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Staged Hybrid Approach in long-standing persistent AF patients : lessons from over 100 cases
Tae Hee Hong, Pyo Won Park, Young Tak Lee, Seung-Jung Park, Kyung Min Park, Young Keun On, Dong Seop Jeong.
Samsung Medical Center, Seoul, Korea, Republic of.

OBJECTIVE: Totally thoracoscopic ablation has emerged as a new approach for lone persistent atrial fibrillation (AF). We evaluated the efficacy and safety of the totally thoracoscopic ablation using short-term post-procedural electrophysiological study (EPS).
METHODS: Between 2012 and 2014, 108 consecutive patients (mean age, 55 ± 8 years) underwent totally thoracoscopic ablation and post-procedural EPS at postoperative 4th day for lone AF. Thoracoscopic ablation included pulmonary vein isolation, superior and inferior line ablation, ganglionated plexus ablation, division of Marshall ligament and resection of left atrial appendage. Recently, we performed additional ablation at both carina of pulmonary vein and right atrium (superior vena cava to inferior vena cava) using cryo-ablator. All patient were followed up every 3 months with 24-holter monitoring and echocardiography.
RESULTS: No death or conversion to open heart surgery occurred. The incidence of perioperative complications including pleural effusion, bleeding and stroke was 6.5% (n=7). No late death was occurred. One patient suffered from pulmonary vein to esophageal fistula at postoperative 2 months. 15.7% of patients (n=17) underwent additional ablation at left atrium during post-procedural EPS. The ablation sites are shown in Figure 1. 9 patients (8.3%) required cavotricuspid isthmus (CTI) ablation for atrial flutter. 92.6% (100/108) patients were in sinus rhythm during follow up. Predictors for AF recurrence were CHAD2 score (p=0.011, Hazard Ratio = 3.4) and absence of spontaneous sinus conversion during thoracoscopic ablation (p=0.018, Hazard Ratio = 3.4)
CONCLUSIONS: The short-term staged hybrid procedure was safe and effective in lone AF. Post-procedural EPS should be considered to improve rhythm outcomes and prevent atrial tachyarrythmia.
Figure 1. The additional ablation sites during post-procedural EPS.

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