International Society for Minimally Invasive Cardiothoracic Surgery
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Left-right-left Technology For The Thoracoscopic Treatment Of The Atrial Fibrillation.
Vadim Popov, MD, PhD, Egor Malyshenko, MD, Maxim Novikov, MD, Natalia Popova, MD, Maxim Anischenko, MD, PhD, Amiran Revishvili, MD, PhD.
A.V.Vishnevsky National Reserch 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 treatment in thoracoscopic surgical ablation. Some authors, in particularly, 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 this structures in the 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 method, which combines the safety of pericardial sinuses dissection from left-sided access, left pulmonary veins differentiation via previously placed guide wire and the simplicity of bipolar clamp placingbehind right pulmonary veins.RESULTS: From 2017 to 2022 including 206 operations of thoracoscopic surgical ablation were performed in our center. 48 (23,3%) procedures were performed according to the traditional right-left technique. The mean operation time was 130,424,1 min. There were 3 (6,2%) conversions to median sternotomy associated with pulmonary artery, left atrium roof and posterior wall injuries due to right-sided pericardial sinuses dissection. One case of death was reported.158 (76,6%) interventions were performed using L-R-L technique, the mean operating time was 132,812,2 min. Neither conversions to sternotomy nor deaths were reported.
There were no significant differences in postoperative blood loss, ventilation time, ICU stay, duration of pleural drainage, severity of pain syndrome, as well as freedom from AF in the groups.CONCLUSIONS:The L-R-L approach in thoracoscopic surgical ablation is not inferior to traditional approaches, but also allows to improve quality of visualization, structures recognition and reduce the risk of great vessels and heart chambers injuries.


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