Hybrid Thoracoscopic and Endocardial Ablation of Lone AF
Hybrid Thoracoscopic and Endocardial Ablation of Lone AF
Between 2009 and 2012, a cohort of 78 consecutive patients underwent ablation of LAF as a standard procedure using a thoracoscopic, hybrid epicardial-endocardial technique.
LAF was defined following the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) Guidelines. Indication for minimally invasive surgery was based on the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECA) Guidelines. Patients were referred for a hybrid procedure in cases of paroxysmal, persistent or long-standing persistent atrial fibrillation (AF) with left atrial (LA) volume index ≥29 mL/m, after one or more failed catheter ablations or based on patient preference.
A transthoracic echocardiograph and a computed tomography (CT) scan were carried out preoperatively (pulmonary vein anatomy, coronary arteries), and all patients underwent a lung function test (spirometry). Exclusion criteria were: presence of atrial or left appendage thrombi, 'giant' left atrium (diameter >6.5 cm), significant coronary artery disease, and previous pulmonary or cardiac surgery. Patient characteristics are shown in Table 1.
All patients were followed up according to the HRS/EHRA/ECA expert consensus statement on catheter and surgical ablation of AF. Success was defined as no episode of AF, atrial flutter (AFL) or any atrial tachycardia (AT) lasting more than 30 seconds off antiarrhythmic drugs (AAD) after the three months blanking period.
Seven-day Holter monitoring (HM) was performed at 3 months, 6 months and 1 year and yearly thereafter. Monitoring was carried out with an external loop recorder (Del Mar Reynolds, Spacelabs Healthcare, Issaquah, WA, USA) and analyzed with Lifescreen Software (Del Mar Reynolds, Spacelabs Healthcare, Issaquah, WA, USA). For analysis, three rhythms were considered as postoperative AF: AF, AFL or AT lasting more than 30 seconds.
All patients reached 1-year follow-up. Median follow-up was 24 months [interquartile range (IQR) 12–36].
AADs were given postoperatively to all patients, and although we recommended discontinuation three months after ablation if the patient appeared to be AF free, their continued use was at the discretion of referring cardiologists. Warfarin was administered on postoperative day 2 with INR target of 2.5 and stopped after three months if the Holter recording showed a sinus rhythm (SR) or patients had a low thromboembolic risk (CHADS2 score <2).
Echocardiography was carried out preoperatively and at follow-up appointments using a commercially available echocardiographic system (Philips iE33; Philips Medical Systems, Eindhoven, The Netherlands). LA diameter was measured in parasternal long-axis view. In the apical 4-chamber view, LA maximum volume was measured by the biplane area-length method and indexed to body surface area (LAVI). Left ventricular Ejection Fraction was calculated with the biplane Simpson's method.
Methods
Between 2009 and 2012, a cohort of 78 consecutive patients underwent ablation of LAF as a standard procedure using a thoracoscopic, hybrid epicardial-endocardial technique.
LAF was defined following the American College of Cardiology/American Heart Association/European Society of Cardiology (ACC/AHA/ESC) Guidelines. Indication for minimally invasive surgery was based on the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECA) Guidelines. Patients were referred for a hybrid procedure in cases of paroxysmal, persistent or long-standing persistent atrial fibrillation (AF) with left atrial (LA) volume index ≥29 mL/m, after one or more failed catheter ablations or based on patient preference.
A transthoracic echocardiograph and a computed tomography (CT) scan were carried out preoperatively (pulmonary vein anatomy, coronary arteries), and all patients underwent a lung function test (spirometry). Exclusion criteria were: presence of atrial or left appendage thrombi, 'giant' left atrium (diameter >6.5 cm), significant coronary artery disease, and previous pulmonary or cardiac surgery. Patient characteristics are shown in Table 1.
All patients were followed up according to the HRS/EHRA/ECA expert consensus statement on catheter and surgical ablation of AF. Success was defined as no episode of AF, atrial flutter (AFL) or any atrial tachycardia (AT) lasting more than 30 seconds off antiarrhythmic drugs (AAD) after the three months blanking period.
Seven-day Holter monitoring (HM) was performed at 3 months, 6 months and 1 year and yearly thereafter. Monitoring was carried out with an external loop recorder (Del Mar Reynolds, Spacelabs Healthcare, Issaquah, WA, USA) and analyzed with Lifescreen Software (Del Mar Reynolds, Spacelabs Healthcare, Issaquah, WA, USA). For analysis, three rhythms were considered as postoperative AF: AF, AFL or AT lasting more than 30 seconds.
All patients reached 1-year follow-up. Median follow-up was 24 months [interquartile range (IQR) 12–36].
AADs were given postoperatively to all patients, and although we recommended discontinuation three months after ablation if the patient appeared to be AF free, their continued use was at the discretion of referring cardiologists. Warfarin was administered on postoperative day 2 with INR target of 2.5 and stopped after three months if the Holter recording showed a sinus rhythm (SR) or patients had a low thromboembolic risk (CHADS2 score <2).
Echocardiography was carried out preoperatively and at follow-up appointments using a commercially available echocardiographic system (Philips iE33; Philips Medical Systems, Eindhoven, The Netherlands). LA diameter was measured in parasternal long-axis view. In the apical 4-chamber view, LA maximum volume was measured by the biplane area-length method and indexed to body surface area (LAVI). Left ventricular Ejection Fraction was calculated with the biplane Simpson's method.
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