Comparative characteristics of a pacemaker implantation after biatrial or left atrial ablation of atrial fibrillation in combination with coronary artery bypass grafting in patients with ischemic heart disease and long-standing persistent atrial fibrillation

Aim      To compare the incidence of a permanent pacemaker (PP) implantation based on the chosen treatment technology (biatrial ablation, BA, or left atrial ablation (LAA) for long-standing persistent atrial fibrillation (AF) with simultaneous coronary bypass (CB).

Material and methods  The study included 116 patients with long-standing persistent AF and indications for CB. Patients were randomized to two equal groups (58 patients in each). Group 1 underwent BA in combination with CB; group 2 patients underwent isolated LAA with simultaneous CB under the conditions of artificial circulation. Incidence of PP implantation was assessed during the early (to 30 days) and late (to 60 months) postoperative periods.

Results For the observation period, a total of 9 PPs was implanted in both groups, 6 in the BA group and 3 in the LAA group (odds ratio, OR, 0.5; 95 % confidence interval, CI, 0.1–2.4; р=0.490). During the early postoperative period, 5 patients in the BA group and 2 patients in the LAA group were implanted with PP (OR, 0.4; 95 % CI. 0–2.5; р=0.438). During the late postoperative period, one (2%) patient of the BA group was implanted with a permanent PP at 30 months of follow-up due to the development of sick sinus syndrome (SSS); also, one (2%) patient of the LAA group required PP implantation at 54 months of follow-up due to the development of SSS. The causes for PP implantation in the BA group included the development of complete atrioventricular (AV) block in 9 % of cases (95 % CI, 4–19 %); sinus node dysfunction and junctional rhythm in 2 % of cases (95 % CI, 0–9 %). Compared to this group, the LAA group showed a statistically significant difference in the incidence of AV block (0 cases, р=0.047). The major cause for PP implantation in the LAA group was the development of sinus node dysfunction in 3 (5 %) patients (95 % CI, 2–14 %).

Conclusion      The use of BA in surgical treatment of long-standing persistent AF with simultaneous myocardial revascularization is associated with a high risk of AV block, which requires permanent PP implantation in the postoperative period. Total incidence of permanent PP implantation for dysfunction of the cardiac conduction system following the combination surgical treatment of long-standing persistent AF and IHD, either CB and LAA or BA, did not differ between the treatment groups both in early and late postoperative periods.

1. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of CardioThoracic Surgery (EACTS)): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. European Heart Journal. 2020;42(5):373–498. DOI: 10.1093/eurheartj/ehaa612

2. Nucifora G, Schuijf JD, van Werkhoven JM, Trines SA, Kajander S, Tops LF et al. Relationship between obstructive coronary artery disease and abnormal stress testing in patients with paroxysmal or persistent atrial fibrillation. The International Journal of Cardiovascular Imaging. 2011;27(6):777–85. DOI: 10.1007/s10554-010-9725-x

3. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal. 2016;37(38):2893–962. DOI: 10.1093/eurheartj/ehw210

4. Weimar T, Schena S, Bailey MS, Maniar HS, Schuessler RB, Cox JL et al. The Cox-Maze Procedure for Lone Atrial Fibrillation: A Single-Center Experience Over 2 Decades. Circulation: Arrhythmia and Electrophysiology. 2012;5(1):8–14. DOI: 10.1161/CIRCEP.111.963819

5. Damiano RJ, Schwartz FH, Bailey MS, Maniar HS, Munfakh NA, Moon MR et al. The Cox maze IV procedure: Predictors of late recurrence. The Journal of Thoracic and Cardiovascular Surgery. 2011;141(1):113–21. DOI: 10.1016/j.jtcvs.2010.08.067

6. Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen S-A 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(4):528–606. DOI: 10.1093/europace/eus027

7. Gillinov AM, Gelijns AC, Parides MK, DeRose JJ, Moskowitz AJ, Voisine P et al. Surgical Ablation of Atrial Fibrillation during Mitral-Valve Surgery. New England Journal of Medicine. 2015;372(15):1399–409. DOI: 10.1056/NEJMoa1500528

8. Phan K, Xie A, Tsai Y-C, Kumar N, La Meir M, Yan TD. Biatrial ablation vs. left atrial concomitant surgical ablation for treatment of atrial fibrillation: a meta-analysis. Europace. 2015;17(1):38–47. DOI: 10.1093/europace/euu220

9. Zheng S, Zhang H, Li Y, Han J, Jia Y, Meng X. Comparison of Left Atrial and Biatrial Maze Procedure in the Treatment of Atrial Fibrillation: A Meta-Analysis of Clinical Studies. The Thoracic and Cardiovascular Surgeon. 2015;64(08):661–71. DOI: 10.1055/s-0035-1554941

10. Uschner D, Schindler D, Hilgers R-D, Heussen N. RandomizeR: An R Package for the Assessment and Implementation of Randomization in Clinical Trials. Journal of Statistical Software. 2018;85(8):1–22. DOI: 10.18637/jss.v085.i08

11. Badhwar V, Rankin JS, Damiano RJ, Gillinov AM, Bakaeen FG, Edgerton JR et al. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. The Annals of Thoracic Surgery. 2017;103(1):329–41. DOI: 10.1016/j.athoracsur.2016.10.076

12. Prasad SM, Maniar HS, Camillo CJ, Schuessler RB, Boineau JP, Sundt TM et al. The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures. The Journal of Thoracic and Cardiovascular Surgery. 2003;126(6):1822–7. DOI: 10.1016/S0022-5223(03)01287-X

13. Gaynor SL, Schuessler RB, Bailey MS, Ishii Y, Boineau JP, Gleva MJ et al. Surgical treatment of atrial fibrillation: Predictors of late recurrence. The Journal of Thoracic and Cardiovascular Surgery. 2005;129(1):104–11. DOI: 10.1016/j.jtcvs.2004.08.042

14. Chernyavsky A.M., Pak I.A., Kareva Yu.E., Rakhmonov S.S., Pokushalov E.A., Romanov A.B. Efficiency of various methods of ablation of longterm persistent atrial fibrillation during coronary artery bypass grafting. Circulation Pathology and Cardiac Surgery. 2015;19(4):54–62.

15. Takasaki T, Sueda T, Imai K, Orihashi K, Takahashi S, Kurosaki T et al. Midterm results of the box pulmonary vein isolation and the cryo-maze procedure for chronic atrial fibrillation associated with mitral valve disease. General Thoracic and Cardiovascular Surgery. 2012;60(2):82–9. DOI: 10.1007/s11748-011-0827-8

16. Wang J, Meng X, Li H, Cui Y, Han J, Xu C. Prospective randomized comparison of left atrial and biatrial radiofrequency ablation in the treatment of atrial fibrillation. European Journal of Cardio-Thoracic Surgery. 2009;35(1):116–22. DOI: 10.1016/j.ejcts.2008.09.014

17. Pecha S, Schäfer T, Subbotina I, Ahmadzade T, Reichenspurner H, Wagner FM. Rhythm outcome predictors after concomitant surgical ablation for atrial fibrillation: A 9-year, single-center experience. The Journal of Thoracic and Cardiovascular Surgery. 2014;148(2):428–33. DOI: 10.1016/j.jtcvs.2013.08.074

18. Gualis J, Castaño M, Martínez-Comendador JM, Marcos JM, Martín C, Estévez-Loureiro R et al. Biatrial vs. isolated left atrial cryoablation for the treatment of long-lasting permanent atrial fibrillation. Midterm recurrence rate. Archivos de Cardiología de México. 2016;86(2):123–9. DOI: 10.1016/j.acmx.2015.09.005

19. Cappabianca G, Ferrarese S, Tutino C, Corazzari C, Matteucci M, Mantovani V et al. Safety and efficacy of biatrial vs left atrial surgical ablation during concomitant cardiac surgery: A meta‐analysis of clinical studies with a focus on the causes of pacemaker implantation. Journal of Cardiovascular Electrophysiology. 2019;30(10):2150–63. DOI: 10.1111/jce.14117

20. Stulak JM, Suri RM, Burkhart HM, Daly RC, Dearani JA, Greason KL et al. Surgical ablation for atrial fibrillation for two decades: Are the results of new techniques equivalent to the Cox maze III procedure? The Journal of Thoracic and Cardiovascular Surgery. 2014;147(5):1478–87. DOI: 10.1016/j.jtcvs.2013.10.084

21. Bogachev-Prokophiev AV, Afanasyev AV, Pivkin AN, Ovcharov MA, Zheleznev SI, Sharifulin RM et al. A left atrial versus a biatrial lesion set for persistent atrial fibrillation ablation during open heart surgery. European Journal of Cardio-Thoracic Surgery. 2018;54(4):738–44. DOI: 10.1093/ejcts/ezy126

22. Bogachev-Prokofiev A.V., Emeshkin M.I., Afanas’ev A.V., Pivkin A.N., Sharifulin R.M., Zheleznev S.I. et al. Comparative analysis of the requirement for pacemaker implantation in the left atrial and biatrial concomitant ablation in patients with valvular heart disease. Annals of Arrhythmology. 2018;15(1):24–33. DOI: 10.15275/annaritmol.2018.1.3

23. Churyla A, Iddriss A, Andrei A-C, Kruse J, Malaisrie SC, Passman R et al. Biatrial or Left Atrial Lesion Set for Ablation During Mitral Surgery: Risks and Benefits. The Annals of Thoracic Surgery. 2017;103(6):1858–65. DOI: 10.1016/j.athoracsur.2016.10.017