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Mid-term Results of Five-box Biatrial Thoracoscopic Ablation of Advanced Atrial Fibrillation on the Beating Heart
Talal Al-Atassi, Isil Uzun, MD, Anja Muehle, MD, Mihaela Te Winkel, NP, Xunzhang Wang, MD, Ali Khoynezhad, MD, PhD.
Cedars-Sinai Medical Center, Los Angeles, CA, USA.

OBJECTIVE: Thoracoscopic ablation of longstanding persistent atrial fibrillation (AF) is emerging as an alternative to more invasive surgical options and to poor results from catheter ablation in this challenging patient population. Herein we report mid-term outcomes of the five-box biatrial thoracoscopic ablation of longstanding persistent AF on the beating heart.
METHODS: This is a single-center, retrospective review of 29 consecutive patients from January 2012 to July 2014 who underwent thoracoscopic epicardial AF ablation. Bipolar radiofrequency was used to create the five-box lesion set and ablate ganglionic plexi, with subsequent entrance and exit block confirmation. The left atrial appendage was occluded. Perioperative and follow-up data were collected.
RESULTS: The mean duration of preoperative longstanding persistent AF was 8.6±8.8 years. 26 patients (90%) had previous percutaneous ablations. The left atrium was enlarged (>4.0 cm) in 16 patients (55%). Peripheral cardiopulmonary bypass support with a small thoracotomy was needed to stop bleeding in 2 patients with heavy adhesions from prior percutaneous ablation. Procedure related complications included pneumothorax in 10 patients (34%), of which only 1 occurred in the last 12 cases, and permanent pacemaker insertion in 3 patients (10%). Four patients (14%) required electrical cardioversion postoperatively and 3 patients (10%) were ablated percutaneously due to recurrent AF (n=2) and atrial flutter (n=1). There were no deaths or strokes during the hospitalization. The mean hospital length-of-stay was 6.4±5.3 days and 86% of the patients were discharged in sinus rhythm. Follow-up was completed with at least an ECG in all patients (100%) with a mean follow-up of 23±2.3 months. Nineteen patients (66%) had Holter-monitoring (mean of 11±3 days of monitoring). At the latest follow-up, 1 patient (4%) was in atrial flutter, none were in atrial fibrillation, 7 patients (24%) were on antiarrhythmic medications, and 8 patients (28%) were anticoagulated. Freedom of AF was observed in 89% of patients at 3 and 6 months, and in 96% of patients at 12 months.
CONCLUSIONS: Thoracoscopic AF ablation on the beating heart for treatment of longstanding persistent AF is technically feasible and achieves high success rates with low procedure-related morbidity at mid-term follow-up.

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