title: Surgical ablation in patients undergoing mitral valve surgery: impact of lesion set and surgical techniques on long-term success.
abstract: OBJECTIVE
  To assess the results and impact of lesion set and surgical technique on long-term success of surgical ablation during mitral surgery.
  
  
  RESULTS
  The patient population consisted of 685 subjects with persistent and long-standing persistent atrial fibrillation (AF) undergoing cardiac surgery for mitral valve disease as the primary indication and concomitant ablation between January 2003 and January 2012 at three institutions. One hundred and sixty-six underwent unipolar (24.2%), 371 (54.2%) bipolar, and 148 (21.6%) had combined ablation. Median follow-up was 58.4 months (interquartile range 43.3-67.9). To appropriately account for death, a competing risk model was employed to identify predictors of cumulative incidence of recurrent AF among lesion set and surgical techniques. Eight-year freedom from recurrent arrhythmia without antiarrhythmic drugs was 0.60 ± 0.02. Success rate was higher using bipolar radiofrequency (RF) (P < 0.001), after performing mitral isthmus line (P = 0.003) and following the biatrial technique (P < 0.001). Competing risk regression revealed that use of unipolar RF [sub-hazard ratio (SHR) 2.41 (1.52-3.43), P < 0.001], combined unipolar/bipolar ablation [SHR 1.93 (0.89-2.57), P = 0.003] and the absence of right atrial ablation [SHR 2.79 (1.27-3.48), P < 0.001] were predictors of cumulative incidence of long-term recurrence.
  
  
  CONCLUSIONS
  Our experience suggests that the use of bipolar clamp improves long-term results in surgical treatment of AF and that right-sided ablation should be routinely added. Randomized studies are necessary to confirm our findings.
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands sandro.gelsomino@maastrichtuniversity.nl.|Careggi University Hospital, Florence, Italy.
authors.forename: Sandro
authors.initials: S
authors.lastname: Gelsomino
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.
authors.forename: Mark
authors.initials: M
authors.lastname: La Meir
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.
authors.forename: Henrica N A M
authors.initials: HN
authors.lastname: Van Breugel
authors.affiliation: University of Magna Graecia, Catanzaro, Italy.
authors.forename: Attilio
authors.initials: A
authors.lastname: Renzulli
authors.affiliation: Careggi University Hospital, Florence, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Rostagno
authors.affiliation: Ospedali Riuniti Brescia, Brescia, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Lorusso
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.
authors.forename: Orlando
authors.initials: O
authors.lastname: Parise
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.
authors.forename: Pieter W J
authors.initials: PW
authors.lastname: Lozekoot
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.
authors.forename: Idserd D G
authors.initials: ID
authors.lastname: Klop
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.
authors.forename: Narendra
authors.initials: N
authors.lastname: Kumar
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.|Careggi University Hospital, Florence, Italy.
authors.forename: Fabiana
authors.initials: F
authors.lastname: Lucà
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.|Careggi University Hospital, Florence, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Matteucci
authors.affiliation: University of Magna Graecia, Catanzaro, Italy.
authors.forename: Filiberto
authors.initials: F
authors.lastname: Serraino
authors.affiliation: University of Magna Graecia, Catanzaro, Italy.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Santè
authors.affiliation: Careggi University Hospital, Florence, Italy.
authors.forename: Sabina
authors.initials: S
authors.lastname: Caciolli
authors.affiliation: Ospedali Riuniti Brescia, Brescia, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Vizzardi
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.
authors.forename: Monique
authors.initials: M
authors.lastname: De Jong
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.
authors.forename: Harry J G M
authors.initials: HJ
authors.lastname: Crijns
authors.affiliation: Careggi University Hospital, Florence, Italy.
authors.forename: Gian Franco
authors.initials: GF
authors.lastname: Gensini
authors.affiliation: University Hospital Maastricht, Maastricht, The Netherlands.
authors.forename: Jos G
authors.initials: JG
authors.lastname: Maessen
mesh_terms: D000368:Aged; D001281:Atrial Fibrillation / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000379:methods*; D017115:Catheter Ablation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006349:Heart Valve Diseases / Q000150:complications* / Q000601:surgery*; D006801:Humans; D007558:Italy; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D009426:Netherlands; D011183:Postoperative Complications / Q000401:mortality; D012008:Recurrence; D012044:Regression Analysis; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Atrial fibrillation; Mitral valve surgery; Surgical ablation