three centers.
A comparison was made to a group of patients, matched for age, gender, body mass index, follow-up duration, and AF type with a history of AF ablation and no prior MV surgery (group 2).
Procedures were carried out under local or general anesthesia depending on the institution. Ablation strategy was according to operator discretion and ranged from pulmonary vein isolation (PVI) only to more extensive strategies including linear ablation at the LA roof and mitral isthmus, ablation of complex fractionated atrial electrograms, cavo-tricuspid isthmus ablation and superior vena cava isolation, depending on AF duration and persistence. The PVI-only strategy was performed either with a radiofrequency catheter or a single-shot cryoballoon.
In the case of repeat procedures for recurrent ATa, persistent isolation of the pulmonary veins and block across lines (if applicable) were evaluated with RF ablation performed, where necessary, to achieve re-isolation or block. Further ablation was eventually performed according to the operator's discretion. Electrical cardioversion was performed at the end of the procedure in the event of failure to restore sinus rhythm.
All patients underwent a clinical evaluation and a 12-lead electrocardiogram (ECG) at 1, 3, 6, and 12 months as well as a yearly 24-h Holter. ATa recurrence was defined according to the HRS/EHRA/ECAS expert consensus document as any recurrence of atrial arrhythmia >30 s (
Complications including vascular damage, thromboembolism, pericardial effusion, esophageal fistula, mechanical valve damage, atrioventricular block, and procedure-related death were systematically recorded.
Statistical analyses were performed in SPSS Statistics 24 (IBM Corporation, Armonk, New York, USA). Propensity-score matching with a 1:1 ratio, without replacement, and with the nearest neighbor technique was used to create groups of patients with similar characteristics out of a database of 180 patients (age, gender, body mass index, LA volume, follow-up duration, and AF type) to compare the outcomes in patients with vs. without MV surgery undergoing ablation.
Comparison of means between groups was performed using independent samples
The baseline clinical characteristics of the study cohort are presented in
Clinical and index procedure characteristics (
Female, |
30 (50.0%) | 33 (55.0%) | 0.84 |
Age, mean ± SD yrs | 65.5 ± 5.8 | 64.3 ± 6.9 | 0.29 |
BMI, mean ± SD kg/m2 | 24.9 ± 4.1 | 25.5 ± 4.1 | 0.31 |
Mitral regurgitation, |
41 (68.3%) | NA | NA |
Mitral stenosis, |
19 (31.7%) | NA | NA |
Mitral valve repair, |
33 (55.0%) | NA | NA |
Mitral valve replacement, |
27 (45.0%) | NA | NA |
Mechanical valve, |
27 (45%) | NA | NA |
Paroxysmal AF, |
32 (53.3%) | 30 (50.0%) | 0.85 |
Non paroxysmal AF, |
28 (46.7%) | 30 (50.0%) | 0.85 |
Time from first AF episode, months | 35.8 ± 6.5 | 33.0 ± 8.4 | 0.16 |
CHA2DS2-VASc Score | 2,4 ± 1.4 | 2.2 ± 1.1 | 0.92 |
Arterial Hypertension, |
36 (60.0%) | 39 (65.0%) | 0.78 |
Diabetes, |
5 (7.1%) | 4 (6.7%) | 0.66 |
Congestive heart failure, |
12 (20.0%) | 7 (11.7%) | 0.32 |
History of stroke, |
6 (10.0%) | 4 (6.7%) | 0.53 |
Anti-arrhythmic drug before the procedure, |
33 (55.0%) | 30 (50.0%) | 0.84 |
Betablockers, |
25 ( |
36 ( |
0.07 |
Flecainide, |
25 ( |
21 ( |
0.57 |
Sotalol, |
4 ( |
3 ( |
0.46 |
Amiodarone, |
10 (16.7%) | 5 ( |
0.27 |
Direct anticoagulant, |
37 (61.7%) | 40 (66.7%) | 0.71 |
Antivitamin K, |
34 (56.7%) | 7 (11.7%) | |
LVEF, mean ± SD % | 51.8 ± 7.5 | 52.7 ± 3.9 | 0.21 |
Left atrial diameter | 47.2 ± 6.7 | 44.3 ± 5.5 | 0.08 |
BMI, body mass index; AF, atrial fibrillation; LVEF, left ventricular ejection fraction.
In group 1, 19 (31.7%) patients had mitral stenosis and 41 (68.3%) had mitral regurgitation. Twenty-seven (45.0%) patients underwent MV replacement with mechanical valves and 33 (55.0%) MV annuloplasty. Eighteen patients underwent concomitant surgical procedures, including coronary bypass in six patients, aortic valve replacement in three patients, tricuspid valve repair in eight patients, and interatrial closure in one patient. Surgical atrial access was granted through the right atrium and the interatrial septum in 32 patients, 12 patients through the left atrium, and 16 patients through the roof.
Procedural characteristics are shown in
Procedural characteristics (
Sinus rhythm at index procedure, |
27 (45.0%) | 43 (71.7%) | |
PVI only at index, |
13 (21.7%) | 29 (48.3%) | |
Left atrium substrate | 47 | 31 | |
Right atrium substrate | 7 | 1 | |
Superior Vena Cava Isolation | 7 | 1 | |
Cavotricuspid Isthmus | 11 | 2 | |
Index procedure time, mean ± SD minutes | 137.45 ± 30.2 | 134.45 ± 19.7 | 0.47 |
Index fluoroscopic time, mean ± SD minutes | 8.1 ± 5.2 | 7.9 ± 3.9 | 0.72 |
PVI, Pulmonary vein isolation.
Following the index ablation, 19 patients (31.6%) from group 1 and 24 patients (40.0%) from group 2 had no recurrence of ATa (
Follow-up characteristics (
Free of arrhythmia after index procedure, |
19 (31.7%) | 24 (40.0%) | 0.34 |
Free of arrhythmia and off-AAD after index procedure, |
9 (15%) | 18 (30%) | 0.08 |
Free of arrhythmia after one repeat procedure, |
48 (80.0%) | 52 (86.7%) | 0.46 |
Free of arrhythmia at end of follow-up, |
54 (90.0%) | 57 (95.0%) | 0.49 |
Out of AAD after last procedure, |
28 (46.6%) | 33 (55.0%) | 0.46 |
Without any recurrence, |
9 ( |
18 ( |
0.22 |
Number of procedures per patient, median (Q1–Q3) | 2 (2–2) | 2 (2-2) | 0.11 |
Atrial tachyarrhythmias recurrence, |
41 (68.3%) | 36 (60.0%) | 0.45 |
Atrial fibrillation, |
19 ( |
28 ( |
0.09 |
Atrial tachycardia | 22 ( |
8 ( |
|
Time to first recurrence, median (Q1–Q3), |
13 (9–17) | 19 (8–22) | 0.06 |
Major complication | 0 | 0 | 0.91 |
AAD, Antiarrhythmic drugs.
Arrhythmia-free survival after the index catheter ablation for atrial fibrillation in patients with previous mitral valve (MV) surgery patients vs. control. The proportion of patients off antiarrhythmic drugs is specified for each group. The number of patients at risk at each time interval is shown below the figure. The
As pointed out in
Each patient underwent a median of 2 (2–2) ablation procedures and was followed for 62 (48–84) months. No difference was observed in both groups regarding the outcome with 54 patients (90.0%) in sinus rhythm in group 1 vs. 57 (95.0%) in group 2 (
No statistical difference was seen between mitral stenosis or regurgitation in terms of overall ATa recurrence, the number of procedures, and the type of ATa.
No major peri or postoperative complications are reported. One pseudo-aneurysm and two groin hematomas were observed in groups 1 and 2 groin hematomas in group 2. Of note, mitral valve entrapment was not observed in either group.
In the present study, we evaluated the safety and long-term efficacy of AF catheter ablation after MV surgery in 60 patients across three experienced European centers. Our results highlight the following key findings: Catheter ablation for AF in patients with a history of MV surgery; (1) offers meaningful results with repeat procedures, similar to those seen in a matched population; (2) results in a higher rate of AT recurrence compared to control patients; and (3) has a favorable safety profile.
This study represents the longest follow-up study of its nature in patients with prior MV surgery, without concomitant surgical ablation, referred for first-time catheter ablation for AF.
After one ablation procedure, arrhythmia-free survival is modest in our cohort, with the majority of patients experiencing a recurrence of an ATa. Similar outcomes were seen in the control group; however, these results are also reflected by other studies of patients with prior MV surgery (
Clinical characteristics and outcome of ablation from studies on populations with previous mitral valve surgery.
Enriquez et al. ( |
2017 | 67 | 33 | 12 | 62% | NA | 42% | NA | NA |
Santangeli et al. ( |
2012 | 178 | NA | 11.5 ± 8.6 | NA | NA | NA | 36% | NA |
Hussein et al. ( |
2011 | 81 | 0 | 24 | 82.7% | 69% | 36% | NA | NA |
Chen et al. ( |
2013 | 21 | 0 | 42.7 ± 17.3 | 33% | NA | 43% | 67% | 43% |
Mountantonakis et al. ( |
2011 | 21 | 12 | 7 ± 4 | 71% | 43% | 43% | 43% | 28% |
Lang et al. ( |
2005 | 26 | 0 | 10 | 73% | NA | 34% | 50% | 23% |
Lakkireddy et al. ( |
2011 | 50 | 0 | 12 | 80% | NA | 34% | NA | NA |
While a single procedure appears to be insufficient to maintain sinus rhythm in these patients, after one repeat RF procedure, the rate of ATa freedom in our MV cohort increased to 80% (
Arrhythmia-free survival in patients with previous mitral valve (MV) surgery patients vs. control at the end of follow-up after a median of 2 (2–2) catheter ablation. The proportion of patients off antiarrhythmic drugs is specified for each group. The number of patients at risk at each time interval is shown below the figure. The
Furthermore, at a median final follow-up of 62 (48–84) months, the long-term rate of sinus rhythm was high at 90%, with no difference seen with respect to the control group. These results suggest that, with repeat ablation, long-term outcomes similar to a control population are achievable in patients with prior MV surgery.
With regards to medium to long-term follow-up, conflicting reports exist in the literature, on smaller cohorts and/or shorter follow-ups (
At the end of the follow-up period, approximately 50% of patients in each group were off AADs. These ratios are comparable to previously published data from Mountantonakis et al. (
We report a higher rate of atrial tachycardia (AT) recurrence in the patients who underwent surgery in our cohort. This phenomenon could be explained by several mechanisms. On the one hand, valve surgery itself can contribute to slow conduction zones facilitating the appearance of re-entry circuits (
Prior safety concerns regarding catheter ablation of atrial arrhythmia in patients post-MV surgery surround the risk of damage to the prosthetic valve (
Our study suggests that patients with symptomatic AF and a history of severe mitral valve disease requiring valvular surgery derive a potential long-term benefit from catheter ablation. Despite the need for repeat ablation procedures in most patients and the continuation of AADs in approximately half of our cohort, the results seen here were similar to a group of matched control patients, suggesting that this treatment strategy is of similar value in both cohorts. The ongoing use of AADs appears to be complimentary to repeat ablation in maintaining sinus rhythm and freedom from symptoms, and the continuation of these should not be viewed as a treatment failure in this group.
This is a non-randomized retrospective observational study with a sample of heterogeneous patients, including the type of MV surgery (repair or replacement) but also the physiopathology of the MV disease itself: rheumastismal and degenerative MV regurgitation propensity scores are performed to reduce the heterogeneity bias and improve the power of the analysis in retrospective studies. Nevertheless, this statistical technique is limited by nature, as only few factors can be matched, and the analysis depends on the available database. Thus, the
In this long-term follow-up study, freedom from atrial arrhythmias after catheter ablation for atrial fibrillation is achievable and safe in patients with a history of mitral valve surgery. With repeated procedures and the use of antiarrhythmic drugs, high rates of sinus rhythm can be achieved in the long term, emphasizing the value of this treatment strategy in this cohort.
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
The studies involving human participants were reviewed and approved by Univeristeit Ziekenhuis Brussel Ethics Committee. The patients/participants provided their written informed consent to participate in this study.
All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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