Short- and mid-term results of thoracoscopic atrial fibrillation ablation

Aim. Evaluation of short- and mid-term (up to one year) results of aт atrial fibrillation thoracoscopic radiofrequency ablation (TRFA) combined with left atrial appendage resection.

Methods. 10 patients with persistent AF were included in the study. In 5 cases surgical ablation was performed as the primary intervention and in 5 cases surgery were preceded by two unsuccessful catheter procedures. Age of the patients was 54.4 (41; 63) years, duration of arrhythmic anamnesis – 5.6 (4.8; 6.8) years, anteroposterior size of the left atrium – 4.7 (45; 51 mm), LV ejection fraction – 63 (58; 68) %. TRFA included an isolation of right and left pulmonary veins, ablation lines along the roof and base of posterior wall of the left atrium, left atrial appendage resection.

Results. In all cases of TRFA exit-block from the pulmonary veins was achieved. Among 10 procedures, a stable sinus rhythm was documented in 6 patients. In the remaining 4 patients AF was observed only in one case, and the other three demonstrated atypical atrial flutter, that given us a reason to repeat catheter procedures. In three cases of left atrial flutter, catheter ablation led to sinus rhythm restoration, and in case of AF and total sclerosis of left atrium a decision to refuse RF ablation was made. Complications were presented by a single case of bilateral phrenic nerve palsy, which required plication of the diaphragm, and two spontaneously resolved pulmonary atelectasis.

Conclusion. The efficacy of atrial fibrillation thoracoscopic radiofrequency ablation during the follow-up period of one year was 90% regarding selective hybrid approach (thoracoscopic + catheter procedure). Procedure safety of TRFA was much lower than that of catheter ablation: the total number of small and big complications was 30%.

1. Roberts SA, Diaz C, Nolan PE, Salerno DM, Stapczynski JS, Zbrozek AS, Ritz EG, Bauman JL, Vlasses PH. Effectiveness and costs of digoxin treatment for atrial fibrillation and flutter. Am J Cardiol 1993; 72: 567-573. doi: 10.1016/0002-9149(93)90353-e

2. Heeringa J, van der Kuip DA, Hofman A, Kors JA, van Herpen G, Stricker BH, Stijnen T, Lip GY, Witteman JC. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 2006; 27(8): 949-53. doi: 10.1093/eurheartj/ehi825

3. Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG. Prevalence, age distribution, and gender of patients with atrial fibrillation: analysis and implications. Arch Intern Med 1995; 155: 469-743.

4. Copley DJ, Hill KM. Atrial Fibrillation: A Review of Treatments and Current Guidelines. AACN Adv Crit Care 2016; 27: 120-128. doi: 10.4037/aacnacc2016281.

5. Gutierrez C, Blanchard DG. Atrial fibrillation: diagnosis and treatment. Am Fam Physician 2011; 83: 61-68.

6. Menezes AR, Lavie CJ, DiNicolantonio JJ, O'Keefe J, Morin DP, Khatib S, Milani RV. Atrial fibrillation in the 21st century: a current understanding of risk factors and primary prevention strategies. Mayo Clin Proc 2013; 88: 394-409. doi: 10.1016/j.mayocp.2013.01.022.

7. Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, et al. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. J Interv Card Electrophysiol 2012; 33(2): 171-257. doi: 10.1007/s10840-012-9672-7.

8. Kearney K, Stephenson R, Phan K, WY Chan, MY Huang, TD Yan. A systematic review of surgical ablation versus catheter ablation for atrial fibrillation. Ann Cardiothorac Surg 2014; 3(1): 15-29. doi: 10.3978/j.issn.2225-319X.2014.01.03

9. Wolf R, Schneeberger E, Osterday R, Miller D, Merrill W, Flege JB Jr, Gillinov AM. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg. 2005; 130: 797-802. doi: 10.1016/j.jtcvs.2005.03.041

10. Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M, Sandoval E, Calvo N, Brugada J, Kelder J, Wijffels M, Mont L. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial. Circulation. 2012; 125(1): 23-30. doi: 10.1161/CIRCULATIONAHA.111.074047

11. Cappato R, Negroni S, Pecora D, Bentivegna S, Lupo PP, Carolei A, Esposito C, Furlanello F, De Ambroggi L. Prospective assessment of late conduction recurrence across radiofrequency lesions producing electrical disconnection at the pulmonary vein ostium in patients with atrial fibrillation. Circulation 2003; 108: 1599-1604. doi: 10.1161/01.CIR.0000091081.19465.F1

12. Muneretto C, Bisleri G, Bontempi L, Curnis A. Durable staged hybrid ablation with thoracoscopic and percutaneous approach for treatment of long-standing atrial fibrillation: a 30-month assessment with continuous monitoring. J Thorac Cardiovasc Surg. 2012; 144(6): 1460-1465. doi: 10.1016/j.jtcvs.2012.08.069.

13. Vos LM, Kotecha D, Geuzebroek GSC, Hofman FN, van Boven WJP, Kelder J, de Mol BAJM, van Putte BP. Totally thoracoscopic ablation for atrial fibrillation: a systematic safety analysis. Europace. 2018 Nov 1;20(11):1790-1797.

14. Pojar M, Vojacek J, Haman L, Parizek P, Omran N, Vobornik M, Harrer J. Thoracoscopic radiofrequency ablation for lone atrial fibrillation: box-lesion technique. J Card Surg 2014; 29(5): 757-762. doi: 10.1111/jocs.12409.