Quality of life improvement from thoracoscopic atrial fibrillation ablation in women versus men: a prospective cohort study.

OBJECTIVES: Thoracoscopic ablation has proven to be an effective and safe rhythm control strategy, especially for persistent atrial fibrillation. However, its impact on quality of life and potential gender differences remains unclear. METHODS: this prospective, single-centre observational study included consecutive patients with symptomatic atrial fibrillation undergoing thoracoscopic ablation. Quality of life was measured using the Short Form 36 (SF-36) and Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaires and longitudinal trend analysis including linear mixed models was used to assess gender-specific differences. RESULTS: 191 patients were included; mean age 63.9 ± 8.6 years, 61 (31.9%) women and 148 (77.5%) with non-paroxysmal atrial fibrillation. Women were older, more symptomatic and reported lower baseline quality of life. AFEQT summary scores substantially improved after three months (relative increase 51.5% from baseline; p < 0.001) and persisted up to 1-year (57.2%; p < 0.001). Women showed substantial quality of life improvement which was comparable to men at 1 year. Distinct gender-related trajectories for AFEQT were observed. Women showed more often clinically important decline over time, yet AF recurrence and age were predictive factors in both men and women. Patients with AF recurrence also experienced QoL improvements, albeit to a lesser extent than those in sinus rhythm (61.3% vs 26.9%, p < 0.001), with no differences between men and women. CONCLUSIONS: Thoracoscopic ablation for atrial fibrillation results in substantial quality of life improvement and was comparable for men and women. Understanding sex-specific and age-related trajectories is important to further enhance patient-centered atrial fibrillation care.

Closed-chest unilateral thoracoscopic ablation: box lesion with radiofrequency clamps only.

In this article, we describe the modified technique of a unilateral closed-chest thoracoscopic ablation and left atrial appendage closure including a box lesion that is made by radiofrequency clamps only for the treatment of atrial fibrillation. By abandoning the unidirectional pen devices and replacing these by radiofrequency clamps, we aim to further improve the procedural efficacy and shorten operation time while minimizing surgical exposure for the patient.

Long-term outcome after totally thoracoscopic ablation for atrial fibrillation.

INTRODUCTION: Totally thoracoscopic ablation for symptomatic atrial fibrillation (AF) refractory to drug or catheter based therapy is indicated as a Class 2A recommendation according to latest guidelines. Evidence for long-term rhythm control and stroke reduction is limited. The aim of this study was to report on long-term outcome after totally thoracoscopic ablation. METHODS AND RESULTS: In total 82 consecutive patients were included that underwent totally thoracoscopic ablation including left appendage closure (2012-2013). The primary outcome was freedom from atrial arrhythmia recurrence. Secondary outcomes were survival, freedom from cerebrovascular events, freedom from reablation and definite pacemaker implantation. The mean age was 59.9 ± 8.6 years and 71% were male. The mean CHA2 DS2 -VASc score was 1.2 ± 1.0. The overall freedom from atrial arrhythmia was 60% after a mean follow up of 4.0 ± 0.6 years. Freedom from cerebrovascular events was 98.8% after mean follow-up of 4.4 ± 0.3 years and overall survival was 98.8%, with one noncardiac related death. The observed rate of ischemic stroke, hemorrhagic stroke or transient ischemic attack was 0.3 per 100 patient-years. CONCLUSIONS: Totally thoracoscopic ablation is an effective sustainable rhythm control therapy for AF with a reasonable recurrence rate and low stroke rate when performed in dedicated AF centers.

Totally thoracoscopic ablation for atrial fibrillation: a systematic safety analysis.

Aims: Thoracoscopic surgical ablation has evolved into a successful strategy for symptomatic atrial fibrillation (AF) refractory to other therapy. More widespread referral is limited by the lack of information on potential complications. Our aim was to systematically evaluate 30-day complications of totally thoracoscopic surgical ablation. Methods and results: We retrospectively studied consecutive patients undergoing totally thoracoscopic surgical ablation at a referral centre in the Netherlands (2007-2016). Patients received pulmonary vein isolation, with additional lesion lines as needed, and left atrial appendage exclusion. The primary outcomes were freedom from any complications and freedom from irreversible complications at 30-days. Secondary outcomes included intra- and post-operative complications according to severity. Included were 558 patients with median age 62 years (interquartile range 56-68 years), 70% male and 53% with a previous failed catheter ablation. The cohort consisted of 43% paroxysmal AF, 47% persistent AF, and 10% long-standing persistent AF. Freedom from any 30-day complication was 88.2%, and from complications with life-long affecting consequences 97.5%. The intra-operative complication rate was 2.3% with no strokes or death observed. The median hospital length of stay was 4 days. The percentage of patients with major and minor complications at 30-days was 3.2% and 8.1%, respectively, with one patient dying of an ischaemic stroke. The only patient groups with excess complications were women aged ≥70 years and patients with a history of congestive heart failure. Conclusions: Totally thoracoscopic ablation is associated with a low complication rate in a referral centre and may be a useful alternative to other rhythm control strategies.

The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review.

Background Unstable distal radius fractures are a popular research subject. However, to appreciate the findings of studies that enrolled patients with unstable distal radius fractures, it should be clear how the authors defined an unstable distal radius fracture. Questions In what percentage of studies involving patients with unstable distal radius fractures did the authors define unstable distal radius fracture? What are the most common descriptions of an unstable distal radius fracture? And is there one preferred evidence-based definition for future authors? Methods A systematic search of literature was performed to identify any type of study with the term unstable distal radius fracture. We assessed whether a definition was provided and determined the level of evidence for the most common definitions. Results The search yielded 2,489 citations, of which 479 were included. In 149 studies, it was explicitly stated that patients with unstable distal radius fractures were enrolled. In 54% (81/149) of these studies, the authors defined an unstable distal radius fracture. Overall, we found 143 different definitions. The seven most common definitions were: displacement following adequate reduction; Lafontaine's definition; irreducibility; an AO type C2 fracture; a volarly displaced fracture; Poigenfürst's criteria; and Cooney's criteria. Only Lafontaine's definition originated from a clinical study (level IIIb). Conclusion In only half of the studies involving patients with an unstable distal radius fracture did the authors defined what they considered an unstable distal radius fracture. None of the definitions stood out as the preferred choice. A general consensus definition could help to standardize future research.

The Minimum Clinically Important Difference of the Patient-rated Wrist Evaluation Score for Patients With Distal Radius Fractures.

BACKGROUND: The Patient-rated Wrist Evaluation (PRWE) is a commonly used instrument in upper extremity surgery and in research. However, to recognize a treatment effect expressed as a change in PRWE, it is important to be aware of the minimum clinically important difference (MCID) and the minimum detectable change (MDC). The MCID of an outcome tool like the PRWE is defined as the smallest change in a score that is likely to be appreciated by a patient as an important change, while the MDC is defined as the smallest amount of change that can be detected by an outcome measure. A numerical change in score that is less than the MCID, even when statistically significant, does not represent a true clinically relevant change. To our knowledge, the MCID and MDC of the PRWE have not been determined in patients with distal radius fractures. QUESTIONS/PURPOSES: We asked: (1) What is the MCID of the PRWE score for patients with distal radius fractures? (2) What is the MDC of the PRWE? METHODS: Our prospective cohort study included 102 patients with a distal radius fracture and a median age of 59 years (interquartile range [IQR], 48-66 years). All patients completed the PRWE questionnaire during each of two separate visits. At the second visit, patients were asked to indicate the degree of clinical change they appreciated since the previous visit. Accordingly, patients were categorized in two groups: (1) minimally improved or (2) no change. The groups were used to anchor the changes observed in the PRWE score to patients' perspectives of what was clinically important. We determined the MCID using an anchor-based receiver operator characteristic method. In this context, the change in the PRWE score was considered a diagnostic test, and the anchor (minimally improved or no change as noted by the patients from visit to visit) was the gold standard. The optimal receiver operator characteristic cutoff point calculated with the Youden index reflected the value of the MCID. RESULTS: In our study, the MCID of the PRWE was 11.5 points. The area under the curve was 0.54 (95% CI, 0.37-0.70) for the pain subscale and 0.71 (95% CI, 0.57-0.85) for the function subscale. We determined the MDC to be 11.0 points. CONCLUSIONS: We determined the MCID of the PRWE score for patients with distal radius fractures using the anchor-based approach and verified that the MDC of the PRWE was sufficiently small to detect our MCID. CLINICAL RELEVANCE: We recommend using an improvement on the PRWE of more than 11.5 points as the smallest clinically relevant difference when evaluating the effects of treatments and when performing sample-size calculations on studies of distal radius fractures.