Thoracoscopic Pulmonary Vein and Left Atrial Posterior Wall Isolation Combined with Left Atrial Appendage Resection in Patients with Long-Standing Persistent Atrial Fibrillation

Abstract

Objective: To evaluate the efficacy and safety of a modified technique for totally thoracoscopic left atrial posterior wall and pulmonary vein isolation in patients with long-standing persistent atrial fibrillation. Methods: From April 2017 to December 2018, we included in this study 28 consecutive patients who underwent thoracoscopic left atrial posterior wall and pulmonary vein radiofrequency isolation combined with left atrial appendage resection. We used a device with irrigated electrodes (Medtronic Cardioblate Gemini-s). The original surgical technique "GALAXY" proposed by Doty in 2012 was modified. The number of ablations was significantly increased, and frequent position changing of the ablation device and change of device angulation were added. Results: Sinus rhythm was restored in all patients. There was no operative mortality, no myocardial infarction, and no stroke or transient ischemic attack. One patient required sternotomy and another survived left anterolateral thoracotomy due to bleeding. A 180-day follow-up (24-hour Holter monitoring) revealed no sign of recurrence of atrial fibrillation or other supraventricular arrhythmia in any patient. Mean follow-up was nine months (range: 6-16 months). At the last follow-up, 26 patients (92,9%) were in sinus rhythm (24-hour Holter monitoring). Conclusion: A frequent ablation device position changing during the surgery makes it possible to achieve complete left atrial posterior wall and pulmonary veins isolation. An increased number of applications allows to avoid a false positive transmural damage assessment showed by impedance drop. Also, frequent position changing of the ablation device and increased number of applications do not affect the number of postoperative complications.

The Minimum Number of Ablation Lines for Complete Isolation of the Pulmonary Veins during Thoracoscopic Ablation for Atrial Fibrillation

“…Previous studies of TTA have revealed that surgeons usually create two to 10 pulmonary vein antral circumferential ablation lines with the Gemini-s ablation device (Medtronic, Minneapolis, MN, USA) or AtriCure Isolator Transpolar Clamp (Atricure, Inc., Cincinnati, OH, USA) [ 17 , 18 , 19 , 22 , 55 ]. Yilmaz et al [ 17 ] created at least three lines; Gaynor et al [ 56 ], two lines; Zotov et al [ 19 ], 10 lines; Wolf et al [ 22 ], at least two lines; Kwon et al [ 21 ], six lines; and Guo et al [ 55 ], three to five lines.…”

“…If a block is not achieved, additional lines are created. The preferred number of ablation lines ranges from two to 10 [ 17 , 18 , 19 ].…”

The Technology of Homogeneous Scar Tissue Creating as a Result of Ablation of the Atrial Wall with a Radiofrequency Bipolar Clamp: an Experimental and Clinical Study

“…All 137 patients underwent thoracoscopic RF fragmentation of the LA [ 8 , 9 ] ; and all underwent surgery using the developed technology for creation of a homogeneous scar tissue.…”

Electrophysiological findings after bilateral thoracoscopic atrial fibrillation ablation using irrigated bipolar radiofrequency energy - a pilot study

“…One of these approaches are thoracoscopic epicardial techniques using radiofrequency (RF) ablation via irrigated bipolar ablation devices to isolate PVs and the entire posterior wall of the LA (the box--lesion technique). 3 The most used instruments for mini--invasive surgical ablation is AtriCure (Ohio, USA). 4 Using these instruments, a stand-alone surgical thoracoscopic ablation cannot achieve transmural lesions in a considerable number of patients.…”