Surgical approaches to maintaining sinus rhythm in patients with type 2 diabetes and long-term persistent atrial fibrillation

BACKGROUND: Treatment of patients with diabetes mellitus (DM) and a long-term persistent form of atrial fibrillation (AF) is an unsolved problem of the healthcare system due to a high risk of disability and mortality. Considering low effectiveness of drug treatment for AF, surgical technologies have been introduced into clinical practice in most countries, but their effectiveness has not been validated for patients with DM. According to various researches isolated interventional treatment of patients with AF and DM is associated with a high rate of recurrence compared to patients without disorders of carbohydrate metabolism. The feasibility of using other surgical approaches (the isolated thoracoscopic procedure or the isolated thoracoscopic procedure in combination with intracardiac intervention) for the treatment of AF for patients with DM has not been determined yet.

AIM: To evaluate the effectiveness and safety of a staged surgical approach to release patients with DM from AF.

MATERIALS AND METHODS: The study included 19 patients aged 53–73 with DM and long persistent AF. Among them there were 4 (21,4%) women and 15 (78,9%) men. To maintain sinus rhythm all patients were undergone with thoracoscopic epicardial ablation. In three mounts, later the invasive electrophysiological studies and radiofrequency ablation were carried out due to reconnection of left atrium (LA).

RESULTS: At the end of the blinded period sinus rhythm was maintained for 17 (89,5%) patients during the observation period. Two patients (10.5%) had AF recurrence. In both cases, the second stage of treatment wasperformed (electrophysiology study and endocardial ablation). Amid normal sinus rhythm after thoracoscopic epicardial ablation the volume of the LA (p=0,013) and the N-terminal prohormone of brain natriuretic peptide (NT-proBNP) (p=0,014) significant decreased. No adverse events were recorded in the perioperative or long-term periods.

CONCLUSION: Аccording to our pilot study, the staged approach to surgical maintenance of sinus rhythm for patients with diabetes and persistent form of atrial fibrillation can be an optimal strategy. The endocardial stage could be performed for this category of patients in case of recurrence of tachysystolic cardiac arrhythmias.

1. Van Gelder IC, Rienstra M, Bunting KV, et al. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024;45(36):3314-3414. https://doi.org/10.1093/eurheartj/ehae176

2. Kolbin AS, Mosikyan AA, Tatarsky BA. Socioeconomic burden of atrial fibrillations in Russia: seven-year trends (2010-2017). Journal of Arrhythmology. 2018;92:42–48. (In Russ).

3. PhD LGMP. Association of Atrial Fibrillation with Diabetes Mellitus, High Risk Comorbidities. Maedica (Bucur). 2022;17(1):143–152. https://doi.org/10.26574/maedica.2022.17.1.143

4. Arakelyan MG, Bockeria LA, Vasilieva EY, et al. 2020 Clinical guidelines for Atrial fibrillation and atrial flutter. Russian Journal of Cardiology. 2021;26(7):4594. (In Russ.) https://doi.org/10.15829/1560-4071-2021-4594

5. Golukhova EZ, Milievskaya EB, Filatov AG, et al. Aritmologiya – 2022. Narusheniya ritma serdtsa i provodimosti. Moscow: Natsional’nyi nauchno–prakticheskii tsentr serdechno–sosudistoi khirurgii im. AN Bakuleva; 2023. (In Russ).

6. Sapelnikov OV, Nikolaeva OA, Ardus DF, et al. One-stage hybrid treatment of rersistental atrial fibrillation. Cardiology and cardiovascular surgery. 2018;11(6):83–86. (In Russ.) https://doi.org/10.17116/kardio20181106183

7. Zotov AS, Khamnagadaev IA, Sakharov ER, et al. The First Experience of the Hybrid Approach in Surgical Treatment of Atrial Fibrillation. Journal of Clinical Practice. 2022;13(4):38–50. (In Russ.) https://doi.org/10.17816/clinpract116052

8. Revishvili AS, Artyukhina EA, Strebkova ED, et al. Evolution of thoracoscopic treatment of atrial fibrillation: from inception to contemporary approaches. Complex Issues of Cardiovascular Diseases. 2023;12(2):107-121. (In Russ.) https://doi.org/10.17802/2306-1278-2023-12-2-107-121

9. Wats K, Kiser A, Makati K, et al. The Convergent Atrial Fibrillation Ablation Procedure: Evolution of a Multidisciplinary Approach to Atrial Fibrillation Management. Arrhythmia Electrophysiol Rev. 2020;9(2):88-96. https://doi.org/10.15420/aer.2019.20

10. Vroomen M, Maesen B, Luermans JL, et al. Epicardial and Endocardial Validation of Conduction Block After Thoracoscopic Epicardial Ablation of Atrial Fibrillation. Innovations (Phila). 2020;15(6):525-531. https://doi.org/10.1177/1556984520956314

11. Gottlieb LA, Dekker LRC, Coronel R. The Blinding Period Following Ablation Therapy for Atrial Fibrillation. JACC Clin Electrophysiol. 2021;7(3):416-430. https://doi.org/10.1016/j.jacep.2021.01.011

12. Harlaar N, Oudeman MA, Trines SA, et al. Long-term follow- up of thoracoscopic ablation in long-standing persistent atrial fibrillation. Interact Cardiovasc Thorac Surg. 2022;34(6):990–998. https://doi.org/10.1093/icvts/ivab355

13. Wang A, Green JB, Halperin JL, Piccini JP Sr. Atrial Fibrillation and Diabetes Mellitus: JACC Review Topic of the Week. J Am Coll Cardiol. 2019;74(8):1107–1115. https://doi.org/10.1016/j.jacc.2019.07.020

14. Онучина Е.Л., Соловьев О.В., Чапурных А.В., Мочалова О.В., Онучин С.Г., Ефремов Д.Н. Нарушения ритма сердца у пациентов с сахарным диабетом 2 типа // Сахарный диабет. — 2008. — Т. 11. — №1. — С. 25-27. https://doi.org/10.14341/2072-0351-5940

15. Gherasim L. Association of Atrial Fibrillation with Diabetes Mellitus, High Risk Comorbidities. Maedica (Bucur). 2022;17(1):143-152. https://doi.org/10.26574/maedica.2022.17.1.143

16. Sun DK, Zhang N, Liu Y, et al. Dysglycemia and arrhythmias. World J Diabetes. 2023;14(8):1163–1177. https://doi.org/10.4239/wjd.v14.i8.1163

17. Artyukhina EA, Taymasova IA, Revishvili AS. Catheter ablation of atrial arrhythmias in patients after thoracoscopic ablation of persistent atrial fibrillation. Russian Journal of Cardiology. 2020;25(7):3655. (In Russ.) https://doi.org/10.15829/1560-4071-2020-3655

18. Khamnagadaev IA, Tokarev AR, Tyurin NI. Endovaskulyarnoe lechenie narushenii ritma serdtsa. In: Endovaskulyarnaya khirurgiya – tekhnologii i praktika. Ed by LS Kokov, NV Bolomatov. Moscow: RAN; 2021. p. 290–311. (In Russ.)