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Totally thoracoscopic ablation with autonomic ganglia ablation for persistent and long-standing persistent atrial fibrillation - midterm results.
Anna Witkowska, Krzysztof Jaworski, Radoslaw Smoczynski, Bartlomiej Szafron, Dominik Drobinski, Monika Niewinska, Malgorzata Machaj, Wojciech Sarnowski, Zygmunt Kalicinski, Jaroslaw Swistowski, Dariusz Kosior, Piotr Suwalski.
Central Clinical Hospital of the Ministry of Interior in Warsaw, Warsaw, Poland.

OBJECTIVE: Atrial fibrillation (AF) become the growing problem because of its increasing prevalence, morbidity and economical costs. Pharmacological treatment have poor long term results and catheter ablation is effective only in selected group of patients. Here we describe midterm results of totally thoracoscopic ablation and autonomic ganglia ablation for persistent and long-standing persistent AF.
METHODS: 33 patients (21 men, 12 women) admitted to our department between November 2011 and December 2013 with persistent and long-standing persistent AF underwent totally thoracoscopic ablation of arrhythmia with left atrial appendage (LAA) stapling. Mean age, time of duration of AF, EUROScoreII, CHA2DS2-VASc score, NT-proBNP level, left atrial dimension and LVEF were 60(±9,5)years, 89(±76)months, 0,96(±0,59)%, 1,9(±1,3), 388,6(±472)pg/ml, 44(±6,9)mm and LVEF 58(±9)%, respectively. One patient (3%) underwent prior stroke. All patients underwent transesophageal echocardiography to rule out thrombus in LAA. Ablation was performed with AtriCure (Ohio, USA) system including bipolar RF pulmonary vein isolation and pattern of connecting lines on the left atrium and trigonal line to the non-coronary sinus. Mapping and epicardial autonomic ganglia ablation was performed. LAA exclusion was performed using Tri-Staple (Mansfield, USA) stapler. In all patients bidirectional block across ablation lines was performed. In perioperative period patients were under continuous rhythm monitoring. 3, 6 and 12 months follow-up using 48 hour ECG-Holter and echocardiography was performed in all patients.
RESULTS: No mortality was observed. 91% patients were in sinus rhythm on admission to intensive care unit and 96% on discharge from hospital. One early patient required sternotomy for bleeding from left atrium without further morbidity. 39% patients required cardioversion in perioperative period due to AF or atrial flutter. In 6 and 12 months follow-up 85% and 89% of patients remain in stable sinus rhythm, respectively. No incidence of stroke or TIA was noticed. Good atrial transport function and anatomical results of LAA exclusion in echocardiography were observed.
CONCLUSIONS: In our experience totally thoracoscopic ablation with autonomic ganglia ablation for persistent and long-standing persistent AF is feasible and gives good midterm results of maintenance of sinus rhythm and atrial transport function after operation. Further studies in this group of patients are needed.

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