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Superior Outcome Of Thoracoscopic Ablation Compared To Catheter Ablation For Persistent Atrial Fibrillation: A Single Center Experience.
Maria Cannoletta, Shouvik Haldar, Toufan Bahrami, Habib Khan, Rashmi Yadav, Tom Wong, Anthony De Souza.
Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
OBJECTIVE: Atrial fibrillation (AF) is the most common sustained tachyarrhytmia and is associated with an increased risk of thromboembolic events. Treatment, most commonly catheter ablation (CA), is still not entirely satisfactory, particularly in cases of long standing persistent atrial fibrillation (LSPAF). This prospective study aims to compare thoracoscopic surgical ablation (SA) under electrophysiology (EP) guidance versus catheter ablation as a first line treatment in this difficult cohort of patients who often are very resistant to treatment.
METHODS: Fifty-one patients (51) with symptomatic LSPAF refractory to medical therapy (AAD) or direct current cardioversion (DCCV) were recruited. Exclusion criteria were: previous cardiac surgery or catheter ablation, LVEF<40%, contraindication to anticoagulation, active malignancy and cerebrovascular accident within 6 months. 26 patients underwent SA under EP guidance and exclusion of left atrial appendage with intraoperative testing of conduction block. 25 patients underwent a stepwise left atrial ablation in cathlab. The rhythm was assessed at 3, 6, 9 and 12 months. Recurrence is documented as any episode of AF lasting longer than 30 seconds.
RESULTS: Intraprocedural success was achieved in 22 SA patients (85%) and in 24 CA patients (96%) (p=0.97). Freedom from AF at 12 months was 73% (19/26) in the SA group and 32% (8/25) in the CA group. We experienced no procedural deaths, stroke or emergency sternotomy. There was one serious adverse event in the CA group at 60 days post procedure, unrelated with the ablation (primary intracerebral haemorrhage). 7 (27%) patients in the SA group experienced major complications (n 2=pneumonia, n 1=pleural effusion, n 3=pulmonary vein stenosis, n 2=phrenic nerve palsy) and 2 (8%) in the CA group (n 1=pulmonary vein stenosis, n 1=pulmonary oedema).
CONCLUSIONS: Surgical treatment with thoracoscopic ablation under EP guidance showed excellent results in terms of freedom from recurrence as a first line procedure in LSPAF compared to CA.
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