Minimally Invasive Thoracoscopic Surgery Is An Effective Approach For Inappropriate Sinus Tachycardia
Seyed Hossein Aalaei Andabili1, William Miles2, Thomas Burkart2, Matthew Mckillop2, Juan Garcia2, Thomas Beaver1.
1Division of Thoracic and Cardiovascular Surgery, Gainesville, FL, USA, 2Division of Cardiology, Department of Medicine, University of Florida, Gainesville, FL, USA.
OBJECTIVE: Inappropriate sinus tachycardia (IST) is an uncommon arrhythmia characterized by increased heart rate that is out of proportion to a normal physiologic demand. IST is challenging for the electrophysiology community due to the risk of phrenic nerve (PN) injury during ablation. In this study, we investigated safety and efficacy of a minimally invasive thoracoscopic surgery for elimination of the IST focus.
METHODS: Patients with IST who failed endocardial ablation underwent minimally invasive thoracoscopic epicardial ablation. Epicardial activation mapping was performed to identified the earliest activation site and any possible migration pathway. The phrenic nerve in each patient was protected by a pericardial retraction suture. Patients’ outcomes were reviewed retrospectively.
RESULTS: From January 2000 to September 2016, 9 patients; 7 females and 2 males underwent minimally invasive thoracoscopic IST ablation at University Center. Mean age of the patients was 37±13 years. All patients were treated with rate/rhythm control medications and had prior endocardial ablation, with the highest attempt at 13 ablations. The most common concomitant comorbidity was asthma (N=4, 45%). Two (22.2%) other patients noticed symptoms following pregnancy. Mean baseline sinus rate was 117±17 bpm (table-1). After surgery, mean heart rate decreased significantly at post-operative day 1 (117±17 versus 85.33±8, p<0.001). No in-hospital death, stroke, or PN injury was detected. One patient required re-intubation, one patient developed post-operative pericarditis, and another patient suffered from pulmonary embolism. Median follow-up was 6 months [range: 1-30]. Freedom from re-intervention was 88% at 6 months. All patients remained off from medication after surgery, except two who needed re-intervention at 4-months and 12 months (table-1).
CONCLUSIONS: Minimally invasive thoracoscopic ablation for IST is a safe and effective approach that preserves the phrenic nerve. Due to the possibility of IST activation site migration, continued follow up after surgery is required.
Table-1. Patients’ pre-operative characteristics and post-operative outcome
|Patient||Age||Gender||Prior Attempts||Failed Medications||Prior Cardiac diagnosis||Baseline HR||POD-1 HR||30-day HR|
|1||34||M||1||BB, CCB, and digoxin||None||117||89||-|
|2||47||F||1||BB and CCB||Atrial fibrillation||131||101||-|
|3||46||F||2||BB and CCB||Atrial fibrillation||94||88||74|
|4||23||M||13||BB and CCB||AVNRT||120||75||77|
|5||61||F||1||BB and CCB||Atrial fibrillation||104||80||75|
|6||44||F||2||BB and CCB||None||108||85||80|
|7||21||F||1||BB, CCB, Flecainide, and digoxin||None||123||87||89|
|9||28||F||3||BB, CCB, and Flecainide||AVNRT||150||88||85|
BB: Beta blocker, CCB: Calcium channel blocker, HR: Heart Rate
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