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Long term success rates of endoscopic epicardial ablation of lone AF: 4 years results
Nicolas Doll, Daniela Y. Seubert, Timo Weimar.
Sana Cardiac Surgery Stuttgart, Stuttgart, Germany.

OBJECTIVE: Percutaneous catheter ablation has been the preferred choice of treatment for many patients with symptomatic drug-refractory atrial fibrillation (AF). However, incomplete ablation lines and varying long-term success rates remain a problem in certain patient subgroups. Endoscopically performed left-atrial ablation in patients with lone AF evolved to a promising allternative. However, long term results of this approach extending into the fourth year have been limited.
METHODS: Epicardial bipolar radiofrequency ablation was performed beating heart via a bilateral endoscopic approach in 142 consecutive patients with lone AF by isolating the pulmonary veins (PVI) using a clamp as well as the posterior left atrial wall by superior and inferior connecting lesions using a linear ablation device, and resecting the left atrial appendage. Pre-, peri- and postoperative data were collected prospectively and included questionnaires and a 24-hour-Holter monitoring at 6 and 12 months and annually thereafter.
RESULTS: Mean follow-up was 22±15 months and was 97% complete. Prolonged monitoring was conducted in 81%. Mean duration of AF was 6.4±5.5 years with 31% paroxysmal and 69% persistent or longstanding persistent AF. Mean operation-time was 172±44 minutes. There was no death, no conversion to sternotomy and no early or late stroke. Freedom from AF was 85%, 88%, 89%, 84% and 74% at 6, 12, 24, 36 and 48 months, respectively. Freedom from AF off antiarrhythmic drugs was 75%, 77%, 85%, 80% and 68% at 6, 12, 24, 36 and 48 months, respectively. There was no significant difference in success rates between types of AF. Of those patients receiving a staged hybrid catheter ablation due to recurrence (n=6), 50% presented with typical atrial flutter, 33% with atypical flutter, 17% with a gap in the PVI. After catheter ablation, 50% of patients with recurrence were in sinus rhythm but were considered as failures in this report.
CONCLUSIONS: Endoscopic radiofrequency ablation on the beating heart reveals high long-term success rates with low procedure-related morbidity. With additional catheter ablation in case of AF recurrence results can even be improved. A randomized trial is advisable to compare this procedure to catheter ablation in certain patient subgroups.

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