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FIRST REPORT OF MINIMALLY-INVASIVE TOTAL-ENDOSCOPIC ROBOTIC SURGERY FOR THE TREATMENT OF INAPPROPRIATE SINUS TACHYCARDIA
Eric M. Hoenicke, MD1, Jeff Nitzsche, MD2, Kevin Daly, BS3, Andrea Natale, MD4, John David Burkhardt, MD4.
1Cardiothoracic and Vascular Surgeons; St. David's South Austin Medical Center, Austin, TX, USA, 2Austin Anesthesiology Group, Austin, TX, USA, 3Atricure, Westchester, OH, USA, 4Texas Cardiac Arrhythmia Institute, Austin, TX, USA.

OBJECTIVE: Surgical treatment for inappropriate sinus tachycardia (IST) has been described for patients who have been refractory to standard pharmacologic or catheter-based approaches (CBA). CBA for IST is additionally challenging because ablation targets are often adjacent to the phrenic nerve, which may cause phrenic nerve injury. Although no consensus exists on the optimal surgical approach, sternotomy, thoracotomy, and thoracoscopy have been described. We describe the first report in the literature of a minimally-invasive total-endoscopic robotic surgery (MITERS) where a migrating focus of IST was surgically ablated.
METHODS: A 32 year old woman was referred for a surgical opinion for symptomatic IST. Pharmacologic and CBA were unable to successfully control her symptoms of exercise intolerance, palpitations, and chest pain. MITERS was recommended for her treatment-refractory IST. A robotic approach was pursued because of enhanced surgical precision negotiating a potentially hostile and adhesed right atrium (RA). Four robotic ports were placed into the second, fourth, sixth, and eighth intercostal spaces in the right anterior chest. Dense intrapericardial adhesions were robotically dissected, completely freeing the RA. An isoproterenol infusion was initiated to achieve target heart rate (HR). Epicardial activation mapping was performed on the RA utilizing a specialized thoracoscopic bipolar pen. A migrating focus of IST was identified and ablated utilizing the thoracoscopic bipolar radiofrequency ablation (RFA) device.
RESULTS: Prior to general anesthesia, the baseline HR was approximately 95 which increased to 115 after induction. With isoproterenol infusion at 20 micrograms/minute, HR increased greater than 155. Epicardial mapping revealed multiple sites of early activation. During RFA of this migrating focus, HR briskly increased to 175 followed by a dramatic drop below 120 with concomitant p-wave inversion. This focus migrated caudally during the procedure. Post-operatively, HR was maintained below 80. There was no IST evident during her entire post-operative in-hospital stay. She was discharged home on post-operative day five.
CONCLUSIONS: This study presents preliminary successful surgical results utilizing MITERS for treatment-refractory IST. This unique combination of minimally-invasive robotic and thoracoscopic RFA may serve as a platform for approaching other challenging treatment-refractory arrhythmias surgically.


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