Recurrence of Arrhythmias after Thoracoscopic MAZE procedure

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Abstract

BACKGROUND: Thoracoscopic version of the MAZE operation alone or in combination with catheter ablation (hybrid approach) has become widespread in the treatment of atrial fibrillation (AFib). However, recurrences of arrhythmias after such operations, in particular recurrence of AFib, remain unresolved problem.

AIM: The aim of this study was to establish the structure of arrhythmia recurrence in patients with long-standing persistent AFib after primary epicardial ablation using the Dallas lesion set technique, as well as determining the optimal RFA strategy for recurrence.

METHODS: 138 catheter ablation procedures for 100 patients, who applied with recurrence of various atrial arrhythmias after thoracoscopic MAZE. 34 patients had 2 or more RFA (31 pts — 2, 2 pts — 3, 1 pts — 4).

RESULTS: After Dallas lesion set thoracoscopic ablation in the structure of recurrences dominated: 1 — AFib recurence; 2 — incisional left atrial flutter. After the operation, a potential arrhythmogenic substrate remains, which must be fully eliminated by RFA (in addition to ablation the main cause of recurrence). This minimally necessary intervention implies: control and reisolation of the pulmonary veins; control and reisolation of the posterior wall; septal line from the mitral valve to the right superior pulmonary vein with Y-shaped branch to the left superior pulmonary vein; cava-tricuspid isthmus-blockade. This will eliminate and prevent in the future potentially possible incisional arrhythmias in fragmentary scars after thoracoscopic MAZE procedure. The return of AFib represents the most difficult group of patients. Restoration of sinus rhythm in recurrent AFib after epicardial ablation is possible, but may require extensive ablations in both atriums, as a result of repeated procedures, until all potential arrhythmia mechanisms, present in a particular patient, are eliminated.

CONCLUSIONS: Catheter ablation remains the only method of effective treatment of recurrences after thoracoscopic MAZE procedure. The complexity and multicomponent nature of long-standing AFib causes the frequent need for repeated procedures, especially in cases of recurrence of atrial fibrillation.

About the authors

Vitaly V. Lyashenko

High Medical Technologies Center

Author for correspondence.
Email: vitalylyashenko5@gmail.com
ORCID iD: 0000-0002-8501-4801
SPIN-code: 3023-3477

Cardiovascular Surgeon

Russian Federation, Kaliningrad

Andrey V. Ivanchenko

High Medical Technologies Center

Email: ivancha74@gmail.com
ORCID iD: 0000-0001-5501-4926

Head of the Department

Russian Federation, Kaliningrad

Angelika S. Postol

High Medical Technologies Center

Email: postol-75@mail.ru
ORCID iD: 0000-0003-0983-3773

Cardiologist

Russian Federation, Kaliningrad

Sardor N. Azizov

S.G. Sukhanov Federal Centre for Cardiovascular Surgery

Email: sazizov@gmail.com
ORCID iD: 0009-0006-1678-9175

Cardiovascular Surgeon

Russian Federation, Perm

Alexander B. Vygovsky

High Medical Technologies Center

Email: vygovsky@list.ru
ORCID iD: 0000-0003-4832-2028

Deputy Chief Physician

Russian Federation, Kaliningrad

Yuri A. Schneider

High Medical Technologies Center

Email: schneider2000@mail.ru
ORCID iD: 0000-0002-5572-3076

MD, Dr. Sci. (Med.), Professor

Russian Federation, Kaliningrad

References

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  2. Pidanov OU, Bogachev-Prokofiev AV, Elesin DA, et al. Thoracoscopic ablation for isolated AFib treatment in Russia. Circulation pathology and Cardio-thoracic surgery. 2018;22(2):14–21. (In Russ.) doi: 10.21688/1681-3472-2018-2-14-21
  3. On YK, Park KM, Jeong DS, et al. Electrophysiologic results after thoracoscopic ablation for chronic atrial fibrillation. The Annals of Thoracic Surgery. 2015;100(3):1595–1603. doi: 10.1016/j.athoracsur.2015.04.127
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  6. Postol AS, Neminushii NM, Ivanchenko AV, et al. Analysis of arrhythmic events in patients group with ICD and hight risk of SCD. Cardiovascular therapy and prophylactic. 2019;18(5):38–46. (In Russ.) doi: 10.15829/1728-8800-2019-5-38-46
  7. Lyashenko VV, Ivanchenko AV, Postol AS, et al. Electrophysiological mechanisms of arrhythmias after thoracoscopic Maze procedure. Journal of Arrhythmology. 2020;27(2):5–15. (In Russ.) doi: 10.35336/VA-2020-2-5-15
  8. Lyashenko VV, Ivanchenko AV, Postol AS, et al. Isolation of the posterior wall of the left atrium – different approaches to the same goal. Annaly aritmologii. 2021;18(1):15–25. (In Russ.) doi: 10.15275/annaritmol.2021.1.2
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2. Fig. 1. Patients with recurrent arrhythmias after thoracoscopic surgery: 34 patients had ≥ 2 RFA after thoracoscopic MAZE surgery (TM) and 2 patients had 3 consecutive radiofrequency ablations (RFA) (described in detail under links). Both patients had atrial fibrillation as the main recurrent arrhythmia. One patient had four RFAs after TM. The restoration of sinus rhythm on RFA was associated with a longer arrhythmia-free period. AFl ― atrial flutter; CS ― coronary sinus; CTI ― cavotricuspid isthmus; IAS ― interatrial septum; LAA ― left atrial appendage; LAPW ― left atrium posterior wall; LPAF ― long-term persistent atrial fibrillation; PV ― pulmonary veins; RA ― right atrium; SR ― sinus rhythm; SSS ― sick sinus syndrome; SVC ― superior vena cava; TA ― thoracoscopic ablation

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3. Fig. 2. Timing of the recurrence of arrhythmias after TM. A total of 100 patients (for several cases radiofrequency ablations after TM, the time of the first recurrence is presented in the scheme). During the first 6 months, 54/100 recurrences had occurred, 37 of them had not maintained a stable sinus rhythm after TM, despite repeated attempts at defibrillation. SR ― sinus rhythm; TM ― thoracoscopic MAZE surgery

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4. Fig. 3. Structure of relapses during the first radiofrequency ablations after TM. Data on the first rhythm disturbance are presented without taking into account transformations during ablation. “Sinus rhythm” in the diagram means that the patient had sinus rhythm at the start of the radiofrequency ablations procedure and underwent induction, or the standard anatomical ablation scheme after TM (described in the “Materials and Methods”). AF ― atrial fibrillation; AFl ― atrial flutter; SR ― sinus rhythm; TM ― thoracoscopic MAZE surgery

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5. Fig. 4. Results of radiofrequency ablation (RFA) of patients whose TM did not lead to the restoration of a stable sinus rhythm. In this group, non-isolated pulmonary veins were more common, which is generally not typical for patients after TM. AF ― atrial fibrillation; AFl ― atrial flutter; CS ― coronary sinus; CTI ― cavotricuspid isthmus; LAPW ― left atrium posterior wall; LatRA ― lateral segments of the right atrium; LPV ― left pulmonary veins; RPV ― right pulmonary veins; SR ― sinus rhythm; TM ― thoracoscopic variant of MAZE surgery

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6. Fig. 5. Multiple radiofrequency ablation (RFA) after TM in the treatment of long-term persistent AF. AF ― atrial fibrillation; AFl ― atrial flutter; CS ― coronary sinus; CTI ― cavotricuspid isthmus; IAS― interatrial septum; ILAPW ― isolation of the left atrium posterior wall; LA ― left atrium; LAA ― left atrial appendage; OF ― oval fossa; RA ― right atrium; RPV ― right pulmonary veins; SR ― sinus rhythm; SVC ― superior vena cava; TM ― thoracoscopic MAZE surgery

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7. Fig. 6. Multiple radiofrequency ablations (RFA) after thoracoscopic MAZE surgery in the treatment of long-term persistent atrial fibrillation. History of patient A. RFA 3. Stimulation from an ablation electrode with dissociated local capture of the site of the rudiment of the left atrial appendage and spontaneous activity within the blocked zone. Ablation points of the mitral line and on the septum on the right are hidden. LA ― left atrium

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8. Fig. 7. Multiple radiofrequency ablations (RFA) after thoracoscopic MAZE surgery in the treatment of long-term persistent atrial fibrillation. History of patient A. RFA 4. Left atrial control. Persistent isolation of the left atrial appendage rudiment site with spontaneous dissociated activity. Purple areas on the posterior wall of the left atrium indicate dissociated activity of the block of pulmonary veins – posterior wall of the left atrium

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9. Fig. 8. Multiple radiofrequency ablations (RFA) after thoracoscopic MAZE surgery in the treatment of long-term persistent atrial fibrillation. History of patient A. RFA 4. Amplitude map of the right atrium is presented at the end of the surgery. On the yellow dot at the base of the right atrial appendage, there is cycle switching of atrial tachycardia, and the restoration of sinus rhythm is on the blue dot

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10. Fig. 9. Multiple radiofrequency ablations (RFA) after thoracoscopic MAZE surgery in the treatment of long-term persistent atrial fibrillation. History of patient A. RFA 4. Active area in the right atrium (a series of images in chronological order, reflecting the change in the activity of the arrhythmogenic zone under the influence of ablation: a ― frequent bursting activity before the start of RFA; b–d ― slowing of the cycle and arrest of spontaneous activity during RFA; e ― rhythm of this area after RFA)

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11. Fig. 10. Multiple radiofrequency ablations (RFA) after thoracoscopic MAZE surgery in the treatment of long-term persistent atrial fibrillation. History of patient A. RFA 4. a ― spontaneous activity of a non-isolated area in the right atrium after the restoration of sinus rhythm; b ― dissociating spontaneous bursting activity of an isolated area in the right atrium in the presence of sinus rhythm

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