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Combination of Energy Sources Versus Cryothermia Alone when Performing the Cox-Maze Procedure for Ablation of Atrial Fibrillation
Niv Ad, Linda Henry, Sharon Hunt, Sari Holmes, Lisa Martin.
Inova Heart and Vascular Institute, Falls Church, VA, USA.
OBJECTIVE:
Surgical ablation for atrial fibrillation (AF) using cryoablation as a standalone technology or combined with bipolar radiofrequency is very common in patients presenting for cardiac surgery in AF. The purpose of this study was to compare outcomes of the Cox-Maze (CMIII/IV) procedure using cryothermia energy alone versus a combination of bipolar radiofrequency and cryothermia.
METHODS:
All patients underwent full CMIII/IV through median sternotomy with concomitant cardiac surgery (N=281). Patients are followed prospectively through our unique AF registry. Health-related quality of life (HRQL, SF-12) and AF symptom severity and frequency were obtained at baseline and follow-up. Perioperative outcomes were obtained from our local Society of Thoracic Surgeons Database. Rhythm was verified with EKG and 24-hr holter. The CMIII/IV lesion set was performed as described by Dr. James Cox using bipolar radiofrequency in combination with cryothermia (n=155) or cryothermia alone (n=126). Propensity score matching (PSM) using a 0.25 caliper was conducted to simulate randomization (n=122/group).
RESULTS:
The combination group was not different than the cryothermia group on perioperative outcomes: permanent stroke (0 vs 0.8%, p=1.00), pneumonia (3% vs 5%, p=0.75), reoperation for bleeding (7% vs 2%, p=0.10), renal failure (4% vs 4%, p=1.00), operative mortality (2.5% vs 0.8%, p=0.62) or readmissions <30 days (13% vs 14%, p=1.00). The combination group experienced more perioperative AF (47% vs 33%, p=0.04) and lower return to sinus rhythm (on and off medications) at 6 months post-surgery (86% vs 96%, p=0.02; 70% vs 85%, p=0.03). At all other follow-up points, the groups were similar on return to sinus rhythm, including 24 months (83% vs 100%, p=0.12; 72% vs 88%, p=0.34). The groups did not differ on cardioversion-free survival (70.4% vs 78.5%, p=0.09) or ablation-free survival (89.6% vs 97.6%, p=0.88) with mean follow-up of 37.0 ± 24.4 months. HRQL (p=0.46) and AF symptom frequency (p=0.91) and severity (p=0.69) improved similarly for both groups.
CONCLUSIONS:
The success rate of the CMIII/IV whether performed using cryoablation alone or combined with radiofrequency showed similar safety and efficacy beyond 6 months. Consideration should be given to offering patients in AF a concomitant CMIII/IV procedure at the time of their cardiac surgery.
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