A New Technique In Thoracoscopic Surgery For Stand-alone Atrial Fibrillation: En Bloc Isolation Of The Left Pulmonary Veins And Appendage
Toshiya Ohtsuka, Mikio Ninomiya, Takahiro Nonaka, Motoyuki Hisagi.
Department of Cardiovascular Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
OBJECTIVE: We evaluated our new technique in thoracoscopic surgery for stand-alone atrial fibrillation that en bloc isolates the left pulmonary veins and appendage.
METHODS: Our previous off-pump port-access thoracoscopic procedure (bilateral pulmonary-vein and superior vena-cava isolations and a box lesion using bipolar radio-frequency ablation devices [clamp and pen] and appendectomy) developed into a new version in which the left pulmonary veins and appendage were isolated together by placing the clamp-isolator alongside the medial base of the appendage (Figure). The procedural safety was evaluated by reviewing the surgical records. The 1-year rhythm-control results from Holter electrocardiography were compared with the corresponding data from the previous method conducted in 324 patients.
RESULTS: Starting in May 2014, the new technique was applied to 188 consecutive patients (102 men [54 %]; mean age 65, range 24-83 years). The clamp-isolator could successfully rest alongside the medial base of the appendage in all except 21 (11 %): the left atrium was oversized for en bloc clamping in 15, the clamp slipped over small appendages in 5 and one patient could not tolerate the technique; they instead received simple left pulmonary-vein isolation. The mean operating time was 81 min. None suffered procedure-related complications including appendage injury or ischemic events. The new and previous technique groups matched in the mean length of atrial fibrillation (4.8 vs. 4.5 years, p = .09) and left-atrial size (47 vs. 46 mm, p = .16). At 1-year follow-up for sinus-rhythm maintenance, there was no significant difference between the new and previous technique in paroxysmal (94 % vs. 92 %, p = .12) and persistent (80 % vs. 77 %, p = .08) cases, but the new technique was better in long-standing cases (71 % vs. 64 %, p = .02).
CONCLUSIONS: In thoracoscopic surgery for stand-alone atrial fibrillation, en bloc isolation of the left pulmonary veins and appendage is safely achievable in most cases, providing better rhythm control efficacy in long-standing atrial fibrillation than simple left pulmonary-vein isolation.
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