Totally thoracoscopic ablation for atrial fibrillation: a systematic safety analysis

Abstract

AimsThoracoscopic surgical ablation has evolved into a successful strategy for symptomatic atrial fibrillation (AF) refractory to other therapy. More widespread referral is limited by the lack of information on potential complications. Our aim was to systematically evaluate 30-day complications of totally thoracoscopic surgical ablation.Methods and resultsWe retrospectively studied consecutive patients undergoing totally thoracoscopic surgical ablation at a referral centre in the Netherlands (2007–2016). Patients received pulmonary vein isolation, with additional lesion lines as needed, and left atrial appendage exclusion. The primary outcomes were freedom from any complications and freedom from irreversible complications at 30-days. Secondary outcomes included intra- and post-operative complications according to severity. Included were 558 patients with median age 62 years (interquartile range 56–68 years), 70% male and 53% with a previous failed catheter ablation. The cohort consisted of 43% paroxysmal AF, 47% persistent AF, and 10% long-standing persistent AF. Freedom from any 30-day complication was 88.2%, and from complications with life-long affecting consequences 97.5%. The intra-operative complication rate was 2.3% with no strokes or death observed. The median hospital length of stay was 4 days. The percentage of patients with major and minor complications at 30-days was 3.2% and 8.1%, respectively, with one patient dying of an ischaemic stroke. The only patient groups with excess complications were women aged ≥70 years and patients with a history of congestive heart failure.ConclusionsTotally thoracoscopic ablation is associated with a low complication rate in a referral centre and may be a useful alternative to other rhythm control strategies.

Long‐term outcome after totally thoracoscopic ablation for atrial fibrillation

“…Since the introduction of the totally thoracoscopic ablation more than a decade ago, this rhythm control strategy has been established as an effective alternative or adjunct to catheter ablation indicated as a class 2A recommendation in latest guidelines for symptomatic AF in (longstanding) persistent or postablation patients with AF . The procedure is expected to become more widely available in upcoming years, especially since the safety of the procedure has been demonstrated, with acceptable complication rates . Despite all new insights and development in clinical practice, long‐term rhythm control in patients with AF remains a major challenge, particularly for patients with (long‐standing) persistent and postablation AF.…”

“…In case of absence of any AF recurrence, the last Holter (24 hours) monitoring was used for latest follow‐up. The patients that were defined as failure at 1‐year follow‐up because of AF recurrence were still considered as failure at latest follow‐up according to the definition of failure by the HRS consensus statement …”

“…Totally thoracoscopic epicardial ablation has evolved over the last decade towards a successful and safe minimally invasive rhythm control strategy, with a Class 2A indication, for patients with symptomatic drug refractory (long‐standing) persistent and postablation atrial fibrillation (AF) . The procedure is associated with a 79% freedom from AF after 2 years, but evidence for long‐term durability is still limited with reported success rates varying between 38% and 83% after a follow‐up up to 5 years .…”

The Maze Procedure and Postoperative Pacemakers

“…That can pose a problem during mitral valve surgery and during a maze procedure regardless of whether left atrial exposure is gained through Waterston's groove or by an anterior transseptal incision. That is one reason why minimally invasive maze procedures performed through a small right anterolateral thoracotomy [6], right-sided thoracoscopic maze procedures [19], and robotic maze procedures [20] are all associated with lower postoperative pacemaker requirements than are maze procedures performed through a median sternotomy. Another potential reason for fewer pacemakers being required after these more minimally invasive approaches may be surgeon selection bias as surgeons who perform the maze procedure by these techniques usually have had more experience with the procedure.…”

“…However, we know that the extensive extracardiac dissection in the original maze-I, maze-II, and maze-III cut-and-sew techniques, combined with an underlying sick sinus syndrome in some, resulted in 20% of all non-PAF patients with successful maze procedures requiring new pacemakers postoperatively. Less extensive extracardiac dissection, as practiced in the minimally invasive cryosurgical maze-III procedure, transthoracic partial maze procedures, and robotic maze-III procedures, result in only 5% to 10% of non-PAF patients requiring postoperative pacemakers [6,14,19,20]. As essentially no patients with documented normal SA nodes required pacemakers after a maze procedure, it is reasonable to conclude that some 5% to 10% of patients with non-PAF have underlying dysfunctional SA nodes.…”