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NOVEL APPROACH FOR THORACOSCOPIC AF ABLATION
Egor Malyshenko, Vadim Popov, Maxim Novikov, Elizaveta Strebkova, Magomed Gasangusenov, Amiran Revishvili.
A.V. Vishnevskiy National research center of surgery, Moscow, Russian Federation.

BACKGROUND:Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, that encourage to develop and improve modern methods of treatment. Thoracoscopic surgical ablation have class IIa recommendation in current clinical guidelines ESC/EACTS 2020 and have good perspective to maintain sinus rhythm.
METHODS:Bilateral, right - left, exposure of the pulmonary veins is a traditional approach in thoracoscopic AF ablation. Some authors , suggest an improved unilateral left approach. The advantage is to reduce the risk of main vessels and heart chambers injury during the pericardial sinuses dissection, especially the transversus sinus due to absence dangerous structures in the direction of surgical dissection site. Positioning the bipolar ablation clamp behind pulmonary veins is associated with technical complexity of the procedure.In our center we use Left-Right-Left approach, which combines the safety of pericardial sinuses dissection from left-sided access, left pulmonary veins differentiation via previously placed colored guide wire and the simplicity of bipolar clamp placing behind right pulmonary veins.RESULTS:From 2017 to January 2021 152 operations of thoracoscopic surgical ablation were performed in our center. 48 procedures were performed according to the traditional right-left technique. The mean operation time was 130,4±24,1 min. There were 3 conversions to median sternotomy associated with pulmonary artery, left atrium roof and posterior wall injuries due to right-sided pericardial sinuses dissection. 1 case of death was reported. 10 interventions were performed with left-sided access. Due to previously mentioned technical difficulties the mean operation time was 145,2±12,6 min. There were neither conversions to sternotomy nor deaths. 2 cases of switching to the right sided access due to the impossibility of clamping and high risk of right pulmonary veins injury were reported. 96 interventions were performed using L-R-L technique, the mean operating time was 132,8±12,2 min. There were no conversion cases or mortality with L-R-L approach. CONCLUSIONS:The L-R-L approach in thoracoscopic surgical ablation is not inferior to traditional approaches in freedom of AF. The L-R-L approach help to increase the safety of procedure as well as it allows improving quality of visualization, structures recognition and reducing the risk of great vessels and heart chambers injuries.


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