Classification of intra-abdominal hypertension.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
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It is time to abandon unethical or impossible to introduce into clinical pathways and look again at rudiments and face limitations. This book takes the reader from stem cell biology through clinical applications, ethics, law, and future possibilities. It is a solid base for every scientist interested in the topic of stem cells. Growing recognition of the limitations of stem cell therapies on the one hand and the rapidly increasing number of unethical therapies available in many countries force the quick establishment of the status quo of knowledge in a form accessible to all interested. This book is the answer to the multi-level and complex aspect of using stem cells in humans. It reveals real possibilities of introducing the latest research in the field of stem cell research. Material summarizes the ups and downs of this complex topic and shows the current trends in global markets and universities.
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She worked for 10 years as GMP Head of Quality Assurance, at Dr. Stanisław Sakiel Burns Treatment Center, and as a University Lecturer. Assistant Professor Kitala is currently involved in writing national programs for medical research and evaluation of clinical research at the Medical Research Agency.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"203598",title:"Ph.D.",name:"Diana",middleName:null,surname:"Kitala",slug:"diana-kitala",fullName:"Diana Kitala",profilePictureURL:"https://mts.intechopen.com/storage/users/203598/images/system/203598.png",biography:"Assistant Professor Diana Paula Kitala graduated with degrees in Biotechnology and Biomedical Engineering, and while writing her doctoral thesis she completed postgraduate studies in the fields of clinical research, biostatistics, laboratory diagnostics, LEAN methodology, and Six Sigma management. She worked for 10 years in a tissue bank as GMP Head of Quality Assurance, in Dr. Stanisław Sakiel Burns Treatment Center, and as a university lecturer. She has taken part in scientific grants, and in 2019 she won the EWMA grant for the project 'Theory of constraints (TOC) and LEAN management for wider application of amniotic mesenchymal stem cells in a group of patients with chronic wounds.” She was nominated for the golden medal for merits for the Silesian Voivodeship. Now she is involved in writing national programs for medical research and evaluation of clinical research in Medcial research Agency. Personally, she is a mom of two daughters and a volunteer in saving stray animals.",institutionString:"Medical Research Agency",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"6",title:"Biochemistry, Genetics and Molecular Biology",slug:"biochemistry-genetics-and-molecular-biology"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"278926",firstName:"Ivana",lastName:"Barac",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/278926/images/8058_n.jpg",email:"ivana.b@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"9021",title:"Novel Perspectives of Stem Cell Manufacturing and Therapies",subtitle:null,isOpenForSubmission:!1,hash:"522c6db871783d2a11c17b83f1fd4e18",slug:"novel-perspectives-of-stem-cell-manufacturing-and-therapies",bookSignature:"Diana Kitala and Ana Colette Maurício",coverURL:"https://cdn.intechopen.com/books/images_new/9021.jpg",editedByType:"Edited by",editors:[{id:"203598",title:"Ph.D.",name:"Diana",surname:"Kitala",slug:"diana-kitala",fullName:"Diana Kitala"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6694",title:"New Trends in Ion Exchange Studies",subtitle:null,isOpenForSubmission:!1,hash:"3de8c8b090fd8faa7c11ec5b387c486a",slug:"new-trends-in-ion-exchange-studies",bookSignature:"Selcan Karakuş",coverURL:"https://cdn.intechopen.com/books/images_new/6694.jpg",editedByType:"Edited by",editors:[{id:"206110",title:"Dr.",name:"Selcan",surname:"Karakuş",slug:"selcan-karakus",fullName:"Selcan Karakuş"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. 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Certain physiological conditions such as morbid obesity and pregnancy may be associated with chronic IAP elevations. However, even small increases in intra-abdominal pressure can have adverse effects on renal function, cardiac output, hepatic blood flow, respiratory mechanics, splanchnic perfusion, and intracranial pressure. IAP is approximately 5–7 mmHg in critically ill adults.
Wendt et al. firstly described oliguria in the presence of elevated intra-abdominal pressure in 1876 [1]. In 1947, Bradley published a seminal study of the renal effects of elevated IAP in humans [2]. Despite these early descriptions of the adverse effects of IAH, physicians are not careful about the significance of increased abdominal pressure.
Until recently, patients with ACS were not infrequently managed in the intensive care unit and typically presented with a tense distended abdomen, increased peak inspiratory airway pressure, severe hypercapnia, hypotension, and oliguria. Abdominal ascites occurs typically at the end stage of liver failure. Massive ascites also influences IAP and causes oliguria and acute kidney injury. Commonly, we recognize this symptom and confused it with hepatorenal syndrome (HRS). In such patients, we should take into account the elevation of renal parenchymal and renal vein pressures, as they are likely the mechanisms of renal impairment. Note that IAH/ACS and HRS are occurring simultaneously. Recently, Matsumoto et al. reported that renal vein dilation predicts poor outcome in patients with refractory cirrhotic ascites [3].
The pathology of IAH/ACS is perfusion imbalance in multiple organs: compression of the portal system in the abdominal cavity, compression of the inferior vena cava system in retroperitoneal organs, compression of the diaphragm in the intrathoracic organ, and perfusion dysfunction of the brain circulation through increase of intrathoracic pressure [4].
The perfusion imbalance in the upper body originated from the abdominal cavity, which causes circulation impairment and further increased intrathoracic cavity pressure and retroperitoneal cavity. This imbalance presents a functional disorder that substantially affects multiple organs.
ACS is similar to the compartment syndrome in muscular diseases. It is a circulatory disease caused by internal pressure of organs sectioned in a small wall of the compliance anatomically [5]. The normal IAP ranges from sub-atmospheric level to 0 mmHg. Certain physiological conditions, such as morbid obesity and pregnancy, may be associated with chronic IAP elevations. Moreover, IAH is defined as an IAP above 12 mmHg. ACS is defined as an IAP above 20 mmHg with evidence of organ failure [6]. IAP is the steady state of pressure concealed within the abdominal cavity. The normal IAP for critically ill patients are 5–7 mmHg range. Once, IAP have increased, patients become the state of IAH. IAH is recognized sustained IAP greater than to 12 mmHg. IAH may also be subclassified according to the duration of symptoms into one of the four groups. This fulminant example of IAH commonly leads to rapid development of ACS. With its development over a protracted time course, the abdominal wall adapts and progressively distends in response to increasing IAP, allowing time for the body to adapt physiologically. The clinical consideration of IAH subtypes is useful in prescribing patients at risk for ACS (Table 1) [6].
Classification of IAH | ||
---|---|---|
Hyperacute IAH | Elevated IAP for seconds | Secondary to physical activity, coughing, laughing, sneezing, straining, or defecation |
Acute IAH | Elevated IAP that develops over hours and can lead to rapid development of ACS | Secondary to trauma or intra-abdominal hemorrhage |
Subacute IAH | Elevated IAP that develops over days and can also lead to ACS | Medical patients |
Chronic IAH | Elevated IAP that develops over months or years. | Pregnancy, morbid obesity, intra-abdominal tumor, ascites |
Classification of intra-abdominal hypertension.
IAH, intra-abdominal hypertension; ACS, abdominal compartment syndrome.
Primary ACS is characterized by the presence of acute or subacute IAH of relatively brief duration occurring as a result of an intra-abdominal cause such as severe acute pancreatitis, abdominal trauma, ruptured abdominal aortic aneurysm, and liver transplantation [7].
Secondary ACS is characterized by the presence of subacute or chronic IAH that develops massive fluid resuscitation such as an extra-abdominal cause such as sepsis, capillary leak, burns [8].
The World Society of Abdominal Compartment Syndrome classified IAH into grade I–IV and ACS (Table 2) [9].
Grading of IAH | |
---|---|
Grade I | IAP 12-15 mmHg |
Grade II | IAP 16-20 mmHg |
Grade III | IAP 21-21 mmHg |
Grade IV | IAP > 25 mmHg |
Grading of intra-abdominal hypertension.
Burch et al. suggested that most patients with grade III and all patients with grade IV should undergo abdominal decompression [10].
Due to the increased intrathoracic pressure, indirect measures of cardiac filling such as central venous pressure and pulmonary artery occlusion pressure give inaccurate results and can be increased despite profound intravascular volume depletion. The decrease in cardiac output caused by intra-abdominal hypertension is therefore exacerbated by hypovolemia [11].
Respiratory distress and failure: Initial signs of ACS include elevated peak airway pressures in intubated patients with decreased tidal volumes. The ensuing increase in intrathoracic pressure and hypoxic pulmonary vasoconstriction can lead to pulmonary hypertension [12].
Intracranial perfusion pressure is decreased by increase in intracranial pressure (ICP) caused by venal perfusion defect, including renal failure. For increased ICP, decompressive laparotomy has been shown to reduce intractable elevated ICP in patients with IAH, and compression of the ureters is not thought to contribute to renal dysfunction, as the insertion of ureteric stents does not result in an improvement in urine output [13].
ACS is characterized by marked reduction in glomerular filtration rate (GFR) and renal plasma flow in the absence of other causes of renal failure. Moreover, changes in cardiac output, direct compression of the renal vessels or renal parenchyma with diminished renal blood flow, increase in renal vascular resistance, and distribution of blood from the renal cortex to the medulla are reported the mechanisms of renal dysfunction [14]. Bradley et al. are the first to report that animals become anuric with an IAP of 30 mmHg [2]. Additional factors that cause IAP to reach ACS range include reduction in cardiac output and elevated levels of catecholamines [15]. Renin, angiotensin, and inflammatory cytokines may also come into play, further worsening renal function.
Diebel et al. reported that the portal vein (PV) pressure decreased experimentally in 65% of patients with an IAP of 40 mmHg, and liver tissue microcirculation quantity decreases to 71% [16].
Liver dysfunction occurs due to decrease PV flow because of IAH. Furthermore, with cardiac dysfunction, liver ischemia becomes worse. Persistent IAP decrease the mean arterial blood pressure in the superior mesenteric artery (SMA) and PV flow by 50% [17].
Rasmussen et al. reported that an IAP of 25 mm Hg results in a 66% decrease in PV blood flow and a 6.5-fold increase in portal/hepatic vascular resistance compared to baseline levels [18].
Furthermore, in studies evaluating the effects of increased IAP on hepatocyte, the characteristics of the sinusoid should be expected to elucidate hepatic dysfunction from increased IAP.
To determine the possibility of bacterial translocation (BT), of which there is failure of the mucous membrane barrier mechanism caused by decline in blood circulation in mucous membranes, pH in the mucous membrane declined as well. Besides, this phenomenon is regarded as the cause of multiple organ dysfunction syndrome (MODS) after ACS, but there is no direct proof. Even if the IAP is at 20 mmHg, blood flow to the intestinal mucosa decreases to 28% experimentally in 61% of the baseline value of 40 mmHg [16]. In MODS, there is gastrointestinal mucous membrane acidosis of which the IAP is expected to be at 10 mmHg is derived from ACS.
There are various methods of measuring intermittent IAP, such as invasive (direct, i.e., needle puncture of the abdomen during peritoneal dialysis or laparoscopy) and noninvasive (indirect, i.e., transduction of intravesicular or “bladder,” gastric, colonic or uterine pressure via the balloon catheter). Noninvasive measurement of bladder internal pressure and intragastric pressure are recommended. The internal bladder pressure are commonly related to IAP measured directly in the range of 5–70 mmHg [6].
Intrabladder pressure monitoring estimated for IAP can be obtained either via a closed transducer technique or the closed Foley Manometer technique, which seems safe and does not alter the risk of UTI in patients with critical illness [19] (Figure 1).
Measurement of intra-abdominal pressure using bladder pressure measurements.
Discussions on IAP to become the adaptation standard of decompression is divided, but more than 25 mmHg is assumed to be a tentative adaptation standard clinically. However, recently, reports on gastrointestinal disorder due to impairment of IAP in the lower abdominal cavity need to be considered. The World Society of the Abdominal Compartment Syndrome suggested a management algorithm for IAH/ACS [20].
An early indication of the open abdomen technique has been shown to reduce mortality [21]. Chen et al. reported that laparoscopy can be used as a safe alternative for ACS decompression [22].
The World Society of the Abdominal Compartment Syndrome has noted that correct fluid therapy and perfusion support during resuscitation form the cornerstone of medical management in patients with abdominal hypertension [23].
Pharmacologic therapy is less effective than drainage procedures. Agustí et al. reported that dobutamine restores intestinal mucosal blood flow in a porcine model of intra-abdominal hyperpressure [24].
If a patient experiences decompensation, ACS should be re-examined as a potential cause.
We reported an autopsy case with HRS and ACS diagnosed with a clinical and histopathological consideration of liver and kidney diseases. Further clinical studies are needed to improve the management of renal failure in patients with acute liver failure and advanced liver cirrhosis (Figures 2 and 3) [25].
Liver: end-stage liver cirrhosis. Microscopic findings showed hepatic sinusoidal dilation due to portal hypertension and severe jaundice.
Kidney: microscopic findings showed swelling in the renal tubules. There was no change in the glomerulus and collecting tubule and no renal fibrosis. CT the right renal vein was compressed by massive ascites (arrow).
HRS was originally described in 1863 by Flint as an association between liver disease and oliguric renal failure in the absence of significant renal histological change [26]. HRS is recognized by intense intrarenal vasospasm caused by the imbalance between vasodilatory and vasoconstrictive mediators seen in end stage of liver disease [27].
Although the precise role of IAH in HRS remains incompletely understood, it can be argued that diminished glomerular perfusion due to venous congestion results in further decline of GFR.
Cade et al. reported significant increases in urine flow rate and creatinine clearance after reduction in IAP from 22 to 10 mmHg with paracentesis in patients with cirrhosis [28]. Moreover, compression of renal vein is suggested to be vital in the development renal dysfunction. IAH is the significant pathological mechanism and independent risk factor in the occurrence and development of HRS [29]. Further, attempts should be made to decrease IAP following surgical decompression, large-volume paracentesis (LVP), and appropriate diuretic drug.
Several methods are reported to control refractory abdominal ascites in end-stage liver cirrhosis, such as avoidance of non-steroidal anti-inflammatory drugs [30], dietary sodium restriction [31], diuretic, LVP, cell-free and concentrated ascites reinfusion therapy [32], transjugular intrahepatic portosystemic shunt [33], and peritoneovenous shunt [34].
IAH is defined as an IAP above 12 mmHg. Hence, abdominal ascites in early stage of liver cirrhosis should be treated and early stage of ascites in outpatient should be managed immediately. Outpatients with clinically apparent ascites will require diuretic therapy in addition to dietary sodium restriction. Diuretic therapy typically consists of treatment regimen for cirrhotic ascites such as combination of oral spironolactone and furosemide. Recently, aquaporin-2 is a vasopressin-regulated water channel expressed in the renal collecting duct. Urine aquaporin-2 is considered a marker of collecting duct responsiveness to tolvaptan. In Japan, on September 2013, tolvaptan was approved (in doses up to 7.5 mg/day) for treating patients with ascites who showed an inadequate response to conventional diuretics [35].
Massive ascites also influences IAP and causes oliguria and acute kidney injury (AKI). Commonly, we recognize this symptom at the stage of end stage of liver cirrhosis. This symptom has the possible involvement with HRS. In such patients, we should take into account the elevation of renal parenchymal and renal vein pressures, as they are likely the mechanisms of renal impairment. Note that IAH/ACS and HRS are occurring simultaneously. Hepatologists should consider IAH and ACS in end-stage liver cirrhosis.
The authors would like to thank Takao Tsuchida in the Division of Gastroenterology and Hepatology at the Niigata University for his excellent assistance in histological analyses.
This work was supported by a Grant-in-Aid for Research Activity Start-up 17H06691 from the Ministry of Education, Culture, Sports, Science and Technology (MEXT) to Hiroteru Kamimura.
Atrial fibrillation (AF) is the most common type of cardiac arrhythmia and remains a major cause of stroke, heart failure (HF), sudden death, and cardiovascular morbidity. Importantly, with an ever-ageing population, the prevalence of AF is increasing, and predicted to rise steeply in the future [1]. AF impairs functional status, cognitive function and reduces the quality of life [2]. Age, sex, race, and geographical location, as well as other modifiable risk factors (diabetes, hypertension, lung disease, obesity and alcohol use) determine the prevalence of AF. The overall prevalence of AF is approximately 1%, but rises significantly with age. In those over 75 years old it has been shown to be greater than 10%, and greater than 15% in those over 85 [3, 4].
\nAs such, the proportion of patients presenting for cardiac surgery in AF, or with a history of AF is also expanding. AF detrimentally affects prognosis in patients with severe valvular heart disease [5], and those undergoing surgery or transcatheter interventions for aortic or mitral valve disease, and in combination with valvular heart disease, increases thromboembolic risk significantly [6, 7]. As with congestive HF, valvular disease and AF share a dynamic interaction that sustain one another, driven by the detrimental effects of volume and pressure overload, maladaptive neurohumoral activation, cardiac fibrosis and a deleterious tachy-cardiomyopathy. Therefore, it is intuitive that immense attention has been, and continues to be focussed upon the potential likely benefits of surgical correction of AF, as part of both concomitant AND stand-alone procedures.
\nThe prevalence of pre-operative AF varies with the encountered cardiac pathology, and this, together with surgical procedure type, influences the likelihood of concomitant surgical AF ablation. In the surgical population, the prevalence is greatly skewed towards mitral valve disease, because this pathology invokes the greatest degree of left atrial (LA) distension [8]. An AF prevalence of 30% is reported in mitral valve surgical patients, and only 14% and 6% in patients undergoing aortic valve or isolated coronary surgery, respectively [9]. Analysis of US registry data from the early 2000s showed that the prospect of concomitant AF ablation was greatest in mitral valve patients (~60%) and double that in aortic valve (~30%) and coronary artery bypass (~25%) surgical patients [10]. The chapter will focus upon the anatomical and physiological principles underlying surgical AF ablation, the technical and surgical aspects regarding specific anatomical lesion sets and their complications. Current evidence and guidelines supporting the use of surgical AF ablation, during both concomitant cardiac surgery and stand-alone surgery will also be reviewed.
\nA large variety of surgical strategies have evolved over past decades for the treatment of AF. As such, standardisation of terminology is difficult and comparison of studies can prove impossible. Anti-arrhythmic procedures are divided into two broad categories: (A) isolation or (B) ablation procedures. Initial surgical procedures were isolation procedures, aimed at confining the arrhythmia to a specific region of the heart [11]. Ablation was not carried out at this early time, as there was insufficient knowledge relating to the electrophysiological mechanisms driving AF. Isolation procedures such as LA isolation and the corridor operation will not be reviewed further in this chapter as they are irrelevant to current clinical practice.
\nStarting in the 1980s, several procedures were developed in an effort to treat AF, including LA isolation (A), corridor operation (B), and atrial transection (C) (\nFigure 1\n). The first attempt to surgically ablate AF was made via the atrial transection procedure in 1986 [12]. This procedure failed after 5 months in the 1 patient in which it was performed. Transection was based upon on the flawed belief that AF was caused by two macro-re-entrant circuits; one around the SVC and IVC orifices and one around the pulmonary veins and the orifice of the LA appendage (LAA). With improving knowledge of the mechanisms driving AF the MAZE procedure and pulmonary vein isolation (PVI) subsequently evolved, and formed the foundation of modern surgical treatment of AF. These two procedures form the main focus of this chapter.
\nSchematic representation of AF isolation/ablation techniques. (A) His bundle ablation, (B) Left atrial isolation procedure, (C) Corridor procedure (D) Atrial transection procedure and (E) MAZE concept [
The MAZE concept underlying the classical MAZE procedure is best encapsulated by the words of Dr James Cox—‘The cardinal feature of a classical MAZE procedure includes lines of conduction block that preclude macro-re-entry anywhere in either atrium while leaving both atria capable of activation by a sinus-generated impulse. Components essential to achieving this include appropriate lesions in
Schematic representation of the surgical MAZE concept [
The first MAZE-I procedure was performed in 1987. It abolished AF and re-established sinus rhythm (SR) effectively. However, the MAZE-I was associated with chronotropic incompetence in approximately 30% of patients, and intra-atrial conduction delay resulting in loss of LA transport due to simultaneous LA and left ventricle (LV) contraction [13]. These two undesirable effects of the MAZE-I procedure, led to modifications in the lesion set thus creating the MAZE II procedure. The anterior-superior LA and right atrium (RA) lesions were repositioned in a more posterior location. The Maze II was performed in less than 15 patients, due to extreme technical difficulty that required SVC transection above the RA to enhance LA exposure [13, 14]. The MAZE III included relocation of anterior lesion sets further posteriorly and a septal lesion to facilitate LA exposure, the latter being omitted subsequently in later iterations of the MAZE III. From 1992 onwards the surgical cut-and sew MAZE-III procedure was performed through a median sternotomy, and the lesion pattern became the standard pattern for MAZE procedures. As the name implies, all cardiac lesions were created by cutting the full thickness of the myocardium and then re-sewing the tissue together, thus inhibiting macro re-entry circuit conduction. It was not until 1997 when the original cut-and-sew MAZE-III procedure was replaced by cryosurgical MAZE-III procedure, where all surgical lesions were replaced by cryoablation lesions created by a linear cryoprobe [13]. The MAZE III was then superseded by the first MAZE IV procedure in 2002. Lesion sets were essentially identical, with lesions in the MAZE IV performed using a combination of bipolar radiofrequency clamps and linear cryoprobes [15] (\nFigure 3\n). Improved speed of execution resulted in less patient morbidity during the MAZE IV, and this is now the gold standard procedure in AF ablation. Surgical AF ablation is most commonly applied as a concomitant procedure during valve or coronary revascularization operations, but also as a primary or stand-alone procedure. The frequency of surgical ablation and durable achievement of SR is increasing, represented mainly by the MAZE III/IV procedures.
\nVersions of the surgical MAZE procedure [
Numerous energy sources have evolved over the past two decades to replace the traditional ‘cut and sew’ technique that aim to replicate transmural lesions, whilst enabling a less time-consuming yet equally effective approach. A fundamental pre-requisite for successful AF ablation, is complete transmurality and continuity bilaterally, and a correct lesion pattern.
\nRadiofrequency ablation (RFA) acts by conducting an alternating electrical current through the myocardium. The energy of this electrical current disperses through myocardial tissue as heat, causing coagulative necrosis, creating an area of non-conducting myocardium. RFA employs an alternating current at 350 kHz-1 MHz to heat tissue to 70–80°C for 1 min, creating a 3–6 mm lesion using unipolar or bipolar devices. Transmurality is indicated by electrical conductance and impedance monitoring. The efficacy of AF ablation during cardiac surgery using either unipolar [16–18], or bipolar ablation [19–21] technology, is well established. Overall, success rates in restoring SR are over 60%, measured at a variety of time points ranging from 12 to 60 months post procedure. However, there is limited evidence to conclude whether bipolar RFA is more effective than unipolar RFA (\nFigure 4\n).
\nRadiofrequency surgical ablation clamp (A) and cryoprobe (B) [
Cryoablation works by using nitrous oxide as a cooling agent for 2 min at −60°C to produce a transmural lesion that can be visualised as an ‘iceball’.
\nTissue injury results by creation of ice crystals within cells disrupting the cell function and electrical conductivity. In addition, microvascular disruption causes cell death. Several studies have proven the efficacy of concomitant cryoablation in the treatment of AF. Cryoablation during concomitant cardiac surgery achieves good rates of SR, ranging from 60 to 80% at a variety of time points ranging from 12 to 60 months post procedure [22, 23] (\nFigure 4\n).
\nMicrowave ablation uses high-frequency electromagnetic radiation to induce oscillation of water molecules, and produces a well-demarcated lesion via thermal injury. Its main strength is the production of excellent epicardial lesions, thus promoting its use in minimally invasive techniques. A success rate ranging between 65 and 85% is observed over a variable follow up period between 6 and 12 months [24]. Long term success rates remain unclear and evidence relating to microwave ablation efficacy is limited. Thus far, bipolar RFA ablation and cryoablation have demonstrated superiority in terms of freedom from AF, AF recurrence rates, and microwave ablation is currently considered less effective than other ablation modalities [25, 26].
\nAlternative energy sources being explored in AF ablation are that of laser and ultrasound. Laser ablation uses a monochromatic, phase coherent beam to cause heating and cellular destruction. Laser has shown efficacy in restoration of SR (>70%) in isolated procedures and during concomitant surgery [27]. However, currently, laser ablation has not gained approval for clinical use outside of trials due to limited evidence supporting its efficacy and safety [27]. Ultrasound, utilises high-frequency sound waves (2–20 MHz) emitted by piezoelectric crystals to cause thermal heating and disruption of cell membranes. It creates permanent transmural lesions when applied epicardially and is advantageous in that CPB is unnecessary, and ablation can be executed on a beating heart. Ultrasound lesions can also be delivered via a balloon catheter, allowing isolated PVI [28, 29]. Reasonable conversion rates to SR have been demonstrated in isolated PVI for lone paroxysmal AF. However, due to frequent complications, such as atrio-oesophageal fistula, pericardial effusion and phrenic nerve palsy, use of ultrasound is not currently recommended, and its role in permanent AF is unproven [28, 29].
\nThe MAZE IV can be performed either through a sternotomy or through a right mini thoracotomy. A combination of RFA and cryoablation is used to create the lesion set in the majority of cases. After gaining access to the chest both pulmonary veins are bluntly dissected, after initiating normothermic cardiopulmonary bypass (CPB). The patient is then cooled to 34°C and RA lesion set performed on a beating heart. A small purse-string suture at the base of the RA appendage allows one jaw of a RFA clamp to pass and create a lesion along the RA free wall (\nFigure 5\n). A vertical atriotomy extending from the intra-atrial septum up towards the atrioventricular groove near the free margin of the heart is made at least 2 cm from the free wall lesion. From the inferior aspect of the incision, the RFA clamp then creates ablation lesions extending to the SVC and down towards the IVC. A linear cryoprobe is used to create an endocardial ablation on the tricuspid annulus at the two o’clock position. The cryoprobe is placed through the previously placed purse-string suture and an endocardial ablation is performed down to the 10 o’clock position on the tricuspid valve. When using a right mini-thoracotomy, the atriotomy is replaced by two additional purse-strings; one just above the intra-atrial septum midway between the SVC and IVC and one just next to the atrioventricular groove (\nFigure 6\n).
\nRadiofrequency surgical ablation clamp performing right sided pulmonary vein isolation [
Right atrial lesion sets for MAZE IV procedure. (A) Majority of linear lesions are created using bipolar radiofrequency clamps, and blue shades represent cryoablation lesions placed at two points on the tricuspid annulus through direct vision or small purse-string sutures (red arrows). (B) Linear lesions also can be created with cryoablation if required for mini-thoracotomy. Right atrial lesion set consisting of an ablation line along the SVC and IVC, ablation along the RA free wall with line to tricuspid valve annulus [
The LA lesion set is then performed under cardioplegic arrest. The LAA is amputated and the RFA clamp passed through to create a connecting lesion into the left superior pulmonary vein. The coronary sinus is marked with methylene blue at a point between the left and the right coronary arteries. A left atriotomy is performed and the posterior LA isolated using the RFA clamp both inferiorly and superiorly to connect the atriotomy to the previously made left pulmonary vein lesion (\nFigure 7\n). From the inferior part of the atriotomy an ablation lesion towards the mitral annulus is created. This lesion crosses the coronary sinus between the right coronary artery (RCA) and the circumflex artery. Cryoablation is then used to bridge the 2 cm gap from the end of the RFA lesion to the mitral valve annulus. Completion of the LA lesion set is carried out by cryoablating the coronary sinus in line with the isthmus lesion on the epicardial surface [30].
\nLeft atrial lesion sets for MAZE IV procedure. (A) Majority of linear lesions are created with bipolar radiofrequency clamps. Blue shades represent cryoablation lesions at the mitral isthmus and left pulmonary veins (minimally invasive approach). (B) Linear lesions can also be created with cryoablation if required for mini-thoracotomy. Left atrial lesion set consisting of bilateral PVI, pulmonary vein roof and floor connecting lesions, lesion from LSPV and amputated LAA, and lesion from inferior atriotomy to mitral valve annulus [
The MAZE IV is regarded as the gold standard surgical treatment for AF. However, the surgery although highly effective is quite invasive with related complications. Therefore, the totally thoracoscopic ablation procedure is gaining support as a minimally invasive alternative, and being performed both in a non-hybrid or (staged) hybrid setting. A large variety of thoracoscopic approaches are now established and regarded as safe [31] (\nFigure 8\n). Totally, thoracoscopic LA ‘MAZE’ procedures and PVI are described [32]. The procedures can be performed using three ports on both sides. On the right side, the pericardium is opened anterior to the phrenic nerve, followed by exploration of Waterston’s groove for subsequent positioning of the ablation device. Prior to PVI, ganglionic plexus location is performed using a transpolar pen and high frequency pacing. A positive plexus location is ablated for 20 s with the transpolar pen. High-frequency pacing is again performed to confirm successful ganglionic plexus ablation, and repeated if necessary. After isolating the right pulmonary veins, some techniques include making a trigonum line. From the trigonum line, a separate lesion is made to the LAA. Blunt dissection around the PVs is performed using a dissector and PVI achieved by bipolar RFA ablation clamp. A minimum of three overlapping ablation lesions are performed at the antrum of the right PVs. Conduction block is confirmed, by the absence of PV potentials if AF is present; and by pacing if SR is present. Ablation is repeated if necessary. Both a roof line and a floor line are created with a linear pen, making up the box lesion. Left sided procedure is then carried out in a similar fashion; the pericardium is opened posterior to the phrenic nerve and ligament of Marshall divided. The LAAO is amputated/occluded by a verity of techniques [32, 33].
\nThoracoscopic PVI and LAA occlusion procedure. (A) Patient position and ports on left side. (B) Bipolar ablation clamp being placed around pulmonary vein hilum. (C) Clip being placed at the base of the left atrial appendage [
However, review of 14 thoracoscopic studies shows that a wide variety of lesion sets are used, most frequently the trigone line, connecting the roof line with the left fibrous trigone; the LAA line, connecting the superior PVs with the LAA; and the bi-caval line [31]. Most described techniques employ bipolar RFA.
\nThere are many suitable types of minimally invasive ablation devices on the market and the box lesion technique is used in most of them. One such novel device is the COBRA Fusion device. For this device the transverse and oblique sinuses are bluntly dissected, along with the layer of fat in the area of the interatrial groove and transverse sinus. A special introducer, with a magnetic tip, is inserted into each sinus to meet behind the heart and form a loop, and the COBRA Fusion 150 (Estech, San Ramon, CA) ablation catheter is then connected to the introducer and pulled around the PVs (\nFigure 9\n).
\nCOBRA Fusion surgical ablation device. A versatile and flexible design for epicardial ablation [
Contact between atrial tissue and the catheter is then achieved using a unique suction device, with a target of suction of −500 mm Hg. The catheter uses unipolar and bipolar RFA to create lesions. The RFA is applied in 2 steps using temperature-control using a setting of 70°C for 60 s. Following this first cycle, the catheter is moved circumferentially to complete the box lesion and a second cycle of energy, both mono- and bipolar is applied. The continuity of lesion is checked visually in a reachable area, and a third overlapping ablation lesion performed if the line of the box lesion appears non-continuous. This third ablation is usually needed between the right superior pulmonary vein and the right inferior pulmonary vein mainly in patients with a large LA. In addition to visual inspection of the lesion line, in patients in SR exit block can be routinely tested by pacing the right PVs and the adjacent posterior LA, and another ablation performed if necessary. Of note however, successful box lesion isolation is only achievable in a minority of patients (<50%) [34].
\nThe majority of high-quality RCTs and meta-analyses of surgical ablation are weighted towards, but not confined to concomitant mitral procedures. As compared with patients in SR, those with AF tend to be older and to have worse baseline risk profiles. High baseline risk influences the decision not to perform concomitant ablation, nevertheless, the majority of studies advocate that worse risk profiles are not a contraindication to surgical ablation [35]. It is established that surgical ablation for AF can be performed without additional operative risk of mortality or major morbidity [35, 36]. Indeed, recent US registry data suggests that surgical ablation is associated with reduced mortality in multiple valve populations [37]. Currently, US guidelines recommended concomitant ablation during mitral surgery (Class 1, Level A), AVR, isolated CABG, and AVR + CABG (Class1, Level B) [35].
\nSurgical ablation for symptomatic AF in the absence of structural heart disease, refractory to medical therapy or catheter-based therapies, receives a class II recommendation as a primary stand-alone procedure (Level B). In addition, surgical ablation for symptomatic persistent or long-standing AF in the absence of structural heart disease is deemed reasonable as a stand-alone procedure, using the MAZE III/IV in comparison to PVI alone (Class IIA, Level B). Current literature shows that few technical restrictions are present opposing surgical ablation at the time of open atrial operations, and most studies agree that AF incidence is approximately halved, with this benefit maintained at 1 year [35, 37].
\nClear direct demonstration of survival benefit following surgical ablation is not straight forward, due to heterogeneous study groups, follow-up periods and limited sample sizes. However, a clear link between restoration of SR and survival is verified in the literature. Regardless of survival benefit, long-term quality of life improvement following surgical ablation has been demonstrated by many, but not all studies [38, 39]. Surgical ablation does not abolish stroke risk, but has been associated with reduction in long-term stroke risk.
\nSurgically untreated AF correlates with increased morbidity and mortality following AVR [40], and freedom from AF is greater after concomitant surgical AF ablation [35]. Reluctance to open the atria during AVR and or CABG discourages full MAZE procedures, and less extensive/invasive epicardial ablative methods are often favoured. Therefore, the potential consequences of non-adherence to the strict MAZE principles outlined earlier, on outcomes must be appreciated. As such, SR recovery appears to be greater with bi-atrial MAZE procedures compared to PVI alone during CABG and or AVR [41, 42]. As with mitral surgery, performing the MAZE procedure during AVR and/or CABG surgery is also established to be safe [43]. SR restoration rates greater than 95% at 5 years have been reported following MAZE procedure and CABG, and concomitant PVI with CABG improves restoration of SR in paroxysmal AF, with SR rates greater than 85% at 18 months [41, 44]. The efficacy of surgical ablation following AVR and or CABG has been shown to be at least equivalent to, if not superior to that following mitral surgery [35, 45].
\nThe European guidelines also advocate concomitant AF ablation during cardiac surgery and agree its safety [46, 47]. A variety of Class II recommendations are made [46]: (A) MAZE surgery, preferably bi-atrial, is recommended in symptomatic patients undergoing cardiac surgery to improve symptoms attributable to AF, balancing the added risk of the procedure and the benefit of rhythm control therapy. (B) Concomitant bi-atrial MAZE or PVI may be considered in asymptomatic AF patients undergoing cardiac surgery [48].
\nIn stand-alone surgery, MAZE procedure via mini-thoracotomy or thoracoscopic PVI have shown success rates ranging from 60 to 85% at 1 year, and success following failed catheter ablation [49, 50]. European guidelines are positive, expressing that isolated epicardial PVI via minimally invasive surgery, OR MAZE surgery potentially using a minimally invasive approach should be considered, in patients with symptomatic refractory AF and failed catheter ablation.
\nThoracoscopic ablation may be more effective in restoring SR than catheter ablation in selected patients, although rate of complications is higher in the surgically group [51, 52]. With ever improving ablation technology and surgical instrumentation, the ability to perform larger lesion sets via a minimally invasive approach is likely to increase; and lead to expansion in the use of stand-alone AF surgery, and hybrid surgical-electrophysiological ablation. Data relating to hybrid procedures is encouraging, with success rates greater than 80% at 1 year [53, 54]. Long procedure times currently impede greater use, and more evidence is required to define optimal patient selection and long-term efficacy.
\nThe data discussed thus far is encouraging for surgical AF ablation. However, it is impossible to draw firm conclusions from the large amount of data relating to surgical AF ablation, with relation to survival, and definitive conclusions relating to efficacy, are hampered by the multi-level heterogeneity, with respect to lesion set performed, nature/duration of AF, patient population, follow up duration and definition/assessment of rhythm outcomes. Satisfactorily sized randomised trials, with standardised lesion sets, energy devices, uniform follow-up and rhythm assessment are needed to provide high level evidence; and are in progress.
\nA recent Cochrane review of 22 published trials concluded for patients with AF undergoing cardiac surgery, that concomitant AF surgery doubles the rate of freedom from AF/atrial arrhythmias while increasing the risk of permanent pacemaker (PPM) implantation. However, the authors described the available evidence as only moderate quality, and concluded that effects on mortality were uncertain. Significant heterogeneity was encountered amongst studies, but safety, stroke risk, and health-related quality of life were not affected by concomitant surgical AF ablation. No benefit of one type of AF ablation over another was demonstrated [47]. All included studies were rated as being at a high risk of bias in at least one assessed domain. The recently published AMAZE randomised trial from Papworth, re-established that surgical ablation increases the proportion of patients in SR at 12 months and 24 months: 61.5% versus 46.9% and 58.5% versus 36.4%, respectively. The trialists concluded that surgical ablation was safe, but it did not improve quality of life or survival at 2 years, a relatively early time point. There was no significant difference in stroke-free survival, in serious adverse events, operative or overall survival, cardioversion or PPM implantation [55]. A major limitation of this study is that lesion sets were
The majority of surgical ablation studies in stand-alone AF have employed minimally invasive approaches; most frequently thoracoscopic off-pump RF PVI plus LAA amputation. Overall rates of freedom from AF of approximately 70–85% are reported at 12 months. Most studies, but not all, show conversion rates to be higher in paroxysmal AF than persistent AF when using PVI [56–58]. It is generally accepted that PVI is a reasonable treatment for paroxysmal AF with freedom rates of 70% reported at 5 years [59]. Direct randomised comparison between PVI and MAZE procedures is hard to find, with studies displaying marked heterogeneity.
\nIn non-paroxysmal AF, PVI alone does not seem to be sufficient for maintenance of SR. In permanent AF patients with LA dilatation and valvular disease, additional lesions seem necessary. Systematic review of multiple studies shows that isolated PVI, has inferior efficacy to on-pump endocardial MAZE procedures, in patients with stand-alone AF, with a clear advantage of performing additional atrial lesions [60]. These effects are echoed in non-stand-alone AF. In a recent study of 260 patients undergoing mitral valve surgery, with pre-dominantly non-paroxysmal AF, patients underwent surgical ablation with either PVI or biatrial MAZE, or mitral valve surgery alone. At, 12 months post-surgery, both ablation groups showed lower rates of AF than those undergoing mitral valve surgeries alone. A higher rate of AF was seen in the PVI group compared to biatrial MAZE (36% versus 23%). The aim of this study was primarily to assess a novel rhythm monitoring strategy post-surgery, and not lesion set comparison. The trial was not powered to detect a difference between the PVI and biatrial MAZE, but re-enforced other studies findings that a more complete lesion set may be superior in restoring SR, in patients undergoing mitral valve surgery [61]. In patients undergoing aortic or mitral valve surgery with permanent AF, PVI alone has been shown to be significantly inferior to PVI + additional LA lesions in restoration of SR; 25% versus 86% at 2 years [62]. This study along with others has demonstrated via electrophysiological mapping that complete continuous isolation of the pulmonary veins is often not achieved during surgical ablation. In a combined population of paroxysmal and persistent AF patients undergoing the Cox-Maze IV procedure, superior freedom from AF was obtained when patients received complete posterior LA isolation via a box-lesion, compared to a line between the inferior PVs only. Patients received a variety of concomitant procedures in this study including; CABG, mitral valve repair, tricuspid valve replacement, closure of patent foramen and aortic valve replacement [63]. Gillinov et al. showed in a randomised mitral valve surgical population with persistent or long-standing persistent AF that surgical ablation significantly improved freedom from AF at 1 year [64]. In a sub-set analysis they showed that PVI alone in comparison to biatrial lesion set creation appeared to show equivalent results; approximately 60% freedom from AF at 1 year. The authors have commented that the study was not adequately powered to show a difference between the two ablation sets, and emphasised the need for larger randomised studies to explore this question. This study has also received criticism for the relatively low percentage use of bipolar RFA in the PVI group (43%), relatively low success rate of freedom from AF at 1 year (60%), and the creation of biatrial lesion sets that did not strictly adhere to the true MAZE concept. The latter criticism, coupled to the factor that adequacy of PVI was confirmed electrophyisologically intra-operatively, may have led to the enhanced efficacy of PVI seen in this study, in this population.
\nFollowing surgical AF ablation, full anticoagulation is common and reasonable until durable restoration of SR is proven, as long as safety criteria for anticoagulation are met. Anticoagulation is usually continued until stable SR is documented by the very least 24-h Holter monitoring. The time point at which monitoring should be conducted is debated, but is commonly at the 6 month follow up point, but many advocate rhythm monitoring at 1 year or beyond, and at multiple time points to capture late recurrence [35]. Sensible practice also recommends an echocardiogram before discontinuing anticoagulation to confirm adequate LA emptying.
\nThere are currently no guideline recommendations for specific anti-arrhythmic drug therapy following surgical ablation. Randomised, controlled, prospective data relating to this question is lacking and is desirable. As discussed earlier there is marked heterogeneity between surgical ablation studies, and this extends to definition of AF recurrence, rhythm assessment protocols and also anti-arrhythmic therapy. Forming firm conclusions based on these studies relating to optimal drug therapy regimens, would be non-scientific and inappropriate. For example, in the recently performed AMAZE trial, amiodarone use in the post-operative period was standardised; however, beta blocker use was left up to the discretion of treating teams [55].
\nOverall, anti-arrhythmic drug therapy is commonly given for 8–12 weeks after catheter or surgical ablation to reduce early AF recurrence. In addition, a 3 month immediate ‘blanking period’, in which rhythm assessment is not performed, is usually employed. A recent controlled trial in a catheter ablation population showed that amiodarone halved early AF recurrences compared with placebo [65].
\nThe ESC guidelines on the management of AF raise the concern that prospective studies are lacking with relation to anti-arrhythmic therapy post-catheter ablation, and available evidence is weak [46]. They conclude that better AF prevention is afforded after catheter ablation with anti-arrhythmic therapy, and this represents reasonable practice. Review of the literature relating to surgical ablation reveals that this sensible practice is employed almost universally. AF conversion is generally measured by the percent of patients off class I or III antiarrhythmic drugs and free of atrial tachyarrhythmia at 3, 6, 9, 12, and 24 months postoperatively. Recurrence is generally defined as any atrial tachyarrhythmia lasting longer than 30 s on a 24-h Holter monitor recording 6 months after surgical ablation. Amiodarone is the most commonly used drug for enhancing rhythm control post-surgical ablation, although routine use is not universal. Concomitant use of beta-blockade is common, although, not always routine. A multitude of data exists relating to the likely benefits of statins, amiodarone and various other drug regimens in the prevention of post-operative AF during routine cardiac surgery. To extrapolate this data to the surgical AF ablation population is reasonable. However, detailed, controlled studies are needed to define the precise short and long-term impact of drug therapy following surgical ablation procedures. Specific delineation of differences between different populations, e.g. CABG versus valvular disease groups, and differing drug regimens is necessary, but maybe challenging. The lack of definite evidence relating to drug therapy is reflected by the STS recommendation for multidisciplinary heart team assessment and long-term follow up to optimise outcomes of surgical ablation for AF [35].
\nSafety and feasibility of surgical ablation technology and techniques was first explored in animal studies. The animal studies described here, stem from the efforts made to firstly (A) transition away from the traditional, technically demanding cut and sew MAZE procedure, as well as to (B) develop quicker, less invasive, +/− beating heart, surgical ablation techniques.
\nThe limitations of animal studies with relation to extrapolation of efficacy to humans must be borne in mind. There are known differences in atrial tissue and epicardial fat thickness, between the various used animal species and humans. Atrial thickness in the domestic pig is similar to that of the human, but levels of epicardial fat in the human are significantly greater, and so too is the thickness of diseased human atria [66]. In addition, electrophysiological differences with relation to impulse generation and AF pathophysiology, varies between animal species and humans. As with human studies, a multitude of devices and lesion sets have been employed, utilising both normal and chronically fibrillating hearts, precluding direct meaningful study comparison. As such, specific animal studies clearly demonstrating efficacy of the MAZE procedure in restoration of SR are lacking. Overall, animal studies are best regarded as the preliminary studies that proved concept, safety and feasibility of surgical ablation in humans. They crucially provided the anatomical basis, technological characteristics/limitations, mechanistic insights and electrophysiological knowledge, which allowed informed ablation use in humans.
\nAn early sheep study clearly established RFA to produce equally effective lesions to the cut and sew surgical technique. The RFA technique was shown to be significantly faster than incision technique with equivalent safety. In this 18 sheep, on-CPB endocardial ablation study, adequate lesion transmurality was demonstrated using pacing at both acute and chronic (1 month) time points. The lesion set performed was similar but not identical to the classical MAZE procedure, and this study amongst others established RFA to be a simple, time saving alternative to surgical incisions during open heart MAZE procedures [67].
\nExamination of a variety of ablation technology devices, in various porcine beating heart ablation models, highlighted large variation in their ability to achieve transmurality [66]. The majority of devices failed to achieve full thickness lesions, a factor along with lesion continuity that has proven critical in preventing AF recurrence. Overall, the most consistently reliable devices for creating transmural lesions were demonstrated to be bipolar RFA clamps [68]. Although, highly reliable when performing PVI, use in creating intra-cardiac lesions during beating heart surgery is restricted to the right side, due to potential catastrophic effects of air embolism on the left. As such, the majority of beating heart animal studies study epicardial devices. Porcine studies amongst others, helped delineate the challenges facing surgical epicardial ablation. These included variability of atrial wall muscle thickness and epicardial fat distribution, enhanced heat insulation by fat, and circulating intra-cavitary blood action as a potential heat sink [66]. These studies also identified the anatomical variation in reliability of transmurality achievement. Zones of difficulty, over Bachmann’s bundle, crista terminalis and at the mitral or tricuspid annuli, LAA and RAA were identified, along with zones of higher success around the pulmonary veins [69].
\nAcute and chronic studies using bipolar RF epicardial lesions have established that they do not significantly change pulmonary vein flow, nor cause significant acute or chronic pulmonary vein stenosis [68, 70]. In addition, pacing and epicardial mapping have both confirmed consistent, successful bidirectional isolation, with the real-time tissue conductance assessment, being able to reliably predict short and long term transmurality. Histologic examination re-enforced safety, showing safe discrete lesions without evidence of stricture, or aneurysm formation [70].
\nA disputed aspect surrounding surgical AF ablation is that of the relationship to PPM insertion. The rate of PPM insertion following surgical AF ablation varies between 6% and 19%. The relationship is unclear, large meta-analyses comparing PPM insertion rates have demonstrated no significant increase in post-operative PPM requirement during concomitant AF ablation [48], yet a Cochrane review has demonstrated an increased requirement [47]. There is a presumed association between RA lesions and PPM implantation, and indeed a recent meta-analysis demonstrated that bi-atrial AF ablation surgery was associated with increased PPM insertion compared to isolated LA ablation [71]. Although not universal, most clinical studies show the increased need for PPM after AF ablation surgery to be driven mainly by sick sinus syndrome [9]. A proposed possible explanation is that of unmasking preoperative sinus node dysfunction. However, due to a multitude of confounding variables and lack of accurate reporting of preoperative data, it is not possible to precisely establish a causal mechanism.
\nAs discussed earlier, despite increased CPB time and hospital length of stay, in the modern era, concomitant surgical AF ablation is regarded as safe, with no increase in mortality demonstrated [47, 72]. In addition, most studies demonstrate no increase in peri-operative stroke [47, 72]. Overall, the frequency of cardiac tamponade, pericardial effusion, myocardial infarction and re-operative bleeding does not appear to increase following concomitant surgical AF ablation [47, 72]. With relation to minimally invasive MAZE procedures and surgical AF ablation for stand-alone AF, safety is also acceptable. Minimally invasive epicardial surgical ablation is perceived to be safer than the endocardial MAZE procedure, because the former requires smaller incisions and does not require CPB. However, no statistically significant difference in mortality has been demonstrated [73]. Mortality rates of less than 0.5% are reported [60]. Results vary and are technique dependent, with some analyses showing lower re-operative bleeding rates and conversion to sternotomy with minimally invasive endocardial MAZE procedure [60], and others favouring minimally invasive epicardial surgical ablation without the use of CPB [73]. Similar conflicting results are noted with respect to the incidence of renal failure and hospital length of stay. As mentioned earlier, controlled studies are required to precisely delineate relationships between efficacy and safety of various minimally invasive techniques.
\nGreat efforts have been directed towards identifying predictors of AF recurrence, but have been hampered by the heterogeneity of studies with relation to ablation set, AF characteristics, rhythm assessment and pharmacological regimens, amongst other variables. Risk factors for recurrence are broadly classified into pre-operative variables and intra-operative variables. Preoperative variables associated with AF recurrence include increasing LA diameter [15, 74, 75], age [76], and prolonged pre-operative duration of AF [75, 76]. In an excellent 280 patient prospective study, Damiano et al. showed in patients with both paroxysmal AF and persistent AF three risk factors for AF recurrence following the MAZE IV procedure: increasing LA size, early post-operative AF and failure to anatomically isolate the entire posterior LA [15]. LA size of over 8 cm being has been shown by the same group to correlate with a >50% chance of AF recurrence. Gillinov et al. also showed in approximately 260 patients undergoing the cut and sew MAZE III procedure and mitral valve surgery, in a cohort of predominantly permanent AF patients, that risk factors for AF recurrence included longer duration of AF, larger LA diameter, older age, and higher left ventricular mass index [76].
Impact of intra-operative variables such as energy source and lesion set are a contested area. Again, heterogeneity of studies hinders comparison. Overall it is difficult to demonstrate that use of various energy sources affects AF recurrence rates. Similar long-term success rates have been observed with either uni- or bipolar RFA and cryoablation [77], yet both superiority of either bipolar RFA [78] or monopolar [79] has been shown in different studies. Although not certain, the bi-atrial lesion set appears to display superiority to isolated LA lesion set in prevention of AF recurrence [78, 80]. In addition, modifiable risk factors such as hypertension, diabetes and smoking are implicated in surgical ablation failure [81].
\nCatheter ablation is highly effective for the treatment of symptomatic, drug refractory AF. The reported efficacy for catheter ablation varies widely, although freedom from AF of up to 70% is reported, with worldwide registry data showing a procedural major adverse event rate of ~ 4.5%. Catheter ablation for the treatment of AF is currently recommended by guidelines as a second-line therapy in patients with paroxysmal and persistent AF after treatment with ≥1 antiarrhythmic drug has failed (Class I recommendation for paroxysmal AF, Class IIa for persistent AF, and Class IIb for long-stranding persistent). Most randomised controlled trials (RCTs) of drug therapy versus catheter ablation have studied patients with preserved left ventricular function [82]. Recently, RCTs have also shown the benefit of rhythm control with catheter ablation over medical therapy for AF associated with heart failure [83]. A recent meta-analysis examining six RCTs confirmed these findings demonstrating catheter ablation to be superior to medical therapy for AF in patients with HF, resulting in greater improvement in LVEF, quality of life and functional status, with a definite survival benefit [84]. Results from the recent CABANA trial also echo these positive catheter ablation effects in HF patients [85]. Although variable, a pooled freedom from AF of 71% was seen in this analysis.
\nThere is not much direct comparison of surgical ablation versus catheter ablation in the literature. The FAST study included 124 patients with drug–refractory AF, LA dilatation and hypertension or failed prior catheter ablation. Patients were randomised to either catheter ablation or thoracoscopic surgical ablation. Catheter ablation consisted of linear antral PVI and optional additional lines. Surgical ablation consisted of bipolar RF PVI, ganglionated plexi ablation, and LAA excision with optional additional lines. Freedom from AF was superior for surgical ablation at 12 months (36.5% versus 65.6%), but this was at the expense of greater rate of complications, driven mainly by pneumothorax, major bleeding, and the need for PPM [52]. A meta-analysis of eight studies showed that thoracoscopic surgical ablation showed significantly greater freedom from AF at 12-months compared to catheter ablation (78.4 versus 53%), with a reduced requirement for repeat ablation [86]. This superiority was maintained in paroxysmal and persistent AF subgroups. However, again, complications were shown to be considerably higher in the surgical group, driven mainly by pleural effusion and pneumothorax. Limitations of the data were the retrospective nature of some of the included studies and the heterogeneity of patients involved.
\nThe superior efficacy demonstrated by surgical intervention is postulated to be due to several factors [86]. The ablation lesion set employed with surgery is generally much more extensive including PVI, but also targeted epicardial ganglionic plexi, LAA excision and additional LA lines. The importance of ganglionic plexi and the LAA in perpetuating AF re-entrant circuits is well recognised [87, 88]. In catheter ablation relative inadequate treatment may be occurring, as additional ablation lines are often not performed, with endocardial lesions consisting of PVI using wide-area antrum ablation alone. In addition, a better ability of surgical technology to create adequate transmural lesions may underlie its superior efficacy.
\nDebate continues regarding the optimal lesion set for stand-alone surgical ablation. Specifically, the comparative efficacy of strategies of PVI versus extended LA lesion sets, or MAZE IV approach remains unknown, and requires further study. Further controlled studies are also needed to delineate the apparent supremacy of surgical ablation over catheter ablation. However, concerns relating to the higher rate of complications and prolonged length of stay of the more invasive surgical approach currently impede adoption of its use on a broader scale. The majority of these complications are non-severe and managed conservatively, and whether such this level of apprehension is justified is unclear. Surgical ablation is increasingly performed as a stand-alone procedure and with improving technology and surgical skill its use is likely to expand with time, either on its own or as part of a hybrid electrophysiological approach.
\nUnfortunately electrophysiological evaluation after bipolar RF PV isolation has been scarcely performed. Only a small minority of surgical ablation studies have performed detailed intra-operative or peri-operative validation of ablation sets [64]. It is clear that confirmation of adequacy of ablation transmurality and continuity impacts upon surgical ablation efficacy and subsequent AF recurrence rate [89, 90]. Several factors oppose routine electrophysiological validation of ablation including; (A) technically challenging to adequately pace in between instead of on the performed ablation lines, (B) time consuming to perform correctly; with epicardial lesions, at least 20 min between PV isolation and endocardial validation is needed and (C) precise delineation of the border between conducting and non-conducting tissue at the distal sleeve of the PV is sometimes difficult to perform without complex mapping techniques. In its simplest form following PVI, entrance block is defined as failure to capture the PVs during pacing from the LA, and exit block can be defined by failure to capture the LA, when pacing from the PVs distal to the RF lesions.
\nFollowing minimally invasive PVI, recurrence rates as high as 40% have been seen despite intra-operative electrophysiological validation. Repeat electrophysiological investigation shows the vast majority are due to PV reconnection. In mini-MAZE [90] and total thoracoscopic procedures [91] intra-operative electrophysiological validation has been associated with higher success rates of 84% and 93% at 24 and 12 months respectively, in mixed AF populations. Sophisticated 3D electrophysiological mapping again showed recurrence was secondary to PV gaps in 50% of patients, with ectopic foci in LAA, peri-mitral LA roof flutter in the remainder. Post-operative recurrence is generally amenable to catheter ablation, with good intermediate-term success [92]. These findings re-enforce the growing belief that the hybrid ablation approach, either immediate or staged will produce the best long term ablation outcomes. Augmented success rates with a combined staged hybrid approach have been achieved, with a required catheter-based ‘touch up’ rate of approximately 20% following surgical intervention [93].
\nThe predominant factor in AF recurrence post-ablation is PV reconnection or incomplete isolation. Several reasons for the gaps around the PVI ring are implicated: (A) clamp application failure over the roof of the superior PVs, (B) incomplete clamping at the bottom of inferior PV, (C) clamp application failure at the antral side of the PV due to the long distance between the superior and inferior PVs, or accessory PVs and (D) increasing LA size. Multiple reasons for improper clamp application and diminished RFA effect are also cited including (A) angulation of clamps rather than perpendicular placement; (B) blood within the PVs limiting tissue involution between the clamps on beating hearts; (C) clamp movement during beating heart ablation; (D) the cooling effect of circulating blood and (E) anatomic factors such as atrial folds, ridges and variable myocardial thickness.
\nImproving the quality of the lesion set, will undoubtedly improve durability and success of surgical ablation; and better intra-operative electrophysiological mapping strategies represents a good target to focus upon. It is clear that simple entrance and exit block confirmation has a false negative rate, most likely related to tissue oedema, trauma and ischaemia, and the optimum universal mapping technique and strategy is not established. Randomised controlled studies with detailed electrophysiological interrogation follow up, are needed to identify this technique and strategy and then standardise their application, and improve surgical lesion set creation.
\nLAA exclusion or occlusion LAAO can be safely performed. Growing interest in LAA intervention has been driven by the observation that 90% of thrombi in non-valvular AF (NVAF) and 60% of those in valvular AF develop in the LAA. LAAO by surgical excision or device occlusion is postulated to reduce the risk of stroke, peripheral thromboemboli, and necessity for oral anticoagulants. Surgical techniques available to isolate the LAA include LAA excision with amputation, or occlusion which can be performed endocardially or epicardially. LAAO can be performed using an implantable device or without. Non-device approaches include surgical two-layer closure with running or mattress sutures, stapling and excision, and placement of surgical purse-strings or clips around the LAA base. Success is dependent on total LAA excision or isolation. Any residual stump of the LAA >1 cm in length, or gap with associated blood flow is thrombogenic [94]. LAA exclusion however has been inconsistent in terms of techniques, rates of complete exclusion, and thus adoption. Studies comparing internal ligation, external staple excision and surgical excision show that complete LAA elimination should not be assumed. Initial stump-free elimination can deteriorate with time, and a residual stump can be immediately present, emphasising the importance of immediate and late echocardiographic interrogation of LAA intervention [95].
\nA variety of devices exist. The most widely used endocardial device is the Watchman device, which is a percutaneously delivered polyester fabric on a nitinol frame (\nFigure 10\n). The Lariat device utilises a combined percutaneous and epicardial approach to deliver a lasso around the appendage guided by an intraluminal magnet tip. The AtriClip is made of two polyester-covered parallel tubes with nitinol springs (\nFigure 11\n). The AtriClip is a self-closing clamp placed epicardially at the base of the LAA to exclude blood flow. In general, endocardial devices remain in contact with intracardiac blood, and therefore anticoagulation for 2 months is recommended following implantation, making them less attractive for patients with contraindications to anticoagulation. Endocardial devices also fail to lie properly in LAAs with unfavourable morphologies.
\nThe watchman left atrial appendage occlusion device. A percutaneously delivered polyester fabric device on a nitinol frame [
Left atrial appendage occlusion AtriClip device. Parallel titanium crossbars apply adequate pressure without crushing or damaging tissue [
The strongest evidence supporting reduction of stroke risk and potentially the elimination of anticoagulation with LAAO comes from the large, multi-centre RCT, PROTECT AF. This study used the percutaneous Watchman LAA device. After 3.8 years of follow-up in patients with NVAF at elevated risk for stroke, percutaneous LAA closure met criteria for both non-inferiority and superiority, compared with warfarin, for preventing the combined outcome of stroke, systemic embolism, and cardiovascular death, as well as superiority for cardiovascular and all-cause mortality [96].
\nIn a large meta-analysis reviewing over 2400 patients, the efficacy of LAA closure compared to warfarin in 2 RCTS, PREVENT AF and the PREVAIL trial was analysed. At a mean follow up of 2.7 years in patients with NVAF at increased risk for stroke or bleeding, LAA intervention improved rates of haemorrhagic stroke, cardiovascular/unexplained death, and non-procedural bleeding. These positive effects were offset by an increase in ischemic strokes, mainly peri-procedural. All-cause stroke or systemic embolism was similar between both strategies. This analysis emphasised a non-inferiority of LAAO to warfarin use; with LAA intervention beneficial effects seeming to be underpinned by the circumvention of anticoagulation-related morbidity and mortality, as opposed to prevention of thromboembolism [97]. However, these positive results could not be automatically extrapolated to surgical LAA intervention.
\nRetrospective analysis of over 10,000 patients undergoing surgical AF ablation with and without concomitant surgical LAAO, showed only 37% underwent LAAO. Concomitant LAAO significantly reduced readmission for thromboembolism and all-cause mortality. The additional procedure was demonstrated to be safe, but the important differentiation between technique of LAAO, nature of AF and echocardiographic parameters between groups was not made [98]. In an updated meta-analysis examining over 3600 patients from 7 studies a significant reduction in stroke, and all-cause mortality was demonstrated in patients with AF undergoing LAAO during cardiac surgery, compared to those not undergoing LAAO. Techniques of suture ligation and stapling were utilised, and a variety of post-operative anticoagulation regimens and follow up periods [99].
\nThe best clinical evidence for LAAO devices exists for the AtriClip device (AtriCure). It is the most commonly used surgical device with over 100,000 recorded implants worldwide. It is applied with concomitant cardiac operations as well as in isolated thoracoscopic procedures safety and efficacy of the AtriClip device was evaluated in the EXCLUDE trial. In 70 patients undergoing primary cardiac operations AtriClip, demonstrated 95% successful exclusion with 98% complete LAA exclusion on CT at 3 months [100]. Success was defined as occlusion with no residual neck >1 cm and no leaks or migration. The upcoming results of the large (n = 4700) multicentre, randomised LAAOS III trial will aid in clarifying the long-term outcomes of LAAO in AF patients undergoing cardiac surgery [101].
\nThe practice of prophylactic LAA closure in patients without AF undergoing cardiac surgery does not appear to be effective. A recent large scale, propensity-matched analysis of prophylactic LAA closure, showed that this was associated with early increase in post-operative AF and no decrease in stroke risk or mortality [102]. The ATLAS trial is now randomising patients without documented AF, at high risk for the developing post-operative AF undergoing elective cardiac surgery; to LAA exclusion with the AtriClip or no concomitant AtriClip placement. The LAAOS III and ATLAS trials are the largest trials investigating efficacy of LAA occlusion for stroke prevention at the time of cardiac surgery; and their results are eagerly awaited.
\nCurrently, the US and the European guidelines state that it is reasonable to, or consideration should be given to, performing LAA intervention in conjunction with surgical AF ablation and during cardiac surgery, for longitudinal thromboembolic morbidity prevention (Class II, Level C/B). European guidelines also say it is reasonable to perform isolated LAA intervention in patients in AF with contraindication to anticoagulation.
\nThere is large variability in anticoagulation strategies post LAAO and surgical ablation alone with mixed-use of warfarin, NOACs and single and dual antiplatelet agents. The optimal anticoagulation therapy is still a matter of debate. Decisions regarding anticoagulation and imaging should be made and tailored to patient and procedural characteristics. The decision is often straight forward, in patients with a contraindication to anticoagulation referred for LAA exclusion. However, for patients without contraindications to anticoagulation, the decision is less simple. The Zurich group has shown in 36 patients receiving AtriClip, with a mean CHA2DS2-VASc score of 3.7, that only one transient ischemic attack (TIA) occurred after >1200 day follow up, with no strokes [98]. Three patients received anticoagulation. They have also shown a reduction in stroke risk in 291 patients with a mean CHA2DS2-VASc score of 3.1, receiving AtriClip during concomitant surgery cardiac surgery [103]. Patients that did not receive anticoagulation after LAA exclusion had a relative risk reduction of 87.5% in stroke, with an observed ischaemic stroke-rate of 0.5/100 patient-years compared with an expected rate in a group of patients with similar CHA2DS2-VASc scores of 4.0/100 patient-years. No evidence of reperfusion or residual stump was observed [104].
\nEvidence regarding anticoagulation management post-operatively is not robust, and further well-powered long-term evidence is needed to confidently guide anticoagulation management in patients receiving the AtriClip but have no contraindications to anticoagulation. Currently, the European guidelines recommend that patients undergoing LAA intervention remain on anticoagulation (Class 1). However, the view that anticoagulation is not needed after AtriClip application is also held by many, with single anti-platelet agent thought to be sufficient.
\nSurgical AF ablation has evolved over the past few decades and is now safe, and associated with minimal morbidity. The gold standard lesion set remains that of the MAZE IV, yet ‘lesser’ lesion sets, are gaining favour within the minimally invasive, hybrid and non-hybrid treatment setting, for treatment of NVAF. It is clear that surgical ablation displays beneficial effects, but the supportive evidence is not of the highest quality, and high quality RCTS with standardised ablation sets, AF criteria and defined rhythm assessment outcomes are needed. New studies need to precisely define and quantify the role of surgical ablation on rhythm, survival, symptoms, thromboembolic risk, and the exact relationship with specific target AF populations. Similarly, high level evidence is needed to quantify the impact of LAA intervention on thromboembolic risk in AF. Identification of the optimal LAA intervention, together with clear guidance on anticoagulation is necessary.
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr.",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Rheinmetall (Germany)",country:{name:"Germany"}}},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. 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Zaharia"},{id:"55977",title:"Dr.",name:"Gabriela",middleName:null,surname:"Ioana-Toroimac",slug:"gabriela-ioana-toroimac",fullName:"Gabriela Ioana-Toroimac"},{id:"91185",title:"Prof.",name:"Grecu",middleName:null,surname:"Florina",slug:"grecu-florina",fullName:"Grecu Florina"},{id:"91186",title:"Dr.",name:"Gianina",middleName:null,surname:"Neculau",slug:"gianina-neculau",fullName:"Gianina Neculau"}]},{id:"45249",doi:"10.5772/56414",title:"Challenges and New Advances in Ocean Color Remote Sensing of Coastal Waters",slug:"challenges-and-new-advances-in-ocean-color-remote-sensing-of-coastal-waters",totalDownloads:3286,totalCrossrefCites:11,totalDimensionsCites:27,abstract:null,book:{id:"3517",slug:"topics-in-oceanography",title:"Topics in Oceanography",fullTitle:"Topics in Oceanography"},signatures:"Hubert Loisel, Vincent Vantrepotte, Cédric Jamet and Dinh Ngoc\nDat",authors:[{id:"66224",title:"Prof.",name:"Hubert",middleName:null,surname:"Loisel",slug:"hubert-loisel",fullName:"Hubert Loisel"},{id:"99752",title:"Dr.",name:"Cédric",middleName:null,surname:"Jamet",slug:"cedric-jamet",fullName:"Cédric Jamet"},{id:"163462",title:"Dr.",name:"Vincent",middleName:null,surname:"Vantrepotte",slug:"vincent-vantrepotte",fullName:"Vincent Vantrepotte"},{id:"167707",title:"MSc.",name:"Dat",middleName:null,surname:"Dinh Ngoc",slug:"dat-dinh-ngoc",fullName:"Dat Dinh Ngoc"}]},{id:"66461",doi:"10.5772/intechopen.85139",title:"Fish Sperm Physiology: Structure, Factors Regulating Motility, and Motility Evaluation",slug:"fish-sperm-physiology-structure-factors-regulating-motility-and-motility-evaluation",totalDownloads:1903,totalCrossrefCites:11,totalDimensionsCites:26,abstract:"For reproduction, most fish species adopt external fertilization: their spermatozoa are delivered in the external milieu (marine- or freshwater) that represents both a drastic environment and a source of signals that control the motility function. This chapter is an updated overview of the signaling pathways going from external signals such as osmolarity and ionic concentration and their membrane reception to their transduction through the membrane and their final reception at the flagellar axoneme level. Additional factors such as energy management will be addressed as they constitute a limiting factor of the motility period of fish spermatozoa. Modern technologies used nowadays for quantitative description of fish sperm flagella in movement will be briefly described as they are more and more needed for prediction of the quality of sperm used for artificial propagation of many fish species used in aquaculture. The chapter will present some applications of these technologies and the information to which they allow access in some aquaculture species.",book:{id:"7912",slug:"biological-research-in-aquatic-science",title:"Biological Research in Aquatic Science",fullTitle:"Biological Research in Aquatic Science"},signatures:"Jacky Cosson",authors:[{id:"188281",title:"Dr.",name:"Jacky",middleName:null,surname:"Cosson",slug:"jacky-cosson",fullName:"Jacky Cosson"}]},{id:"20911",doi:"10.5772/19948",title:"The Significance of Suspended Sediment Transport Determination on the Amazonian Hydrological Scenario",slug:"the-significance-of-suspended-sediment-transport-determination-on-the-amazonian-hydrological-scenari",totalDownloads:4181,totalCrossrefCites:13,totalDimensionsCites:24,abstract:null,book:{id:"304",slug:"sediment-transport-in-aquatic-environments",title:"Sediment Transport in Aquatic Environments",fullTitle:"Sediment Transport in Aquatic Environments"},signatures:"Naziano Filizola, Jean-Loup Guyot, Hella Wittmann, Jean-Michel Martinez and Eurides de Oliveira",authors:[{id:"36890",title:"Dr.",name:"Naziano",middleName:null,surname:"Filizola",slug:"naziano-filizola",fullName:"Naziano Filizola"},{id:"60004",title:"Dr.",name:"Jean-Michel",middleName:null,surname:"Martinez",slug:"jean-michel-martinez",fullName:"Jean-Michel Martinez"},{id:"60005",title:"Dr.",name:"Jean-Loup",middleName:null,surname:"Guyot",slug:"jean-loup-guyot",fullName:"Jean-Loup Guyot"},{id:"102592",title:"Dr.",name:"Hella",middleName:null,surname:"Wittmann",slug:"hella-wittmann",fullName:"Hella Wittmann"},{id:"102593",title:"Mr.",name:"Eurides",middleName:null,surname:"De Oliveira",slug:"eurides-de-oliveira",fullName:"Eurides De Oliveira"}]},{id:"60698",doi:"10.5772/intechopen.74923",title:"Overview on Mediterranean Shark’s Fisheries: Impact on the Biodiversity",slug:"overview-on-mediterranean-shark-s-fisheries-impact-on-the-biodiversity",totalDownloads:1123,totalCrossrefCites:14,totalDimensionsCites:19,abstract:"Bibliographic analysis shows that the Mediterranean Sea is a hot spot for cartilaginous species biodiversity, including sharks, rays, and chimaeras; 49 sharks and 36 rays were recorded in this region. However, they are by far the most endangered group of marine fish in the Mediterranean Sea. The IUCN Red List shows clearly the vulnerability of elasmobranchs and the lack of data; 39 species (53% of 73 assessed species) are critically endangered, endangered, or vulnerable. The biological characteristics of elasmobranchs (low fecundity, late maturity, and slow growth) make them more vulnerable to fishing pressure than most teleost fish. Overfishing, the wide use of nonselective fishing practices, and habitat degradation are leading to dramatic declines of these species in the Mediterranean Sea. In general, elasmobranchs are not targeted but are caught incidentally. In many fisheries, they are, however, often landed and marketed. A decline in cartilaginous fish species landings has been observed while fishing effort has generally increased. Better understanding of the composition of incidental and targeted catches of sharks by commercial fisheries are fundamentally important for the conservation of these populations. Moreover, problems encountered by elasmobranchs in the area are highlighted, and conservation measures are suggested.",book:{id:"6266",slug:"marine-ecology-biotic-and-abiotic-interactions",title:"Marine Ecology",fullTitle:"Marine Ecology - Biotic and Abiotic Interactions"},signatures:"Mohamed Nejmeddine Bradai, Bechir Saidi and Samira Enajjar",authors:null}],mostDownloadedChaptersLast30Days:[{id:"60368",title:"Biological and Medicinal Importance of Sponge",slug:"biological-and-medicinal-importance-of-sponge",totalDownloads:2585,totalCrossrefCites:1,totalDimensionsCites:3,abstract:"Sponges are multicellular, heterotrophic parazoan organisms, characterized by the possession of unique feeding system among the animals. They are the most primitive types of animals in existence, featuring a cell-based organization where different cells have different tasks, but do not form tissues. Sponges (Porifera) are a predominantly marine phylum living from the intertidal to the abyssal (deepest ocean) zone. There are approximately 8500 described species of sponges worldwide with a prominent role in many reef coral communities. Several ecological studies reported have shown that secondary metabolites isolated from sponges often serve defensive purposes to protect them from threats such as predator attacks, biofouling, microbial infections, and overgrowth by other sessile organisms. In the recent years, interest in marine sponges has risen considerably due to presence of high number of interesting biologically active natural products. More than 5300 different natural products are known from sponges and their associated microorganisms, and every year hundreds of new substances are discovered. In addition to the unusual nucleosides, other classes of substances such as bioactive terpenes, sterols, fatty acids, alkaloids, cyclic peptides, peroxides, and amino acid derivatives (which are frequently halogenated) have been described from sponges or from their associated microorganisms. Many of these natural products from sponges have shown a wide range of pharmacological activities such as anticancer, antifungal, antiviral, anthelmintic, antiprotozoal, anti-inflammatory, immunosuppressive, neurosuppressive, and antifouling activities. This chapter covers extensive work published regarding new compounds isolated from marine sponges and biological activities associated with them.",book:{id:"6344",slug:"biological-resources-of-water",title:"Biological Resources of Water",fullTitle:"Biological Resources of Water"},signatures:"Musarat Amina and Nawal M. Al Musayeib",authors:[{id:"213049",title:"Dr.",name:"Musarat",middleName:null,surname:"Amina",slug:"musarat-amina",fullName:"Musarat Amina"},{id:"213050",title:"Dr.",name:"Nawal",middleName:null,surname:"M. Al Musayeib",slug:"nawal-m.-al-musayeib",fullName:"Nawal M. Al Musayeib"}]},{id:"59865",title:"Marine Fisheries in Nigeria: A Review",slug:"marine-fisheries-in-nigeria-a-review",totalDownloads:3937,totalCrossrefCites:9,totalDimensionsCites:11,abstract:"Fisheries production especially from marine is important for the socio-economic development of Nigerians and its contribution to the nation’s economic growth through the Gross Domestic Product (GDP). Nigeria is blessed with enough marine fisheries resources that could enhance increased fish production. Yet, fish supply from domestic production is far below the fish demand of her citizens. This chapter is therefore focused on marine fisheries in Nigeria. We adopted a desk review approach. This chapter is divided into different sections such as the Nigerian fisheries sector, marine fisheries resources in Nigeria, status of marine fisheries production in Nigeria, marine fisheries regulations, and constraints to optimal marine fisheries production in Nigeria. We concluded that the contribution of aquaculture to marine fisheries production has been low, compared to the marine capture fisheries production. Also, we noted that despite the availability of regulations, noncompliance by fisher folks has not helped to optimize marine fisheries production. We therefore recommended that the culture of marine fishes should be intensified. Marine waters should also be protected against destruction and pollution as a result of human activities. Available marine fisheries regulations should be enforced and violators of the regulations should be punished as stipulated in the regulations.",book:{id:"6266",slug:"marine-ecology-biotic-and-abiotic-interactions",title:"Marine Ecology",fullTitle:"Marine Ecology - Biotic and Abiotic Interactions"},signatures:"Olalekan Jacob Olaoye and Wahab Gbenga Ojebiyi",authors:null},{id:"57327",title:"Closed Aquaculture System: Zero Water Discharge for Shrimp and Prawn Farming in Indonesia",slug:"closed-aquaculture-system-zero-water-discharge-for-shrimp-and-prawn-farming-in-indonesia",totalDownloads:2527,totalCrossrefCites:2,totalDimensionsCites:4,abstract:"This chapter focuses on the development and application of zero water discharge (ZWD) system, which has become an alternative solution to conventional methods of aquaculture production. With this system, it is expected to answer many issues in aquaculture cultivation, such as environmental damage, disease outbreak, and land-use change, and to create a sustainable aquaculture cultivation system. ZWD system is an improved batch system with an emphasis on microbial manipulation in rearing tank. The principle of microbial selection is based on the role of each microbial component in nutrient cycle in the rearing tank. This chapter contains in detail how methods and stages are performed in order to conduct this system, including design of construction system, cultivation of microbial components, initial conditioning of this system, and microbial manipulation. The performance of the system was tested in crustacean culture such as white shrimp and giant freshwater prawns, and it showed that the system can increase the average survival rate of 10–20%. In addition, the technical and economic feasibility of this system was evaluated to illustrate the production efficiency upon the application of this system in the industry.",book:{id:"6344",slug:"biological-resources-of-water",title:"Biological Resources of Water",fullTitle:"Biological Resources of Water"},signatures:"Gede Suantika, Magdalena Lenny Situmorang, Pingkan Aditiawati,\nDea Indriani Astuti, Fahma Fiqhiyyah Nur Azizah and Harish\nMuhammad",authors:[{id:"216920",title:"Dr.",name:"Gede",middleName:null,surname:"Suantika",slug:"gede-suantika",fullName:"Gede Suantika"},{id:"220079",title:"Dr.",name:"Magdalena Lenny",middleName:null,surname:"Situmorang",slug:"magdalena-lenny-situmorang",fullName:"Magdalena Lenny Situmorang"},{id:"220081",title:"Dr.",name:"Pingkan",middleName:null,surname:"Aditiawati",slug:"pingkan-aditiawati",fullName:"Pingkan Aditiawati"},{id:"220082",title:"Dr.",name:"Dea Indriani",middleName:null,surname:"Astuti",slug:"dea-indriani-astuti",fullName:"Dea Indriani Astuti"},{id:"220083",title:"MSc.",name:"Fahma Fiqhiyyah Nur",middleName:null,surname:"Azizah",slug:"fahma-fiqhiyyah-nur-azizah",fullName:"Fahma Fiqhiyyah Nur Azizah"}]},{id:"59973",title:"Genetic Applications in the Conservation of Neotropical Freshwater Fish",slug:"genetic-applications-in-the-conservation-of-neotropical-freshwater-fish",totalDownloads:1716,totalCrossrefCites:3,totalDimensionsCites:9,abstract:"Neotropical fish correspond to approximately 30% of all fish species worldwide. The diversity of fish species found in Neotropical basins reflects variations in life-history strategies and exhibition of particular morphological, physiological and ecological attributes. These attributes are mainly related to different forms of feeding, life maintenance and reproduction. Today, fish populations are being threatened by anthropogenic actions that are having a visible impact on the natural state of continental aquatic ecosystems. The main causes are overfishing, non-native species introduction, reservoir-dam systems, mining, pollution and deforestation. The biology and population dynamics of the species are still unclear due to lack of research. Genetic tools can be useful resources for the conservation of Neotropical fish species in several ways. Molecular genetic markers are considered powerful tools to identify cryptic and hybrid fish and also allow the evaluation of the genetic variability and structure of populations of Neotropical ichthyofauna. Several analyses of molecular markers have been performed on Neotropical fish, including allozyme analysis, restriction fragment length polymorphisms in regions of DNA (RFLP), randomly amplified polymorphic DNA (AFLP), randomly amplified polymorphic DNA (RAPD), microsatellites, single nucleotide polymorphisms (SNPs) and mitochondrial DNA (mtDNA) markers. In order to analyse a high number of markers, next generation sequencing has allowed researchers to generate a large amount of genomic information that can be applied to the conservation of Neotropical fish.",book:{id:"6344",slug:"biological-resources-of-water",title:"Biological Resources of Water",fullTitle:"Biological Resources of Water"},signatures:"Vito Antonio Mastrochirico Filho, Milena V. Freitas, Raquel B.\nAriede, Lieschen V.G. Lira, Natália J. 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This mangrove is a biodiversity hot spot, and one of the richest in ecosystem services in the world, but due to lack of data it is often not mentioned in many global mangrove studies. Inland areas are sandy and mostly inhabited by button wood mangroves (Conocarpus erectus) and grass species while seaward areas are mostly inhabited by red (Rhizophora racemosa), black (Laguncularia racemosa) and white (Avicennia germinans) mangroves species. Anthropogenic activities such as oil and gas exploration, deforestation, dredging, urbanization and invasive nypa palms had changed the soil type from swampy to sandy mud soil. Muddy soil supports nypa palms while sandy soil supports different grass species, core mangrove soil supports red mangroves (R. racemosa), which are the most dominant of all species, with importance value (Iv) of 52.02. The red mangroves are adapted to the swampy soils. They possess long root system (i.e. 10 m) that originates from the tree stem to the ground, to provide extra support. The red mangrove trees are economically most viable as the main source of fire wood for cooking, medicinal herbs and dyes for clothes.",book:{id:"6411",slug:"mangrove-ecosystem-ecology-and-function",title:"Mangrove Ecosystem Ecology and Function",fullTitle:"Mangrove Ecosystem Ecology and Function"},signatures:"Aroloye O. Numbere",authors:[{id:"215285",title:"Dr.",name:"Aroloye O.",middleName:null,surname:"Numbere",slug:"aroloye-o.-numbere",fullName:"Aroloye O. 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Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',annualVolume:11404,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"49517",title:"Prof.",name:"Hitoshi",middleName:null,surname:"Tsunashima",fullName:"Hitoshi Tsunashima",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTP4QAO/Profile_Picture_1625819726528",institutionString:null,institution:{name:"Nihon University",institutionURL:null,country:{name:"Japan"}}},{id:"425354",title:"Dr.",name:"Marcus",middleName:"Fraga",surname:"Vieira",fullName:"Marcus Vieira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003BJSgIQAX/Profile_Picture_1627904687309",institutionString:null,institution:{name:"Universidade Federal de Goiás",institutionURL:null,country:{name:"Brazil"}}},{id:"196746",title:"Dr.",name:"Ramana",middleName:null,surname:"Vinjamuri",fullName:"Ramana Vinjamuri",profilePictureURL:"https://mts.intechopen.com/storage/users/196746/images/system/196746.jpeg",institutionString:"University of Maryland, Baltimore County",institution:{name:"University of Maryland, Baltimore County",institutionURL:null,country:{name:"United States of America"}}}]},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering",scope:"The Biotechnology - Biosensors, Biomaterials and Tissue Engineering topic within the Biomedical Engineering Series aims to rapidly publish contributions on all aspects of biotechnology, biosensors, biomaterial and tissue engineering. We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",annualVolume:11405,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"35539",title:"Dr.",name:"Cecilia",middleName:null,surname:"Cristea",fullName:"Cecilia Cristea",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYQ65QAG/Profile_Picture_1621007741527",institutionString:null,institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"40735",title:"Dr.",name:"Gil",middleName:"Alberto Batista",surname:"Gonçalves",fullName:"Gil Gonçalves",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYRLGQA4/Profile_Picture_1628492612759",institutionString:null,institution:{name:"University of Aveiro",institutionURL:null,country:{name:"Portugal"}}},{id:"211725",title:"Associate Prof.",name:"Johann F.",middleName:null,surname:"Osma",fullName:"Johann F. 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