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OBJECTIVE: We report stroke-prevention and rhythm-control by our thoracoscopic surgery in non-valvular atrial fibrillation.
METHODS: 4 sub-axillary thoracoscopic ports were made for the technique: the left atrial appendage was closed with an endoscopic cut-and-staple device; bilateral pulmonary veins and superior vena cava isolations were carried out with a bipolar radio-frequency epicardial ablation clamp. Anticoagulation immediately discontinued unless the patients had other thromboembolic risks. Periodical Holter electrocardiography and neurological check-ups were conducted.
RESULTS: Starting in 2008, 522 patients (men: 292 [56 %]) were operated by a single surgeon. 352 (Paroxysmal: 218, Non-paroxysmal: 134, Mean [SD] age: 65 [9] years, Mean CHA2DS2-Vasc score: 2.1, Mean HAS-BLED score: 1.5) chose appendectomy plus ablation, while 170 (Paroxysmal: 28, Non-paroxysmal: 142, Mean [SD] age: 74 [5] years, Mean CHA2DS2-Vasc score: 4.6, Mean HAS-BLED score: 3.3) chose appendectomy alone. The mean operative time was 77 min for the appendectomy plus ablation; 28 min for the appendectomy alone. In 12 (23 %) patients, thoracoscopy was switched to mini-thoracotomy approach. Cardio-pulmonary bypass was prepared and used in 1 case with complicated heart anomaly. Blood loss was less than 50 ml in all except 5 (1 %); none underwent blood transfusion. The mean hospital stay was 5.8 days after the appendectomy plus ablation and 3.9 days after the appendectomy alone. There was no hospital death and no major complications, such as stroke, phrenic nerve palsy, serious pneumonia. Cardiotomy-associated pericarditis was observed in 24 (4.6 %) patients. 3 (0.6 %) patients underwent pace-maker implantation. During the follow-up period (Mean [SD]: 35 [25] months), 7 (1.3 %) patients died, 2 (0.4 %) suffered coronary artery ischemia. Only 9 (1.7%) continued oral anticoagulation. All-cause neurological symptom occurred in 12 patients, but only 3 patients suffered cardiogenic stroke (Figure). 5 years after surgery, Holter electrocardiography documented continuous sinus rhythm in 90% of the paroxysmal, 71% of the non-paroxysmal cases.
CONCLUSIONS: Our thoracoscopic surgery is safely achievable and provides satisfactory anticoagulation-free brain protection and acceptable rhythm-control in non-valvular atrial fibrillation.