Totally Endoscopic Ablation of Lone Atrial Fibrillation: Initial Clinical Experience

Thoracoscopic Surgical Ablation of Lone Atrial Fibrillation: Long-term Outcomes at 7 Years

BACKGROUND

Antiarrhythmic drugs and transcatheter ablation in atrial fibrillation (AF) provide suboptimal rhythm control with a not negligible rate of failure in paroxysmal AF (PAF) and nonparoxysmal AF (n-PAF) at midterm and long-term follow-up. This study evaluated the safety profile and long-term efficacy of thoracoscopic ablation in patients with lone AF.

METHODS

A consecutive 153 patients with lone AF were prospectively enrolled and underwent thoracoscopic surgical ablation. Inclusion criteria were symptomatic AF refractory to pharmacologic therapy (Vaughan-Williams class I-III), age >18 years, and absence of left atrial thrombosis. Exclusion criteria were long-standing AF >5 years, left atrial diameter >55 mm, and contraindication to oral anticoagulation. The "box lesion set" (encircling of pulmonary veins) was always used. Exclusion of the left atrial appendage was performed only in selected cases. The primary study end point was freedom from AF. Secondary end points were overall survival and cumulative incidence function of cardiac event-related death, cerebrovascular accidents, and pacemaker implantation.

RESULTS

There was no in-hospital mortality. Early postoperative complications were pacemaker implantation (4/153 [2.6%]), cerebrovascular accident (2/153 [1.3%]) with full recovery of both, and bleeding requiring surgical revision (2/153 [1.3%]). Overall freedom from AF at 7 years was 86% ± 4% (76.9% in n-PAF, 96.1% in PAF). Survival freedom from AF in patients without antiarrhythmic drugs in PAF and n-PAF groups was 79.1% and 52.2%, respectively.

CONCLUSIONS

Thoracoscopic surgical ablation of lone AF by means of an isolated left atrial box lesion provided an excellent long-term rhythm outcome, even in long-standing persistent AF. The isolated left atrial ablation showed an excellent safety profile with low incidence of pacemaker implantation and postoperative complications.

Rhythm outcomes of minimally-invasive off-pump surgical versus catheter ablation in atrial fibrillation: A meta-analysis of reconstructed time-to-event data

BACKGROUND

Mid- and long-term rhythm outcomes of catheter ablation (CA) for atrial fibrillation (AF) are reported to be suboptimal. Minimally invasive surgical off-pump ablation (MISOA), including both thoracoscopic and trans-diaphragmatic approaches, has been developed to reduce surgical invasiveness and overcome on-pump surgery drawbacks. We sought to compare the efficacy and safety of MISOA and CA for AF treatment.

METHODS

A systematic review and meta-analysis of the literature was performed including studies comparing MISOA and CA. The primary endpoint was survival freedom from AF at follow-up after a 3-month blanking period. Subgroup analysis of the primary endpoint was performed according to the type of surgical incision and hybrid approach.

RESULTS

Freedom from AF at 4 years was 52.1% ± 3.2% vs 29.1% ± 3.5%, between MISOA and CA respectively (log-rank p < 0.001; Hazard Ratio: 0.60 [95%Confidence Interval (CI):0.50-0.72], p < 0.001). At landmark analysis, a significant improvement in rhythm outcomes was observed in the MISOA group after the 5th month of follow-up (2 months from the blanking period). The Odds Ratio between MISOA and CA of postoperative cerebrovascular accident incidence and postoperative permanent pacemaker implant (PPM) were 2.00 (95%CI:0.91-4.40, p = 0.084) and 1.55 (95%CI:0.61-3.95, p = 0.358), respectively. The incidence rate ratio of late CVA between MISOA and CA was 0.86 (95%CI:0.28-2.65, p = 0.787), while for late PPM implant was 0.45 (95%CI:0.11-1.78, p = 0.256).

CONCLUSIONS

The current meta-analysis suggests that MISOA provides superior rhythm outcomes when compared to CA in terms of sinus rhythm restoration. Despite the rhythm outcome superiority of MISOA, it is associated to higher postoperative complications compared to CA.

Total thoracoscopic repair of ventricular septal defect: A single-center experience

Objectives

To explore the safety and efficacy of total thoracoscopic repair of ventricular septal defects (VSD). We compared clinical outcomes of VSD via a total thoracoscopic approach with those of mini‐sternotomy.

Methods

We retrospectively reviewed clinical data from patients with VSD from 2012 to January 2019. According to the surgical pattern, they were divided into two groups: the total thoracoscopic surgery group (36 patients, 27 females, aged 29 ± 9.52 years), and a mini‐sternotomy group (31 patients, 12 females, aged 28 ± 8.67 years).

Results

There were no deaths in either group. In the thoracoscopic group, cardiopulmonary bypass (CPB) time and aortic cross‐clamping (ACC) time were significantly longer than those of the mini‐sternotomy group (CPB time: 112 ± 23.16 min vs. 78 ± 37.90 min, respectively, p < .001; ACC time: 65 ± 19.94 min vs. 50 ± 24.90 min, respectively, p < .001). postoperative hospital stay time (5.11 ± 2.48 days vs. 5.90 ± 6.27 days, p = .488) and chest drainage (139.86 ± 111.71 ml vs. 196.13 ± 147.34 ml, p = .081) tended to be lower in the thoracoscopy group, although there was no significant difference. No residual shunt or tricuspid regurgitation was found at follow‐up.

Conclusions

Total thoracoscopic repair is safe and effective in patients with VSD, with or without tricuspid regurgitation.

Epicardial Atrial Ablation Using a Novel Articulated Robotic Medical Probe via a Percutaneous Subxiphoid Approach

Objective

Minimally invasive epicardial atrial ablation to cure atrial fibrillation through the use of a percutaneous subxiphoid approach currently has a lack of dedicated technology for intrapericardial navigation around the beating heart. We have developed a novel articulated robotic medical probe and performed preliminary experiments in a porcine preparation.

Methods

In five large, healthy pigs, the teleoperated robotic system was introduced inside the pericardial space through a percutaneous subxiphoid approach. Secondary visualization of the left atrium and left atrial appendage was achieved with the use of a 5-mm scope inserted through a left thoracic port. The operator actively controlled the path of the robot by using a master manipulator. The catheter, with an irrigated radiofrequency tip, was guided through the working port of the robot to achieve epicardial ablation of the left atrium.

Results

Access to the pericardial space and progression around the left atrium was successful in all cases, with no interference with the beating heart such as a fatal arrhythmia, unexpected bleeding, and hypotension. Epicardial ablation was successfully performed in all five cases. No adverse hemodynamic or electrophysiological events were noted during the trials. When the animals were killed, there was no visually detected injury on the surrounding mediastinal structures caused by ablation. Transmural ablation was confirmed by histopathology of the left atrium.

Conclusions

We have developed a dedicated articulated robotic medical probe and successfully performed epicardial left atrial radiofrequency ablation. Based on the feedback from these preliminary experiments, the radius of curvature and proper visualization of the device are being improved in the next generation prototype.

Unilateral robotic hybrid mini-maze: a novel experimental approach

BACKGROUND

A complete Cox maze IV procedure is difficult to accomplish using current endoscopic and minimally invasive techniques. These techniques are hampered by inability to adequately dissect the posterior structures of the heart and place all necessary lesions. We present a novel approach, using robotic technology, that achieves placement of all the lesions of the complete maze procedure.

METHODS

In three cadaveric human models, the technical feasibility of using robotic instruments through the right chest to dissect the posterior structures of the heart and place all Cox maze lesions was performed.

RESULTS

The entire posterior aspect of the heart was dissected in the cadaveric model facilitating successful placement of all Cox maze IV lesions with robotic assistance through minimally invasive incisions.

CONCLUSION

The robotic Cox maze IV procedure through the novel right thoracic approach is feasible. This obviates the need for sternotomy and avoids the associated morbidity of the conventional Cox-maze procedure.

Hybrid surgical and catheter treatment for atrial fibrillation

Advances in surgery for atrial fibrillation from cut and sew technique to thoracoscopy and new energy source have enabled minimally invasive approach which avoids median sternotomy and cardiopulmonary bypass. However, minimally invasive approach is unable to match the outcome of classic surgical technique due to difficulty in creating some of linear ablation lines. Hybrid procedure using catheter mapping and ablation in addition to minimally invasive surgical ablation has gained interest to combine the advantages of both procedures. No large study has been conducted to date comparing this new technique to other existing treatments. The aim of this paper is to review the data on hybrid procedure for atrial fibrillation and assess its early outcome and efficacy.

Robotics in cardiac surgery: past, present, and future

Robotic cardiac operations evolved from minimally invasive operations and offer similar theoretical benefits, including less pain, shorter length of stay, improved cosmesis, and quicker return to preoperative level of functional activity. The additional benefits offered by robotic surgical systems include improved dexterity and degrees of freedom, tremor-free movements, ambidexterity, and the avoidance of the fulcrum effect that is intrinsic when using long-shaft endoscopic instruments. Also, optics and operative visualization are vastly improved compared with direct vision and traditional videoscopes. Robotic systems have been utilized successfully to perform complex mitral valve repairs, coronary revascularization, atrial fibrillation ablation, intracardiac tumor resections, atrial septal defect closures, and left ventricular lead implantation. The history and evolution of these procedures, as well as the present status and future directions of robotic cardiac surgery, are presented in this review.

2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design

This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.

Outcomes of Surgical Atrial Fibrillation Ablation: The Port Access Approach vs. Median Sternotomy

Background

The aim of this study is to evaluate the clinical and rhythm outcomes of atrial fibrillation (AF) ablation through a port access approach compared with sternotomy in patients with AF associated with mitral valve diseases.

Materials and Methods

From February 2006 through December 2009, 135 patients underwent biatrial AF ablation with a mitral operation via either a port-access approach (n=78, minimally invasive cardiac surgery [MICS] group) or a conventional sternotomy (n=57, sternotomy group). To adjust for the differences in the two groups' baseline characteristics, a propensity score analysis was performed.

Results

After adjustment, there were no significant differences in the two groups' baseline profiles. The cardiopulmonary bypass time was significantly longer (p=0.045) in the MICS group (176.0±49.5 minutes) than the sternotomy group (150.0±51.9 minutes). There were no significant differences (p=0.31) in the two groups' rate of reoperation for bleeding (MICS=6 vs. sternotomy= 2, p=0.47) or the requirement for permanent pacing (MICS=1 vs. sternotomy=3). The major event-free survival rates at two years were 87.4±8.1% in the MICS group and 89.6±5.8% in the sternotomy group (p=0.92). Freedom from late AF at 2 years was 86.8±6.2% in the MICS group and 85.0±6.9% in the sternotomy group (p=0.86).

Conclusion

Both the port-access approach and sternotomy showed tolerable clinical outcomes following biatrial AF ablation with mitral valve surgery.

Surgical treatment of atrial fibrillation: a review

Atrial fibrillation is the most commonly sustained arrhythmia in man. While it affects millions of patients worldwide, its incidence will markedly increase with an aging population. Primary goals of AF therapy are to (1) reduce embolic complications, particularly stroke, (2) alleviate symptoms, and (3) prevent long-term heart remodelling. These have been proven to be a challenge as there are major limitations in our knowledge of the pathological and electrophysiological mechanisms underlying AF. Although advances continue to be made in the medical management of this condition, pharmacotherapy is often unsuccessful. Because of the high recurrence rate of AF despite antiarrhythmic drug therapy for maintenance of sinus rhythm and the adverse effects of these drugs, there has been growing interest in nonpharmacological strategies. Surgery for treatment of AF has been around for some time. The Cox-Maze procedure is the gold standard for the surgical treatment of atrial fibrillation and has more than 90% success in eliminating atrial fibrillation. Although the cut and sew maze is very effective, it has been superseded by newer operations that rely on alternate energy sources to create lines of conduction block. In addition, the evolution of improved ablation technology and instrumentation has facilitated the development of minimally invasive approaches. In this paper, the rationale for surgical ablation for atrial fibrillation and the different surgical techniques that were developed will be explored. In addition, it will detail the new approaches to surgical ablation of atrial fibrillation that employ alternate energy sources.

Surgical treatment of lone atrial fibrillation

Currently, off-pump video-assisted thoracoscopic epicardial pulmonary vein isolation offers an attractive alternative to on-pump Maze procedures for surgical treatment of lone atrial fibrillation. Nevertheless, on-pump Maze procedures through a mid-sternotomy approach still play an important role in patients with lone atrial fibrillation on many occasions, especially in patients with failed percutaneous pulmonary vein alone. The aim of this article was to give a brief review of the surgical strategies for treating lone atrial fibrillation, and present the possible indications for on-pump Maze procedures through a mid-sternotomy approach.

The New Era of Cardiac Surgery Hybrid Therapy for Cardiovascular Disease

Surgical therapy for cardiovascular disease carries excellent long-term outcomes but it is relatively invasive. With the development of new devices and techniques, modern cardiovascular surgery is trending toward less invasive approaches, especially for patients at high risk for traditional open heart surgery. A hybrid strategy combines traditional surgical treatments performed in the operating room with treatments traditionally available only in the catheterization laboratory with the goal of offering patients the best available therapy for any set of cardiovascular diseases. Examples of hybrid procedures include hybrid coronary artery bypass grafting, hybrid valve surgery and percutaneous coronary intervention, hybrid endocardial and epicardial atrial fibrillation procedures, and hybrid coronary artery bypass grafting/carotid artery stenting. This multi-disciplinary approach requires strong collaboration between cardiac surgeons, vascular surgeons, and interventional cardiologists to obtain optimal patient outcomes.

A new vacuum-assisted probe for minimally invasive radiofrequency ablation

PURPOSE

The Cobra Adhere XL (Estech, San Ramon, CA) is a multiple-electrode, temperature-controlled, monopolar radiofrequency probe with a vacuum-assisted stabilization system. We evaluated this new technology for epicardial ablation of atrial fibrillation in mitral valve patients through a right mini-thoracotomy.

DESCRIPTION

Between June and August 2008, 12 patients underwent minimal invasive surgery for mitral disease and ablation for atrial fibrillation with the Cobra Adhere XL (Estech). Three patients had paroxysmal atrial fibrillation. Off-pump pulmonary vein isolation was performed with an epicardial oval lesion parallel to the mitral plane. In 10 patients, an endocardial lesion to the mitral annulus was added.

EVALUATION

There were no operative deaths or major postoperative complications. At a mean follow-up of 8.76 +/- 1.0 months, 11 patients (91.67%) were in stable sinus rhythm. Echocardiography underscored a complete recovery of atrial transport function in most of these patients (90.91%). No major cardiac and cerebrovascular events occurred during follow-up.

CONCLUSIONS

Left-side ablation combined with minimally invasive surgery for mitral disease can be easily, safely, and effectively performed with the Cobra Adhere XL probe.

Robotics in Cardiac Surgery

Minimally invasive surgery has revolutionized the surgical field over the last two decades. Robotic assisted surgery is the latest iteration towards less invasive techniques. Cardiac surgeons have slowly adapted minimally invasive and robotics techniques into their armamentarium. In particular, minimally invasive mitral valve surgery has evolved over the last decade and become the preferred method of mitral valve repair and replacement at certain specialized centres worldwide because of excellent results. We have developed a robotic mitral valve surgery program which utilizes the da Vinci® telemanipulation system allowing the surgeon to perform complex mitral valve repairs through 5mm port sites rather than a traditional median sternotomy. in this rapidly evolving field, we review the evolution and clinical results of robotically-assisted mitral valve surgery and take a look at the other cardiac surgical procedures for which da Vinci® is currently being used.

A novel highly articulated robotic surgical system for epicardial ablation

We have developed a novel, highly articulated robotic surgical system to enable minimally invasive intrapericardial interventions through a subxiphoid approach and have performed preliminary tests of epicardial left atrial ablation in porcine (N=3) and human cadaver (N=2) preparations. In this study, the novel highly articulated robotic surgical system successfully provided safe epicardial ablations to the left atrium in porcine beating heart models via a subxiphoid approach. We have also performed complex guidance of the robot and subsequent ablation in a cadaveric preparation for successful pulmonary vein isolation.

Preliminary results with a training program for thoracoscopic atrial fibrillation therapy

BACKGROUND

Novel devices have been designed for the treatment of atrial fibrillation (AF) using minimally invasive approaches. This study aimed to determine the usefulness of a sheep model for training in cardiac surgical ablation using a minimally invasive approach in an experimental hands-on training course.

METHODS

After initial training using a laparoscopic pelvic trainer, 15 sheep were subjected to surgery by six thoracic surgeons attending a hands-on thoracoscopic course. Dissection to the posterior wall of the pulmonary veins was followed by insertion of a microwave device around both the caudal cava vein and the pulmonary veins. The complications were recorded, and the effectiveness of the surgery was evaluated by complete deployment of the microwave device. The animals were killed after completion of the procedure.

RESULTS

Isolation of the cava vein and the pulmonary veins and placement of the microwave probe were performed successfully for 10 animals using a complete thoracoscopic approach. Two animals died during the procedure. The main complications of the procedure were hemorrhage and difficulty isolating the blood vessels using a minimally invasive procedure. After the training period, the thoracoscopic surgical maneuvers were accurate and reliable.

CONCLUSION

The technical feasibility of performing safe and efficient thoracoscopic placement of a microwave device in a sheep model was demonstrated in this study, suggesting that the results of this study are a useful contribution to the development of an animal model for surgical training and experimental cardiac surgeries.

Minimally invasive epicardial injections using a novel semiautonomous robotic device

BACKGROUND

We have developed a novel miniature robotic device (HeartLander) that can navigate on the surface of the beating heart through a subxiphoid approach. This study investigates the ability of HeartLander to perform in vivo semiautonomous epicardial injections on the beating heart.

METHODS AND RESULTS

The inchworm-like locomotion of HeartLander is generated using vacuum pressure for prehension of the epicardium and drive wires for actuation. The control system enables semiautonomous target acquisition by combining the joystick input with real-time 3-dimensional localization of the robot provided by an electromagnetic tracking system. In 12 porcine preparations, the device was inserted into the intrapericardial space through a subxiphoid approach. Ventricular epicardial injections of dye were performed with a custom injection system through HeartLander's working channel. HeartLander successfully navigated to designated targets located around the circumference of the ventricles (mean path length=51+/-25 mm; mean speed=38+/-26 mm/min). Injections were successfully accomplished following the precise acquisition of target patterns on the left ventricle (mean injection depth=3.0+/-0.5 mm). Semiautonomous target acquisition was achieved within 1.0+/-0.9 mm relative to the reference frame of the tracking system. No fatal arrhythmia or bleeding was noted. There were no histological injuries to the heart due to the robot prehension, locomotion, or injection.

CONCLUSIONS

In this proof-of-concept study, HeartLander demonstrated semiautonomous, precise, and safe target acquisition and epicardial injection on a beating porcine heart through a subxiphoid approach. This technique may facilitate minimally invasive cardiac cell transplantation or polymer therapy in patients with heart failure.

[Minimally invasive direct cardiac surgery with the jakoscope retractor]

The authors present a surgical retractor named jakoscope, useful in the field of abdominal, urological, vascular, thoracic and cardiac surgery procedures. This multifunctional device offers the possibility to utilize Minimally Invasive Direct Access Surgical Technology (MIDAST) in the above mentioned surgical specialties. In their department the authors use the jakoscope retractor for aortic valve replacement, off-pump coronary bypass operations and radiofrequency pulmonary vein ablation by mini-thoracotomy approach. In this report they published for the first time their experience with jakoscope device in the field of cardiac surgery. In these operations the device assured adequate minimally invasive direct access, without complications.