Landmark analysis of the risk of recurrence after resection or ablation for HCC: A nationwide study.

BACKGROUND: The risk of HCC recurrence at particular landmarks since the initial treatment is unknown. With this registry-based study, we aimed to provide a nuanced description of the prognosis following resection or ablation for HCC, including landmark analyses. METHODS: Using the Danish nationwide health care registries, we identified all patients who received resection or ablation in 2000-2018 as the first HCC treatment. HCC recurrence was defined as a new HCC treatment > 90 days after the first treatment. We conducted competing risk landmark analyses of the cumulative risk of recurrence and death. RESULTS: Among 4801 patients with HCC, we identified 426 patients who received resection and 544 who received ablation. The 2 treatment cohorts differed in cirrhosis prevalence and tumor stage. The 5-year recurrence risk was 40.7% (95% CI 35.5%-45.8%) following resection and 60.7% (95% CI: 55.9%-65.1%) following ablation. The 1-year recurrence risk decreased over the landmarks from 20.4% (95% CI: 16.6%-24.6%) at the time of resection to 4.7% (95% CI: 0.9%-13.9%) at the 5-year landmark. For ablation, the risk decreased from 36.1% (95% CI: 31.9%-40.4%) at the time of treatment to 5.3% (95% CI: 0.4%-21.4%) at the 5-year landmark. The risk of death without recurrence was stable over the landmarks following both resection and ablation. CONCLUSIONS: In conclusion, the risk of recurrence or death following resection or ablation for HCC is high from the treatment date, but the risk of recurrence decreases greatly over the survival landmarks. This information is valuable for clinicians and their patients.

Comparison of liver resection and radiofrequency ablation in long-term survival among patients with early-stage hepatocellular carcinoma: a meta-analysis of randomized trials and high-quality propensity score-matched studies.

BACKGROUND: Whether radiofrequency ablation (RFA) and liver resection (LR) are comparable treatments for early-stage hepatocellular carcinoma (HCC) is controversial. We conducted this study to provide ample clinical evidence for the argument. METHODS: The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched to identify randomized controlled trials (RCTs) and propensity score-matched (PSM) studies that compared long-term outcomes of both RFA and LR for patients with early-stage HCC. The hazard ratios (HRs) with 95% confidence intervals (95% CI) of overall survival (OS) and disease-free survival (DFS) were calculated. RESULTS: Thirty-six studies consisting of six RCTs and 30 PSM studies were included in this study, and a total of 7384 patients were involved, with 3694 patients being treated with LR and 3690 patients with RFA. Meta-analysis showed that LR provided better OS and DFS than RFA (HR: 1.22, 95% CI: 1.13-1.31; HR: 1.56, 95% CI: 1.39-1.74, respectively). A sensitivity analysis indicated that the results were stable. For the subgroup of patients with BCLC 0 stage, RFA and LR resulted in similar OS and DFS. For the subgroup of patients with single tumor sizes less than 3 cm, RFA reached similar OS (HR: 1.19, 95% CI: 0.90-1.58) but worse DFS compared with LR (HR: 1.45, 95% CI: 1.11-1.90). For the subgroup of ablation margin larger than 0.5 cm, LR still resulted in better OS than RFA (HR: 1.29, 95% CI: 1.09-1.53); while the ablation margin was larger than 1 cm, both RFA and LR resulted in similar OS. The modality of RFA was also a factor that affected results. Subgroup analysis showed that patients receiving ultrasound-guided RFA had worse OS and DFS than LR (HR: 1.24, 95% CI: 1.14-1.36; HR: 1.44, 95% CI: 1.25-1.66, respectively). CONCLUSIONS: Meta-analysis showed that LR provided better OS and DFS for patients with early-stage HCC. However, RFA and LR had similar effects on long-term survival in patients with BCLC 0 stage HCC. RFA and LR probably had similar effects on OS in patients with solitary HCC less than 3 cm or when the ablation margin was larger than 1 cm which need more studies to confirm. The effects of different modalities of RFA on long-term survival are needed for further assessment.

Computed tomography-guided cryoablation for adrenal metastases secondary to lung cancer.

OBJECTIVES: The objective of the study was to assess the clinical efficacy of computed tomography (CT)-guided cryoablation as a means to treat adrenal metastasis (AM) secondary to lung cancer. MATERIALS AND METHODS: This study was a single-center retrospective study that analyzed 39 consecutive patients with AM secondary to lung cancer who underwent CT-guided cryoablation in our center. The rates of complete ablation, local recurrence, local recurrence-free survival (RFS), and overall survival (OS) were analyzed. RESULTS: The rates of primary and secondary complete ablation were 94.9% and 100%, respectively, and none of the patients suffered from a hypertensive crisis associated with the treatment. Over the follow-up period, 20.5% of the patients experienced local recurrence, and the median RFS duration was 26 months. The cumulative 1-, 3-, and 5-year local RFS rates in this study were 84.6%, 51.3%, and 5.9%, respectively. Extra-adrenal gland metastases were detected in five patients. Over the course of follow-up, 26 patients died. The mean OS duration was 34 months with cumulative 1-, 3-, and 5-year OS rates of 89.7%, 53.4%, and 8.3%, respectively. Advanced age (P = 0.001), primary adenocarcinoma (P = 0.006), other primary lung cancers (P = 0.038), and primary Stage III lung cancers (P = 0.007) were all found to be independent predictive factors of poor OS in these patients. CONCLUSION: CT-guided cryoablation can be safely and effectively used to control AM secondary to lung cancer, and patients with AM secondary to lung squamous cell carcinoma may be best suited for this form of treatment.

Catheter Ablation in Neonate with Heart Failure Due to Incessant Atrioventricular Reentrant Tachycardia

Abstract The atrioventricular (AV) reentrant tachycardia (AVRT) is the most common cause of supraventricular tachycardia (SVT) in the young pediatric population. Some newborns might present with congestive heart failure and require interventional treatment. Catheter ablation in small infants (<6 months and <5 kg) is still poorly performed and controversial due to high complications rate in this group of patients.1 We report a case of a 28 days old infant (3,5 kg) with a drug-refractory left accessory pathway mediated tachycardia and severe hemodynamic compromise, who underwent catheter ablation. Radiofrequency ablation should be part of the therapeutic arsenal in a context of drug-resistant supraventricular tachycardia with hemodynamic compromise, despite the greater risks of complications in this special population.

Management of Arrhythmias After Heart Transplant: Current State and Considerations for Future Research.

Orthotropic heart transplantation remains the most effective therapy for patients with end-stage heart failure, with a median survival of ≈13 years. Yet, a number of complications are observed after orthotropic heart transplantation, including atrial and ventricular arrhythmias. Several factors contribute to arrhythmias, such as autonomic denervation, effect of the surgical technique, acute and chronic rejection, and transplant vasculopathy among others. To minimize risk of future arrhythmias, the bicaval technique and minimizing ischemic time are current surgical standards. Sinus node dysfunction is the most common indication for early (within 30 days) pacemaker implantation, whereas atrioventricular block incidence increases as time from transplant increases. Atrial fibrillation can occur in the first few weeks following transplantation but is uncommon in the long term unless secondary to a precipitant such as acute rejection. The most common atrial arrhythmias are atrial flutters, which are mainly typical, but atypical circuits can be observed such as those that involve the remnant donor atrium in regions immediately adjacent to the atrioatrial anastomosis suture line. Choosing the appropriate pharmacological therapy requires careful consideration due to the potential interaction with immunosuppressive agents. Despite historical concerns, adenosine is effective and safe at reduced doses if administered under cardiac monitoring. Catheter ablation has emerged as an effective treatment strategy for symptomatic supraventricular tachycardias, including ablation of atypical flutter circuits. Cardiac allograft vasculopathy is an important risk factor for sudden cardiac death, yet the role of prophylactic implantable cardioverter-defibrillator implant for sudden death prevention is unclear. Current indications for implantable cardioverter-defibrillator implantation are as in the nontransplant population. A number of questions for future research are posed.

Changing trends in hepatocellular carcinoma management: Results from a nationwide database in the last decade.

OBJECTIVE: The therapeutic strategies for hepatocellular carcinoma (HCC) have greatly expanded in recent years. However, the actual usage of each of these treatments in clinical routine remains unknown. Here, we analysed the distribution and changes of the main surgical and radiological therapeutic procedures nationwide during the last decade. METHODS: Retrospectively, analysis of the data on all >18-year-old patients with a diagnosis of HCC identified in the French Program for the Medicalization of Information Systems database that contains all discharge summaries from all French hospitals. The number and percentage of the therapeutic procedures performed from January 2010 to December 2019 were extracted. RESULTS: A total of 68,416 therapeutic procedures were performed in 34,000 HCC patients. Whereas HCC incidence remained stable, the annual number of procedures frankly increased over the decade (from 4267 to 8042). Trans-arterial chemoembolization was the most frequently performed technical procedure, with a double-digit annual growth from 2010 (n = 1932) to 2015 (n = 4085), before stabilization from 2016. Selective internal radiation therapy displayed the highest increase in the decade (+475%). Among curative treatments, the annual number of percutaneous tumour ablations more than doubled in 10 years, till representing 64% of curative treatments in cirrhotic patients in 2019. Surgical tumour resections showed a 1.5-fold increase in 10 years, due to the great increase in minimally invasive approaches, whereas the proportion of open resection progressively decreased. CONCLUSION: Minimally invasive procedures have gained major importance in HCC management during the last decade. Percutaneous thermal ablation has emerged as the first curative treatment performed for patients with HCC.

Does ablation of atrial fibrillation at the time of septal myectomy improve survival of patients with obstructive hypertrophic cardiomyopathy?

OBJECTIVE: To evaluate the outcomes after septal myectomy in patients with obstructive hypertrophic cardiomyopathy according to atrial fibrillation and surgical ablation of atrial fibrillation. METHODS: We reviewed patients with obstructive hypertrophic cardiomyopathy who underwent septal myectomy at the Mayo Clinic from 2001 to 2016. History of atrial fibrillation was obtained from patient histories and electrocardiograms. All-cause mortality was the primary end point. RESULTS: A total of 2023 patients underwent septal myectomy, of whom 394 (19.5%) had at least 1 episode of atrial fibrillation preoperatively. Among patients with atrial fibrillation, 76 (19.3%) had only 1 known episode, 278 (70.6%) had recurrent paroxysmal atrial fibrillation, and 40 (10.2%) had persistent atrial fibrillation. Surgical ablation was performed in 190 patients at the time of septal myectomy, including 148 with pulmonary vein isolation and 42 with the classic maze procedure. Among all patients, operative mortality was 0.4%, and there were no early deaths in patients undergoing surgical ablation. Over a median follow-up of 5.6 years, patients with preoperative atrial fibrillation had increased mortality (hazard ratio, 1.36; 95% confidence interval, 0.97-1.91; P = .070) after multivariable adjustment for comorbidities. When considering the impact of atrial fibrillation with or without surgical treatment, the adjusted hazard ratio for mortality in patients undergoing ablation compared with no ablation was 0.93 (95% confidence interval, 0.52-1.69; P = .824). CONCLUSIONS: Atrial fibrillation is present preoperatively in one-fifth of patients with obstructive hypertrophic cardiomyopathy undergoing myectomy and showed a trend toward higher all-cause mortality. Survival of patients undergoing septal myectomy with preoperative atrial fibrillation was similar between those who did and did not receive concomitant surgical ablation.

Surgical microwave ablation of otherwise non-resectable colorectal cancer liver metastases: Expanding opportunities for long term survival.

BACKGROUND: Colorectal liver metastases (CRLM) are the most common extra-lymphatic metastases in colorectal cancers, however, only 15-20% of these patients are candidates for resection. We reviewed our institutional experience with 135 surgical ablations for unresectable CRLM. METHODS: Retrospective review of surgically ablated CRLM from 2009 to 2018. Patient-specific variables were obtained from the medical record. Kaplan-Meier modeling was performed for survival analyses. RESULTS: We ablated 135 CRLM in 36 patients over 40 procedures. Median age was 52 years and 58% of patients were male. All patients received systemic chemotherapy. The ablation procedure was completed laparoscopically in 68% of procedures. Median number of ablated lesions per patient was 2 (range 1-15). Median maximum diameter of ablated lesions was 1.9 cm (range 0.5-12.2). Median follow up of the study was 28 months. In this time, median disease-free survival was not reached. Of the 135 lesions ablated, the per-lesion recurrence rate was 6/135 (4.4%). Median overall survival was 81 months. CONCLUSIONS: Surgical ablation of CRLM can provide excellent local control and long-term survival outcomes in patients who may otherwise not be candidates for other liver-directed therapies.

Ablation of atrial fibrillation during coronary artery bypass grafting: Late outcomes in a Medicare population.

BACKGROUND: This study compares outcomes of patients with preoperative atrial fibrillation undergoing coronary artery bypass grafting (CABG) with or without concomitant atrial fibrillation ablation in a nationally representative Medicare cohort. OBJECTIVES: This study examined early and late outcomes in CABG patients with a preoperative history of atrial fibrillation to determine the correlation between surgical atrial fibrillation ablation to mortality and stroke or systemic embolization. METHODS: In the Medicare-linked Society of Thoracic Surgeons database, 361,138 patients underwent isolated CABG from 2006 to 2013; 34,600 (9.6%) had preoperative atrial fibrillation; 10,541 (30.5%) were treated with surgical ablation (ablation group), and 23,059 were not (no ablation group). Propensity score matching was performed using a hierarchical mixed model. Long-term survival was summarized using Kaplan-Meier curves and Cox regression models with robust variance estimation. The stroke or systemic embolization incidence was modeled using the Fine-Gray model. Median follow-up was 4 years. RESULTS: Long-term mortality in propensity score-matched CABG patients (mean age 74 years; Society of Thoracic Surgeons risk score, 2.25) receiving ablation versus no ablation was similar (log-rank P = .30). Stroke or systemic embolization occurred in 2.2% versus 2.1% at 30 days and 9.9% versus 12.0% at 5 years (Gray P = .0091). Landmark analysis from 2 to 5 years showed lower mortality (hazard ratio, 0.89; 95% confidence interval 0.82-0.97; P = .0358) and lower risk of stroke or systemic embolization (hazard ratio, 0.73; 95% confidence interval, 0.61-0.87; P = .0006) in the ablation group. CONCLUSIONS: Concomitant ablation in CABG patients with preoperative atrial fibrillation is associated with lower stroke or systemic embolization and mortality in patients who survive more than 2 years.

Impact of ablation algorithm versus tumor-dependent parameters on local control after microwave ablation of malignant liver tumors.

BACKGROUND: The aim of this study is to assess the effect of tumor versus ablation-algorithm dependent parameters on local recurrence (LR) after microwave ablation (MWA) of liver malignancies. METHODS: This was an institutional review board-approved study of patients who underwent laparoscopic or open MWA of malignant liver tumors. The impact of ablation algorithm (stepwise or direct heating, single or overlapping ablations, and ablation margin) and tumor-dependent (type, size, location, and blood vessel proximity) parameters on LR was analyzed using Kaplan-Meier and Cox proportional hazards. RESULTS: A total of 179 patients with 602 liver tumors underwent 200 MWA procedures. Colorectal liver metastasis (CLM) was the most frequent tumor type followed by neuroendocrine liver metastasis (NELM), other metastatic tumors, and hepatocellular cancer (HCC). For patients followed at least a year with imaging, LR rate was 8.8% per lesion and 13.1%,1.3%, 11.7%, and 12.6%, for CLM, NELM, HCC, and other tumor types, respectively. On multivariate analysis, independent predictors of LR included tumor type, tumor size, and ablation margin. CONCLUSION: LR after MWA for malignant liver tumors is predicted by both tumor and surgeon-dependent factors. Variations in the ablation algorithm did not affect LR, leaving the ablation margin as the only parameter that could be modified to optimize local tumor control.

Safety and efficacy of the combination therapy of transcatheter arterial chemoembolization and ablation for hepatocellular carcinoma with inferior vena cava tumor thrombus: A consecutive case series.

This study was designed to propose a classification of inferior vena cava tumor thrombus (IVCTT) and retrospectively evaluate the safety and efficacy of the combination therapy of transcatheter arterial chemoembolization (TACE) and sequential percutaneous ablation for hepatocellular carcinoma (HCC) with IVCTT. All HCC patients with IVCTT who underwent the combination therapies of TACE and sequential percutaneous ablation therapy between January 2015 and December 2017 in Beijing Youan Hospital were included in the study. The demographic, clinical, and pathological data were recorded. The response rate and overall survival (OS) rate were statistically analyzed. A classification system of IVCTT types was proposed based on the anatomical structure and ablation technique, which contained five types of IVCTT. Different types of IVCTT require different ablation strategies. For the response rate of IVCTT, complete response was achieved in all six patients. The 1- and 2-year OS rates were 88.3% and 55.6%, respectively. The new classification system and corresponding ablation strategies proposed in this study provided guidance for the use of ablation therapy for IVCTT. The combination therapy of TACE and ablation is effective and safe for treating HCC with IVCTT.

Limitation of non-transplant treatment and proper timing for liver transplantation in patients with hepatocellular carcinoma considering long-term survival.

In this study, we investigated the long-term survival of patients with hepatocellular carcinoma (HCC) after conventional treatment other than liver transplantation (LT) in our institute and discuss the limitation of non-transplant treatment for HCC and the proper indictors of LT in the recent comprehensive era.Between 2003 and 2016, 181 patients with HCC aged ≦70 years received active treatment including liver resection, radiofrequency ablation (RFA), and transcatheter arterial chemoembolization (TACE). We analyzed the factors associated with overall survival and proposed new priority for the indicators of LT in HCC patients according to the extracted factors by comparing the survival with 39 transplanted patients with HCC.Child-Turcotte-Pugh (CTP) score (HR: 1.276; 95% CI: 1.049-1.552, P = .015), and number of tumors (HR: 1.238; 95% CI: 1.112-1.377, P < .001) were selected as significant factors associated with the survival after active treatments for HCC. Patients with LT had significantly better long-term survival compared with those with non-transplant patients regardless of aforementioned factors. However, regarding relatively short survival (3 years), patients with CTP score of ≧9 and/or ≧3 tumors with non-transplant treatment had poorer survival compared with those of transplanted patients (P < .05).We propose that CTP score of 9 and/or 3 tumors before non-transplant, intensive treatment might be a new priority for considering indicators of LT in patients with HCC.

Classification of hepatocellular carcinoma diameter by statistical technology and prognostic evaluation in patients after the combined use of transarterial chemoembolization and radiofrequency ablation.

OBJECTIVE: This study aimed to classify hepatocellular carcinomas (HCCs) according to their diameter using statistic technology and evaluate the prognosis of the classified groups after the combined use of transarterial chemoembolization (TACE) and radiofrequency ablation (RFA). MATERIALS AND METHODS: Electronic medical records of 128 consecutive patients who underwent TACE-RFA as the initial treatment for HCC from January 2010 to April 2018 were retrospectively analyzed. TACE was initially performed with subsequent RFA performed after 3-7 days. The decision tree model was used to classify overall survival (OS), progression-free survival (PFS), local recurrence rate (LRR), and treatment complications in HCC. RESULTS: The tumors were divided into three groups of sizes ≤2.9 cm, 2.9-4.8 cm, and >4.8 cm. The group of tumors >4.8 cm showed inferior OS, PFS, and LRR than the other two groups (P < 0.05) on long-term follow-up but not in thefirst 6 months (P > 0.05). The groups of tumors ≤2.9 cm and 2.9-4.8 cm showed no statistically significant difference in OS, PFS, and LRR (P > 0.05). CONCLUSIONS: The cutoff points of 2.9 and 4.8 cm were achieved using the objective decision tree model rather than the artificial division of 3 and 5 cm. The prognosis was not significantly different between the groups of tumors ≤2.9 cm and 2.9-4.8 cm, and the prognosis of the two groups was better than the group of tumors >4.8 cm in the long-term follow-up but not in thefirst 6 months.

Position paper concerning the competence, performance and environment required for the practice of ablation in children and in congenital heart disease.

The population of patients with congenital heart disease (CHD) is continuously increasing, and a significant proportion of these patients will experience arrhythmias because of the underlying congenital heart defect itself or as a consequence of interventional or surgical treatment. Arrhythmias are a leading cause of mortality, morbidity and impaired quality of life in adults with CHD. Arrhythmias may also occur in children with or without CHD. In light of the unique issues, challenges and considerations involved in managing arrhythmias in this growing, ageing and heterogeneous patient population and in children, it appears both timely and essential to critically appraise and synthesize optimal treatment strategies. The introduction of catheter ablation techniques has greatly improved the treatment of cardiac arrhythmias. However, catheter ablation in adults or children with CHD and in children without CHD is more technically demanding, potentially causing various complications, and thus requires a high level of expertise to maximize success rates and minimize complication rates. As French recommendations regarding required technical competence and equipment are lacking in this situation, the Working Group of Pacing and Electrophysiology of the French Society of Cardiology and the Affiliate Group of Paediatric and Adult Congenital Cardiology have decided to produce a common position paper compiled from expert opinions from cardiac electrophysiology and paediatric cardiology. The paper details the features of an interventional cardiac electrophysiology centre that are required for ablation procedures in adults with CHD and in children, the importance of being able to diagnose, monitor and manage complications associated with ablations in these patients and the supplemental hospital-based resources required, such as anaesthesia, surgical back-up, intensive care, haemodynamic assistance and imaging. Lastly, the need for quality evaluations and French registries of ablations in these populations is discussed. The purpose of this consensus statement is therefore to define optimal conditions for the delivery of invasive care regarding ablation of arrhythmias in adults with CHD and in children, and to provide expert and - when possible - evidence-based recommendations on best practice for catheter-based ablation procedures in these specific populations.

Treatment outcomes of percutaneous radiofrequency ablation versus adrenalectomy for adrenal metastases: a retrospective comparative study.

PURPOSE: To retrospectively evaluate the clinical outcomes of percutaneous ultrasound (US)-guided radiofrequency ablation (RFA) in treatment of adrenal metastasis (AM), and to compare with adrenalectomy (Adx). METHODS: From June 2008 to August 2018, a total of 60 patients with AM treated at our hospital were retrospectively reviewed, of whom 29 treated by RFA (RFA group) and 31 by Adx (Adx group). The technical success, local tumor progression (LTP) and overall survival (OS) after the treatment were evaluated and compared. RESULTS: In RFA group, the first technical success was 72.4% and the second technical success was 86.2%. In Adx group, all the AMs were successfully resected. After 24.5 ± 19.1 months follow-up period, a total of 8 patients (6 in RFA group and 2 in Adx group) were detected LTP. The 1-, 2- and 3- LTP rates after treatment were 17.1%, 30.9% and 44.7% in RFA group, and 6.5%, 6.5% and 6.5% in Adx group, respectively (P = 0.028). However, for AM ≤ 5 cm, the LTP between the two groups were comparable (P = 0.068). The 1-, 2- and 3- OS rates after treatment for AM were 85.0%, 42.4% and 27.8% in RFA group, and 93.0%, 66.1% and 52.3% in Adx group, respectively (P = 0.057). RFA offered shorter treatment time (23.6 ± 16.9 vs. 155.6 ± 58.8 min, P < 0.001), shorter hospital stay (7.8 ± 3.9 vs. 15.0 ± 4.9 days, P < 0.001), and lower hospital cost ($3405.7 ± 1067.8 vs. $5248.0 ± 2261.3, P = 0.003) than Adx. CONCLUSION: In comparison with Adx, percutaneous US-guided RFA, as an alternative treatment, is feasible and effective in controlling AM, especially in AM ≤ 5 cm in diameter.

Radical Laser Interstitial Thermal Therapy Ablation Volumes Increase Progression-Free Survival in Biopsy-Proven Radiation Necrosis.

BACKGROUND: Treatment for surgically inaccessible medically refractory cerebral radiation necrosis (RN) has remained limited. Recently, laser interstitial thermal therapy (LITT) has gained traction as an effective means of treating these lesions but limited data are available regarding the effect of ablation size on patient outcome. Therefore, this study analyzed various outcome measures as a function of ablation volume/diameter for a series of 20 patients with surgically inaccessible biopsy-proven RN. METHODS: Twenty patients with biopsy-proven RN treated with LITT from 2013 to 2018 at our institution were retrospectively reviewed. Local progression-free survival (PFS), overall survival, and steroid dependence were analyzed with Kaplan-Meier and Cox regression analysis for ablation volume/diameter. Comparison of preoperative and postoperative Karnofsky Performance Status was conducted with a matched paired t test. RESULTS: Patients with subtotal ablation (<100% increase in pre-LITT lesion volume or <0 mm increase in pre-LITT lesion diameter) had higher risk of local disease progression (hazard ratio, 12.4; P = 0.004) compared with patients with total ablations. Patients who received radical ablations (>200% increase in pre-LITT lesion volume or >2 mm increase in pre-LITT lesion diameter) showed the most favorable PFS (P < 0.0458 and P < 0.0378, respectively). There was no difference in post-LITT Karnofsky Performance Status and time to steroid freedom between ablation groups. Overall survival increased with radical diametric ablation (P = 0.0401). CONCLUSIONS: Although LITT has proved to be an effective salvage therapy for patients with RN, detailed volumetric studies have not been explored. Our results suggest that radical ablations have the potential to increase PFS.

Three-year Survival Rate after Radiofrequency Ablation for Surgically Resectable Colorectal Lung Metastases: A Prospective Multicenter Study.

Background Although radiofrequency ablation (RFA) is widely performed for the treatment of colorectal cancer (CRC) lung metastases, its efficacy for candidates with surgically resectable disease is unclear. Purpose To evaluate the prognosis after RFA in participants with resectable CRC lung metastases. Materials and Methods For this prospective multicenter study (ClinicalTrials.gov identifier: NCT00776399), participants with five or fewer surgically resectable lung metastases measuring 3 cm or less were included. Participants with CRC and a total of 100 lung metastases measuring 0.4-2.8 cm (mean, 1.0 cm ± 0.5) were chosen and treated with 88 sessions of RFA from January 2008 to April 2014. The primary end point was the 3-year overall survival (OS) rate, with an expected rate of 55%. The local tumor progression rate and safety were evaluated as secondary end points. The OS rates were generated by using the Kaplan-Meier method. Log-rank tests and Cox proportional regression models were used to identify the prognostic factors by means of univariable and multivariable analyses. Adverse events were evaluated according to the Common Terminology Criteria for Adverse Events, version 3.0. Results Seventy participants with CRC (mean age, 66 years ± 10; 49 men) were evaluated. The 3-year OS rate was 84% (59 of 70 participants; 95% confidence interval [CI]: 76%, 93%). In multivariable analysis, factors associated with worse OS included rectal rather than colon location (hazard ratio [HR] = 7.7; 95% CI: 2.6, 22.6; P < .001), positive carcinoembryonic antigen (HR = 5.8; 95% CI: 2.0, 16.9; P = .001), and absence of previous chemotherapy (HR = 9.8; 95% CI: 2.5, 38.0; P < .001). Local tumor progression was found in six of the 70 participants (9%). A grade 5 adverse event was seen in one of the 88 RFA sessions (1%), and grade 2 adverse events were seen in 18 (20%). Conclusion Lung radiofrequency ablation provided a favorable 3-year overall survival rate of 84% for resectable colorectal lung metastases measuring 3 cm or smaller. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Gemmete in this issue.

Surgical ablation of atrial fibrillation concomitant to coronary-artery bypass grafting provides cost-effective mortality reduction.

BACKGROUND: Data on the longitudinal impact of surgical ablation (SA) for atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG) remain limited. This study examined 2-year risk-adjusted mortality and total hospital costs in Medicare beneficiaries with AF requiring CABG with or without SA. METHODS: CABG was performed in 3745 Medicare beneficiaries with AF in 2013, with concomitant SA in 17% (626 of 3745). Risk-adjusted mortality, morbidity, and cost during the first 2 postoperative years for patients with SA and those without SA were compared. A piecewise Cox proportional hazard model (0-90 days and 91-729 days) was used to risk-adjust mortality. RESULTS: Compared with the no SA group, the SA group had lower rates of heart failure before surgery (31% vs 36%), chronic lung disease (27% vs 33%), renal failure (4% vs 7%), and urgent or emergent presentation (34% vs 49%) (all P < .05). Risk-adjusted index admission costs were higher with SA (rate ratio [RR], 1.11; P < .01), as were readmissions for AF (hazard ratio [HR], 1.14; 95% confidence interval [CI], 1.00-1.29; P = .04) and pacemaker/defibrillator implantation (HR, 1.37; 95%, 1.08-1.74; P = .01). Risk-adjusted inpatient days and inpatient costs were similar after 2 years (RR, 0.97; P = .31 and RR = 1.04; P = .17, respectively); however, the risk-adjusted hazard for late mortality (91-729 days) was significantly lower with SA (HR, 0.71; 95% CI, 0.52-0.97; P = .03). CONCLUSIONS: In patients with AF requiring CABG, SA was associated with a 29% lower risk-adjusted hazard for late mortality. Index hospital costs were higher with SA, but total inpatient costs were not different in the 2 groups after 2 years. SA appears to be a cost-effective intervention to enhance late 2-year survival in patients with AF undergoing CABG.

Surgical Treatment for Stand-Alone Atrial Fibrillation in North America.

BACKGROUND: Surgical treatment of symptomatic atrial fibrillation has been performed for 3 decades. We reviewed trends and outcomes of surgical ablation (SA) for stand-alone atrial fibrillation using The Society of Thoracic Surgeons Adult Cardiac Surgical Database (STS-ACSD). METHODS: The STS-ACSD was reviewed from 2011 to 2017 (N = 7187) for trends. Contemporary data from 2014 to 2017 (n = 3893) were used to compare three subgroups: off pump (n = 3252), on pump (n = 491), and patients with incision conversion or conversion from off pump to on pump (n = 150). Propensity score matching was conducted to balance groups. RESULTS: Annual growth of stand-alone SA was 7%. Median age of patients was 64 years (interquartile range, 57 to 70), and 30% were female. Overall 30-day mortality was 0.8% and perioperative stroke incidence was 0.8%. Most SA procedures were off pump (84%), with 12% greater odds for off pump per year (odds ratio [OR] 1.12, P < .001). The off-pump group had fewer biatrial SA (21% vs 71%, P < .001) and left atrial appendage obliterations (53% vs 95%, P < .001) compared with the on-pump group. After matching, uneventful off-pump SA had similar mortality (0.4% vs 0.9%, P = .292) vs on-pump SA, but reduced incidence of renal failure (0.9% vs 2%, P = .033). After risk adjustment, the conversion group had worse perioperative outcomes vs the off-pump group, including greater incidence of stroke (OR 5.37, P < .001) and operative mortality (OR 9.98, P < .001). Mortality (OR 4.69, P = .011) was also greater for conversion vs on pump. CONCLUSIONS: Steady growth of stand-alone SA operations was noted. Procedures performed either on pump or off pump were relatively safe. However, intraoperative conversion was associated with significantly higher morbidity and mortality. Patient selection, improvement of surgical techniques, and long-term follow-up should be emphasized to improve decision making and outcome.