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Endoscopic epicardial radiofrequency ablation of lone atrial fibrillation in 105 Patients: 3-years results
Timo Weimar, Martina Vosseler, Markus Czesla, Vladimir Voth, Wolfgang Hemmer, Nicolas Doll.
Sana Cardiac Surgery Stuttgart, Stuttgart, Germany.

OBJECTIVE: Catheter ablation has been the preferred choice of treatment for many patients with symptomatic atrial fibrillation (AF). However, incomplete ablation lines and varying success rates remain a problem, especially in patients with persistent AF. We report the efficacy of an endoscopic approach to perform a left-atrial lesion-set on the beating heart.
METHODS: Between 2009 and 2012, epicardial bipolar radiofrequency ablation was performed via a bilateral endoscopic approach on 105 consecutive patients with lone AF (mean age: 60±11 years, 71% male). The pulmonary veins (PVI) and the posterior left-atrial wall were isolated using a clamp and a linear ablation device, respectively. A trigonal-line was added connecting the right PVI to the aortic non-coronary sinus. The left-atrial appendage was resected using a stapling-device. Bi-directional conductance block was confirmed for all lesions. Data were collected prospectively. Electrocardiograms, 24-hour Holter or pacemaker interrogation was obtained at 6 and 12 months and annually thereafter. 92% of patients received prolonged monitoring. Late recurrence was defined as any episode of AF, atrial flutter or atrial tachycardia lasting longer than 30 seconds. Quality-of-life was assessed by the SF-36 Health-Survey.
RESULTS: Mean follow-up was 14.3±7.8 months and 97% complete. Mean duration of AF was 6.4±5.7 years with 30% paroxysmal, 24% persistent and 37% long-standing persistent AF. 25% of patients had previously failed a mean of 2.1±1.0 catheter ablations, 9% had experienced thromboembolic events. Median procedure-time was 169 minutes (range: 95-355). There was no death, no conversion to sternotomy and no early or late stroke. Endoscopic re-exploration for bleeding occurred in one patient (1%). Freedom from AF was 87%, 89%, 92% and 80% at 0.5, 1, 2 and 3 years, respectively. Freedom from both AF and antiarrhythmic drugs was 73%, 78%, 88% and 80% at 0.5, 1, 2 and 3 years, respectively. Quality-of-life improved significantly in all physical and mental domains. Left-atrial size and body-mass-index were the only predictors for failure. Type and duration of AF were not predictive for recurrent AF.
CONCLUSIONS: Endoscopic ablation can be performed safely with good success rates and might develop to a better alternative to catheter ablation in the treatment of persistent AF.


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