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Background: Percutaneous catheter ablation has been the preferred choice of treatment for many patients with symptomatic drug-refractory atrial fibrillation (AF), although incomplete ablation lines and varying long-term success rates remain a problem, especially in patients with persistent AF. This report evaluates the feasibility and efficacy of a totally endoscopic approach to perform a surgical left atrial lesion set.
Methods: Between 2009 and 2011, epicardial bipolar radiofrequency ablation on the beating heart was performed via a bilateral endoscopic approach on 74 consecutive patients with lone AF (mean age: 59±13 years, 72% male). The pulmonary veins were isolated (PVI) by a clamp, a complete box-lesion was performed including a roof and bottom line connecting the left and right PVI as well as a trigonal-line connecting the right PVI to the aortic non-coronary sinus using a linear ablation device. Additionally, the left atrial appendage was resected. Bi-directional conductance block was confirmed for the PVI and the box-lesion. Data were collected prospectively for all patients. Mean follow-up was 10±5 months (range: 4-25) and 100% complete. Electrocardiograms, 24-hour holter monitoring or pacemaker interrogation was obtained at 6 and 12 months and annually thereafter. 86% of patients received prolonged monitoring. Late recurrence was defined as any episode of AF, atrial flutter or atrial tachycardia lasting longer than 30 seconds.
Results: Mean duration of preoperative AF was 6.5±5.7 years with 38% paroxysmal and 62% persistent or long-standing persistent AF. 34% of patients had previously failed a mean of 2.1±1.0 catheter ablations and 12% had experienced thromboembolic events. Median operation-time was 176 minutes (range: 95-275), mean hospital-stay was 8.5±4.7 days. There was no death, no conversion to sternotomy and no early or late stroke. Freedom from AF was 88%, 92% and 83% at 6, 12 and 24 months, respectively. Freedom from both AF and antiarrhythmic drugs was 67%, 81% and 83% at 6, 12 and 24 months, respectively.
Conclusions: Epicardial bipolar radiofrequency ablation can be safely performed endoscopically on the beating heart with high success rates and might develop to a considerable alternative to percutaneous catheter ablation in the treatment of symptomatic patients with drug-refractory persistent AF.