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Pericardioscopic Treatment of Atrial Fibrillation in Patients Previously Undergoing Cardiac Surgery
Andy C. Kiser, Anil Gehi, Paul Mounsey.
University of North Carolina, Chapel Hill, NC, USA.

Objective: The surgical management of complex atrial fibrillation (AF) in patients that have previously undergone cardiac surgery is difficult; often necessitating a redo, open procedure. Pericardioscopic access to the hostile pericardium can be successfully and safely achieved enabling epicardial ablation of the posterior left atrium which, when performed in simultaneous collaboration with electrophysiology (EP), enables a less invasive surgical option.
Methods: Eight patients with previous cardiac surgery with symptomatic persistent (6) or long-standing persistent (2) AF underwent port-access pericardioscopic unipolar radiofrequency ablation of their posterior left atrium in a hybrid electrophysiology laboratory. Immediately following epicardial ablation, endocardial mapping and ablation was performed to complete antral pulmonary vein isolation and mitral isthmus ablation. Additional complex fractional atrial electrogram ablation, superior vena cava ablation, and cavotricuspid isthmus ablation was left to the discretion of the elecrophysiologist. Follow-up was completed with continuously recording implanted monitors (Reveal) or pacemakers.
Results: Seven patients underwent successful completion of the procedure. The average AF duration was 6.2 years. The average left atrial size was 5 cm. All had failed at least one (range 1-4) electrical cardioversion and 3 of 7 patients had failed previous catheter ablations. The average surgical and catheter ablation times were 73 and 222 minutes, respectively. All patients had electrical entry and exit block of the pulmonary veins and electrically isolated posterior left atrium. The average ICU duration was 29.6 hours and average length of stay was 4 days. At an average follow-up of 210 days, all patients had 0% AF burden but remained on antiarrhythmic medications. There were no perioperative or postoperative bleeding, strokes, readmissions, or deaths except one patient that required transfusion for a large groin hematoma. Transdiaphragmatic access to the pericardium was unsuccessful in one patient so the procedure was completed with endocardial catheter ablation alone.
Conclusions: Patients that have had previous cardiac surgery can safely undergo surgical epicardial ablation of the posterior left atrium which, when combined with a simultaneous endocardial ablation procedure, offers potentially improved outcomes but warrant longer term follow up.

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