Abstract
OBJECTIVES
Thoracoscopic epicardial ablation with a limited lesion set led to suboptimal results for advanced paroxysmal atrial fibrillation (AF) or persistent AF. Whether additional right atrial lesions improve the result is unclear.
METHODS
We conducted a retrospective study involving 80 consecutive patients with paroxysmal or persistent AF, left atrial (LA) dilation (LA diameter >40 mm) and failed prior interventional ablation (40 patients, 50%) who underwent thoracoscopic epicardial ablation with box lesions (36 patients) or bi-atrial (BA) lesion (44 patients) in our institution. Freedom from atrial tachyarrhythmias after the procedures was compared between the box lesion group and BA lesion group.
RESULTS
Baseline differences included more patients with persistent AF (86.4% vs 47.2%) and larger left atrium [48.00 (44.00–50.75) vs 42.00 (41.25–44.00) mm] in the BA lesion group. There was no difference in procedural complications between the 2 groups. After a mean follow-up of 32 months, the freedom from atrial tachyarrhythmias off antiarrhythmic drugs at 6, 12 and 24 months was 77.2%, 77.2% and 77.2% in the BA lesion group and 69.4%, 50.0% and 40.6% in the box lesion group, respectively (P = 0.006). After adjustment for sex, age, body mass index, LA diameter, AF type, history of AF, and previous interventional ablation, BA lesion was an independent predictor of lower atrial tachyarrhythmia recurrence (hazard ratio 0.447, 95% confidential interval 0.208–0.963; P = 0.040).
CONCLUSIONS
Compared with the box lesion set, thoracoscopic epicardial ablation with BA lesion sets might provide better freedom from atrial tachyarrhythmias for paroxysmal or persistent AF with LA dilation. Randomized control trials are warranted to confirm the benefit of BA lesion sets in these patients.
Keywords: Atrial fibrillation, Surgical ablation, Thoracoscopy, Box lesion, Bi-atrial lesion, Dilated atrium
Thoracoscopic epicardial ablation off-pump has been an evolving technique in the management of atrial fibrillation (AF) in the past 15 years.
INTRODUCTION
Thoracoscopic epicardial ablation off-pump has been an evolving technique in the management of atrial fibrillation (AF) in the past 15 years. The 2020 European Society of Cardiology guidelines for the diagnosis and management of AF stated that thoracoscopic surgical ablation is reasonable in patients who have symptomatic paroxysmal or persistent AF refractory to antiarrhythmic drug (AAD) therapy and have failed percutaneous AF ablation, or with evident risk factors for catheter failure, to maintain long-term sinus rhythm (SR) [1]. Thoracoscopic radiofrequency ablation frequently targeting the pulmonary vein (PV) or posterior left atrium and left atrial appendage (LAA) exclusion has been applied.
Thoracoscopic epicardial off-pump procedures using limited lesion sets were previously suggested to not be very effective [2–4]. Several electrophysiological studies have demonstrated that the right atrium might play an important role in the AF mechanism [5, 6]. In patients with paroxysmal or persistent AF and left atrial (LA) dilation, in addition to the left atrium, the right atrial substrate might be responsible for AF episodes and maintenance. This study aimed to explore the superior SR maintenance of a bi-atrial (BA) lesion set in comparison to a box lesion set during thoracoscopic epicardial ablation off-pump in these patients.
PATIENTS AND METHODS
Study population
Two hundred and five consecutive patients with AF underwent thoracoscopic epicardial off-pump ablation from September 2010 to November 2019 at Fuwai Hospital, Beijing, China. The selection criteria of thoracoscopic epicardial ablation included one of the following: symptomatic AF refractory or intolerant to one or more AAD therapies, failed interventional catheter or cryoablation and patient preference for thoracoscopic surgical ablation instead of interventional ablation after awareness of efficacy and safety and in the absence of organic valvular disease. After excluding patients with normal LA size or long-standing persistent AF, 80 patients with paroxysmal or persistent AF with LA dilation (LA diameter >40 mm) [2] were retrospectively included in this study. Thirty-six and 44 patients underwent thoracoscopic ablation with box lesion sets or BA lesion sets, respectively (Fig. 1). The Institutional Review Board at Fuwai Hospital approved this study (date of review, 24 October 2019; approval 2017-880).
Figure 1:
Flow diagram of patient inclusion.
Thoracoscopic epicardial ablation
Before December 2016, box lesion sets were routinely applied in thoracoscopic epicardial ablation for AF. Thereafter, for advanced paroxysmal or persistent AF, the procedure was mainly completed with BA ablation. Epicardial ablation was performed with access to the bilateral thoracic cavity. A double-lumen endotracheal tube was used for selective lung ventilation. Two working ports with 15 mm were located in the mid-axillary fifth intercostal space and the mid-clavicular second intercostal space. A camera port of 10 mm was placed in the anterior-axillary third intercostal space. Generally, left-side ablation was performed first. The right-side approach was similar to the left-side approach with 3 ports but positioned more anteriorly.
Bi-atrial lesion set
On the left side, after the pericardium was opened, the LAA was first removed by a linear staple (EZ 60, Ethicon Endosurgery, Cincinati, Ohio, USA), and the Marshall ligament was divided by an ultrasound scalpel. After bilateral PV isolation was created with a bipolar radiofrequency clamp (Isolator, Atricure, Mason, Ohio, USA), the left-sided roof line, the left-sided bottom line and the left fibrous trigone line were created with a bipolar radiofrequency clamp by separately redirecting the upper and lower jaws of the clamp into the transverse sinus and oblique sinus. Then, we completed the left fibrous trigone line [7] with a bipolar radiofrequency pen (Isolator, Atricure, Mason, Ohio, USA). The linear line connecting the left inferior PV to the great vein and the line connecting the left superior PV to the root of the LAA were made with a bipolar radiofrequency pen. On the right side, after the right-sided roof line and the bottom line were made using a bipolar radiofrequency pen, the left-sided lesion set was completed. At the right atrium, a linear lesion connecting the superior vena cava to the inferior vena cava, a linear right atrial appendage lesion (the apex to the base at the level of the root of the aorta) and a linear lesion connecting the right atrial appendage to the superior vena cava–inferior vena cava linear lesion were made (Fig. 2A). The bipolar clamp was usually applied to ablate at least 6 times per lesion, and lesions created by bipolar pens were ablated for 80 s at 1 place. A detailed description was previously reported by our group [8].
Figure 2:
Schematic diagram of the bi-atrial lesion set and box lesion set during thoracoscopic epicardial ablation. (A) Bi-atrial lesion set and (B) box lesion set. IVC: inferior vena cava; LAA: left atrial appendage; LCX: left circumflex branch; LPV: left pulmonary vein; PA: pulmonary artery; RPV: right pulmonary vein; SVC: superior vena cava.
Box lesion set
As shown in Fig. 2B, the box lesion set only included the bilateral PV isolation, the roof line, the bottom line and the linear lesion connecting the left superior PV to the root of the LAA. We routinely applied bipolar clamps to make the left-sided roof and floor line by putting the upper jaw into the transverse sinus and the lower jaw into the oblique sinus simultaneously, and an additional bipolar pen (Isolator, Atricure, Mason, Ohio, USA) was needed to complement the box lesion when the left atrium was enlarged. If we could do a complete box lesion with bipolar clamps, we would not use the bipolar pens, but in this condition, a short-term drop in blood pressure was of concern.
Post-procedure management
After the procedure, all patients were under continuous rhythm monitoring until discharge. AAD treatment was initiated as soon as possible after the procedure. Taking into account the rapid onset of the drug, short half-life and negative side effects on the thyroid and lung and liver, sotalol was the first consideration to patients. Amiodarone and propafenone were alternative drugs for patients who were extremely sensitive to sotalol (corrected Q-T interval longer than 500 ms). Oral anticoagulation was started as soon as possible if patients were at low risk of bleeding. The patients were given warfarin as the first consideration, and new oral anticoagulants were at the discretion of the patients themselves. AADs and oral anticoagulation were continued for 3 months.
Follow-up
The patients were followed up at 3, 6 and 12 months and annually thereafter after the procedure. Major adverse events, including cardiac death, stroke, heart failure and severe bleeding, were recorded. A 24-h Holter monitoring at least was performed at every interval after the intervention. Any arrhythmia symptoms or suspicious AF recurrence following ablation were deemed deserving 12-lead electrocardiogram (ECG) or 24 h Holter monitoring. After a blanking period of 3 months, all documented episodes of AF, atrial flutter or atrial tachycardia for >30 s were considered recurrence. In patients with recurrence and CHA2DS2-VASc ≥2, continuous oral anticoagulation was recommended.
Statistical analysis
Categorical data are presented as frequencies and proportions, and continuous variables are presented as medians with interquartile ranges. Continuous variables in the box lesion group (Box group) and BA lesion group were compared based on the non-parametric Mann–Whitney U-test. Binary and categorical variables were compared based on the Fisher’s exact test. Kaplan–Meier survival curves were constructed between the Box group and BA group, and the log-rank test was used to compare the difference in SR restoration during follow-up. Univariable and multivariable Cox proportional hazards regression were used to determine hazard ratios (HRs) and corresponding 95% confidential intervals (CIs). A backward variable selection approach with a significance level <0.2 was performed, and variables with P-value <0.2 in univariable analysis were included in multivariable regression analysis. All statistical analyses were performed using SPSS 23.0 for Windows (SPSS Inc., Chicago, IL, USA) and R version 4.0.2 (R Foundation for Statistical Computing, Vienna, Austria).
RESULTS
Patients characteristics
The baseline characteristics of the patients are summarized in Table 1. There were more patients with persistent AF in the BA group (86.4% vs 47.2%, P < 0.001). Patients in the BA group had a larger LA diameter (anteroposterior left atrial diameter, measured at the left parasternal axis plane by transthoracic echocardiography) than patients in the Box group [48.00 (44.00–50.75) vs 42.00 (41.25–44.00) mm, P < 0.001]. There were more patients with tricuspid regurgitation (TR) in the BA group (P = 0.002). There were no other significant differences between those patient groups. In the 2 groups, almost half of the patients had failed prior interventional ablation.
Table 1:
Characteristics of the 80 patients who underwent thoracoscopic epicardial ablation for AF
| Box group (n = 36) | BA group (n = 44) | P-value | |
|---|---|---|---|
| Age (years), median (IQR) | 60.50 (54.25–63.75) | 61.50 (53.00–65.00) | 0.735 |
| Male gender, n (%) | 26 (72.2) | 35 (79.5) | 0.616 |
| Body mass index (kg/m2), median (IQR) | 26.20 (24.48–28.26) | 25.88 (24.91–27.93) | 0.768 |
| Type of AF, n (%) | <0.001 | ||
| Paroxysmal AF | 19 (52.8) | 6 (13.6) | |
| Persistent AF | 17 (47.2) | 38 (86.4) | |
| History of AF (years), median (IQR) | 6.00 (2.00–8.00) | 4.00 (1.00–8.00) | 0.261 |
| Previous interventional ablation, n (%) | 21 (58.3) | 19 (43.2) | 0.261 |
| Hypertension, n (%) | 14 (38.9) | 25 (56.8) | 0.170 |
| Diabetes, n (%) | 2 (5.6) | 9 (20.5) | 0.110 |
| Previous stroke, n (%) | 4 (11.1) | 6 (13.6) | 1.000 |
| Coronary artery disease, n (%) | 3 (8.3) | 7 (15.9) | 0.497 |
| Hyperlipidaemia, n (%) | 5 (13.9) | 9 (20.5) | 0.636 |
| Peripheral vascular diseases, n (%) | 2 (5.6) | 6 (13.6) | 0.410 |
| Mitral regurgitation, n (%) | 0.253 | ||
| Mild | 27 (75.0) | 35 (79.5) | |
| Moderate | 4 (11.1) | 1 (2.3) | |
| Tricuspid regurgitation, n (%) | 0.002 | ||
| Mild | 17 (47.2) | 37 (84.1) | |
| Moderate | 5 (13.9) | 2 (4.5) | |
| LAD (mm), median (IQR) | 42.00 (41.25–44.00) | 48.00 (44.00–50.75) | <0.001 |
| LVEDD (mm), median (IQR) | 48.50 (45.00–50.00) | 48.50 (46.25–51.00) | 0.249 |
| LVEF, median (IQR) | 61.50 (56.50–65.75) | 60.50 (60.00–65.00) | 0.950 |
| CHA2DS2VASc, n (%) | 0.313 | ||
| 0 | 8 (22.2) | 8 (18.2) | |
| 1 | 15 (41.7) | 20 (45.5) | |
| 2 | 7 (19.4) | 13 (29.5) | |
| ≥3 | 6 (16.7) | 3 (6.8) | |
| Preoperative oral anticoagulants, n (%) | 32 (88.9) | 37 (84.1) | 0.746 |
| Preoperative class I or III AADs, n (%) | 28 (77.8) | 27 (61.4) | 0.148 |
AADs: antiarrhythmic drugs; AF: atrial fibrillation; BA: bi-atrial; IQR: interquartile range; LAD: left atrial diameter; LVEDD: left ventricular end-diastolic diameter; LVEF: left ventricular ejection fraction.
Procedure and perioperative data
Six patients (13.6%) restored SR during surgery in the BA group, in which AF converted to SR when ablation was performed at the left atrium in 2 patients (4.5%) and at the right atrium in 4 patients (9.1%). The median postoperative mechanical ventilatory support time was 10.9 (0–13.5) h in the Box group and 14.0 (11.0–16.8) h in the BA group (P = 0.001). Tracheal intubation was removed immediately after the procedure in the operating room in some younger patients in the Box group. There was no difference in the volume of pleural drainage or postoperative length of stay between the 2 groups (Table 2).
Table 2:
Perioperative results after thoracoscopic epicardial ablation with box lesions or BA lesions for paroxysmal or persistent atrial fibrillation with left atrium dilation
| Perioperative details | Box group (n = 36) | BA group (n = 44) | P-value |
|---|---|---|---|
| Ventilation time (h), median (IQR) | 10.9 (0–13.5) | 14.0 (11.0–16.8) | 0.001 |
| Volume of pleural drainage (ml), median (IQR) | 485.0 (340.0–835.0) | 480 (340.0–680.0) | 0.345 |
| Volume of pleural drainage (the first day after surgery) (ml), median (IQR) | 195.0 (102.5–267.5) | 172.5 (82.5–227.5) | 0.363 |
| Hospital length of stay after surgery (days), median (IQR) | 6.7 (5.7–6.7) | 6.5 (5.3–9.0) | 0.249 |
| Complications, n (%) | 3a (8.3) | 5 (11.4) | 0.724 |
| Perioperative mortality | 0 | 0 | |
| Stroke | 1 (2.8) | 0 | 0.450 |
| Permanent pacemaker implantation | 1 (2.8) | 0 | 0.450 |
| Pulmonary embolism | 0 | 3 (6.8) | 0.248 |
| Conversion to sternotomy | 2 (5.6) | 2 (4.5) | 1.000 |
| Pulmonary vein bleeding | 2 | 1 | |
| Adhesions/adherences | 0 | 1 |
One patient who underwent conversion to sternotomy experienced stroke in the Box group.
BA: bi-atrial; IQR: interquartile range.
Safety
During the perioperative period, 3 patients (8.3%) in the Box group and 5 patients (11.4%) in the BA group experienced complications (P = 0.724) (Table 2). No patient died perioperatively. One patient (2.8%) underwent stroke and another patient (2.8%) needed permanent pacemaker implantation in the Box group. Compared to the Box group, 3 patients (6.8%) were diagnosed with non-symptomatic small pulmonary embolism according to LA enhanced computed tomography before discharge. After 3 months of oral anticoagulation, repeated enhanced computed tomography did not display any thrombosis in the pulmonary artery in these patients.
Follow-up
Freedom from atrial tachyarrhythmia recurrence
After a median follow-up of 32 months (range from 12 to 60 months), 23 patients (63.9%) underwent atrial tachyarrhythmia recurrence (2 patients underwent atrial flutter) in the Box group; 10 patients (22.7%) underwent atrial tachyarrhythmia recurrence (4 patients underwent atrial flutter) in the BA group. The percentage of patients free from atrial tachyarrhythmias without AADs was 69.4% at 6 months, 50.0% at 12 months and 40.6% at 24 months in the Box group and 77.2% at 6 months, 77.2% at 12 months and 77.2% at 24 months in the BA group (P = 0.006) (Fig. 3). Freedom from atrial tachyarrhythmias with AADs was 77.2% at 6 months, 55.6% at 12 months and 45.1% at 24 months in the Box group and 79.5% at 6 months, 79.5% at 12 months and 79.5% at 24 months in the BA group (P = 0.016). At the latest follow-up, 2 patients suffered from stroke in the Box group and 1 patient in the BA group. Nobody died during follow-up in either group.
Figure 3:
Kaplan–Meier curve representing the percentage of patients free from ATA without AADs up to 3 years after ablation with box lesions and BA lesions. AADs: antiarrhythmic drugs; ATA: atrial tachyarrhythmia; BA: bi-atrial; plus sign (+) indicates censored (some patients did not know the exact time of recurrence, so we described the end point events at each fixed follow-up time point).
Seven patients with recurrent atrial tachyarrhythmias underwent an electrophysiology study and catheter ablation in the Box group and 2 patients in the BA group. Voltage mapping during redo catheter ablation in the patients who had recurrent AF showed that non-transmural lesions were mainly ablated by the bipolar pen. At the last follow-up, 4 of 7 (57.1%) patients converted to SR in the Box group, and none of the patients (0/2) converted to SR in the BA group after the last catheter ablation procedure.
Risk factors for freedom from atrial tachyarrhythmia recurrence
Univariable Cox regression analysis showed that BA ablation (HR 0.392, 95% CI 0.185–0.833; P = 0.015) was significantly associated with a lower risk of atrial tachyarrhythmia recurrence off AADs during the follow-up period. In the multivariable Cox regression analysis, after adjustment for sex, age, body mass index, left atrial diameter, AF type, duration of AF and previous interventional ablation, BA ablation (HR 0.447, 95% CI 0.208–0.963; P = 0.040) was an independent predictor of lower atrial tachyarrhythmia recurrence during the follow-up period (Fig. 4).
Figure 4:
Forest plot of univariable and multivariable Cox regression analyses of recurrence of atrial tachyarrhythmias. Green indicates univariable analyses and red indicates multivariable analyses. AF: atrial fibrillation; BMI: body mass index; CI: confidential interval; HR: hazard ratio; LA: left atrial; LVEF: left ventricular ejection fraction.
DISCUSSION
The main finding in this study was that BA lesions could achieve better restoration of SR than box lesions when patients with paroxysmal or persistent AF and LA dilation underwent thoracoscopic epicardial ablation. Freedom from atrial tachyarrhythmias off AADs at 6, 12 and 24 months was 77.2%, 77.2% and 77.2% after thoracoscopic ablation with a BA lesion set in these patients. It could be expected that thoracoscopic epicardial ablation for AF patients without structural heart disease will become increasingly popular because of its low invasiveness and the recommendation of guidelines. When surgeons make a decision on the ablation lesion set of advanced paroxysmal AF or persistent AF, the encouraging results of our study will provide an additional option.
The Cox-maze procedure is the cornerstone of surgical treatment of AF. The stand-alone Cox-maze procedure was not popular in treating AF without structural heart disease owing to invasiveness and fears of associated increased morbidity [9, 10]. To overcome these limitations, thoracoscopic epicardial ablation with less trauma and without cardiopulmonary bypass was introduced to treat lone AF. Isolated PVs, box lesions or Dallas lesions have been widely applied in thoracoscopic epicardial ablation [4, 11] and are not equivalent to the Cox-maze lesion set [12, 13]. The conventional Cox-maze procedure considered the left and right atrium as an electrical continuum [14]. Based on the macro-re-entrant circuits of the Cox-maze procedure [15] and electrophysiological mapping findings [6, 16], the right atrium is likely to play a role in the mechanism of persistent AF, especially when the left atrium is dilated, which implies more advanced structural remodelling. Generally, the mechanism of paroxysmal AF was mainly associated with a focus trigger on PVs. In this cohort, in addition to an enlarged left atrium, most patients (16/25) with paroxysmal AF had previous failed interventional ablation, and others had TR. The AF mechanism in these patients might be more complex. In this study, the results showed that thoracoscopic BA ablation could obtain superior freedom from atrial tachyarrhythmias compared to ablation with box lesions in these patients. AF converting to SR in 4 patients during ablation at the right atrium supports the theory and evidence of the importance of right atrium drivers in maintaining AF.
To improve the efficacy of thoracoscopic ablation for advanced paroxysmal AF or persistent AF, we explored ablation with a BA lesion set consistent with the principle of the Cox-maze procedure. In the BA group, 86% of patients had persistent AF, all patients with paroxysmal AF had TR and two-third had failed prior interventional ablation. The results showed that freedom from atrial tachyarrhythmias off AADs at 6, 12 and 24 months was 77.2%, 77.2% and 77.2% after BA thoracoscopic ablation, which was better than box lesions. In the BA group, despite a larger LA size, more patients with persistent AF and more patients with TR, a better freedom from atrial tachyarrhythmias was achieved, which implied a possible efficacy benefit of BA ablation in advanced paroxysmal AF and persistent AF. Janusauskas et al. [17] reported the results of minimally invasive stand-alone BA surgical ablation in 91 patients, and freedom from AF was 59% and 45% at 1 and 2 years postoperatively. We noticed that there was only a box lesion at left atrium in this study. However, in our study, in addition to box lesions, we created a left fibrous trigone line and a linear line connecting the left inferior PV to the great vein to interrupt mitral-dependent atrial flutter and re-entrant circuits located in the mitral isthmus, which was equivalent to the left maze lesion set. Bartuś et al. [18] reported similar results to our study; SR maintenance was 84% at 1 year after thoracoscopic ablation with a Cox-maze III lesion set in 25 patients (persistent AF, 21 patients).
Although a better result was acquired after thoracoscopic BA ablation in these patients, the BA lesion set applied in our study could not be equivalent to the Cox-maze procedure. Although the ablation line to the tricuspid annulus cannot be created by stand-alone epicardial ablation at the right atrium, which increases the risk of atrial flutter, it is very easily treated endocardially in the catheter lab. Moreover, transpolar radiofrequency pens cannot reliably create transmural lesions from the epicardial surface on the beating heart due to the heat-sink [19]. When intramural/transmural re-entry [20] coexists with non-transmural tissue lesions, it is reasonable that the risk of AF recurrence would increase. However, even if AF recurs, it is possible to complete the epicardial–endocardial Cox-maze lesion set by subsequent catheter ablation when BA lesion is created during thoracoscopic epicardial ablation [8, 21].
The main postoperative complication was non-symptomatic small pulmonary embolism in the BA group. In a recent meta-analysis of totally thoracoscopic procedures for the treatment of AF, the results showed that the incidence of postoperative pulmonary embolism was 0.17% [4]. Our study displayed a significantly higher incidence of pulmonary embolism, which might be associated with the ablation method at the right atrium and postoperative atelectasis. We ablated for 80 s with a bipolar pen in every application to create a transmural lesion [19]. The atrial muscles between the right atrial pectinate were very thin, and durable ablation might increase the risk of mural thrombosis. Postoperative computerized tomography imaging did not display the appearance of pulmonary embolism at 3 months after the procedure in these patients. However, early postoperative anticoagulation and airway management are warranted. In addition, BA ablation may increase the risk of pacemaker implantation; however, no patients in the BA group were implanted with pacemakers in this study. First, we were conscious of being far away from the sinus node area during right atrial ablation; second, patients with restored SR in the BA group did not have sick sinus syndrome.
Limitations
The retrospective single-centre study design with a small sample size and the relatively short follow-up time limited the drawing of broad conclusions. In addition, there was a large selection bias between the 2 groups in our study, which also affected the reliability of the study results and should be adjusted by propensity scoring or inverse probability of treatment weighting instead of multivariable regression analysis alone. We used a box lesion set primarily for patients with paroxysmal and persistent AF and a BA lesion set primarily for persistent and long-standing persistent AF. Hence, to maintain the relative comparability of baseline characteristics between the 2 groups, we excluded patients with long-standing persistent AF, which led to a high exclusion rate and might influence the results. In this study, we did not routinely check the conduction block of the lesion set during the procedure, which might contribute to AF recurrence. In addition, ECG testing was only performed at every follow-up time point and symptomatic moment, which possibly resulted in missed asymptomatic atrial tachyarrhythmia episodes.
CONCLUSION
In patients with advanced paroxysmal AF or persistent AF, thoracoscopic BA ablation might provide better freedom from atrial tachyarrhythmia recurrence than box lesion ablation. Randomized control trials are warranted to confirm the benefit of the BA lesion set in these patients.
Funding
This study was supported by grants from the Ministry of Science and Technology of People’s Republic of China (2016YFC1302001). The funder had no role in the study design, data collection, data analysis, data interpretation or writing of the manuscript.
Conflict of interest: none declared.
Author contributions
Zhe Zheng: Conceptualization; Methodology; Project administration; Supervision; Writing—original draft; Writing—review & editing. Haojie Li: Data curation; Formal analysis; Investigation. Sheng Liu: Resources; Validation. Ge Gao: Resources; Validation. Chunyu Yu: Data curation; Formal analysis. Hengqiang Lin: Data curation; Resources. Ying Meng: Methodology.
Reviewer information
Interactive CardioVascular and Thoracic Surgery thanks Steven Hunter, Leonardo Paim and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.
ABBREVIATIONS
- AAD
Antiarrhythmic drug
- AF
Atrial fibrillation
- BA
Bi-atrial
- CI
Confidential interval
- HR
Hazard ratio
- LA
Left atrial
- LAA
Left atrial appendage
- PV
Pulmonary vein
- SR
Sinus rhythm
- TR
Tricuspid regurgitation
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