The totally thoracoscopic left atrial maze procedure for the treatment of atrial fibrillation

Short-term results of two strategies in thoracoscopic ablation for lone atrial fibrillation

Background: Thoracoscopic ablation is an effective treatment of patients with atrial fibrillation. Nowadays, 2 types of ablative devices are available in clinical practice allowing one to perform the thoracoscopic procedure Medtronic and AtriCure. However, the contemporary clinical literature does not have enough data that would compare these two approaches. Aims: to perform a comparative analysis of the short-term results of two minimally invasive strategies in thoracoscopic ablation for atrial fibrillation. Methods: 232 patients underwent thoracoscopic ablation for atrial fibrillation in two clinical centers for the period from 2016 to August 2021. The patients were divided into 2 groups. The first group was represented by those patients to whom a Medtronic device was applied (n=140), the second group was treated with an AtriCure device (n=92). The patients were comparable in their age, gender, initial severity of the condition. The follow-up consisted of laboratory tests, chest Х-ray, electrocardiography, 24-hour Holter monitor, echocardiography. The structure and prevalence of postoperative and intraoperative complications, specifics of the postoperative period were compared between the two groups. Results: According to the structure and prevalence of intraoperative complications the 2 groups are comparable to each other: 4.3% and 1.1% for the 1st group and 2nd group, respectively (p 0.05). The postoperative complications had developed in 6 (4.3%) and 5 (5.4%) patients in groups 1 and 2, respectively (p 0.05). At the time of discharge from hospital, a sinus rhythm was registered in 93.6% of patients (1st group), and 85.9% (2nd group) (p 0.05). Conclusions: Both strategies have demonstrated comparable short-term results in patients with lone atrial fibrillation. A further research is needed to evaluate the effectiveness of this strategy in a long-term period.

A Chronicle of Hybrid Atrial Fibrillation Ablation Therapy: From Cox Maze to Convergent

The burden of AF is increasing in prevalence and healthcare resource usage in the UK and worldwide. It can result in impaired quality of life for affected patients, as well as increased risk of stroke, heart failure and mortality. A holistic, integrated approach to AF management is recommended, which may include a focus on reducing risk factors and on medical management with anticoagulation and anti-arrhythmic drugs. There are also various ablation strategies that may be considered when anti-arrhythmic drugs fail to alleviate symptoms and reduce AF burden. These ablation techniques range from standalone percutaneous endocardial catheter ablation to open surgical ablation procedures concomitant with cardiac surgery. More recently, hybrid ablation that combines aspects of both surgical and electrophysiologically targeted ablation has been described. This article reviews the evolution of ablation strategies, beginning with the origin of the Cox maze IV procedure and continuing to the recent hybrid convergent approach, and provides a summary of the associated outcomes.

Immersive 3D Virtual Reality-Based Clip Sizing for Thoracoscopic Left Atrial Appendage Closure

Objective: Surgical left atrial appendage (LAA) closure using epicardial clips has become popular in stroke prevention in patients with atrial fibrillation. Optimal placement of the clip is essential to achieve complete LAA occlusion and to prevent complications due to compression of the circumflex artery. We determine the added value of immersive virtual reality (VR) in accurately assessing LAA base size and selection of an appropriately sized clip. Methods: We studied the feasibility of measuring the LAA base using VR and conventional computed tomography (CT). A retrospective analysis was performed of LAA base measurements in 15 patients who had undergone thoracoscopic LAA clipping. Subsequently, we compared the placed clip size with imaging-acquired LAA base size to retrospectively evaluate intraprocedural sizing. Results: We successfully applied a VR platform to measure LAA base size. The median LAA base size measured in CT (23.8 mm, interquartile range [IQR] 22.3 to 26.4 mm) and intracardial virtual reality (23.4 mm, IQR 21.6 to 25.5 mm) did not differ significantly (P = 0.416). VR measurements of the LAA base in surgeon's view (25.7 mm, IQR 24.2 to 29.2) were significantly higher than those of 2-dimensional CT (P = 0.037) and intracardial 3-dimensional (3D) VR (P < 0.05) measurements. All measurements differed significantly with placed clip sizes (P < 0.05). There were no clip malpositioning-related events. Conclusions: Immersive VR is a feasible method for obtaining anatomical information on LAA base size. In this retrospective analysis, CT and VR-based measurements of LAA base size differed significantly from intraoperatively placed LAA clips, indicating potential oversizing when measured intraoperatively. Using intuitive 3D VR-based imaging might be a useful method to assist in accurate preprocedural sizing of LAA base and can potentially prevent oversizing.

Closed chest unilateral thoracoscopic ablation: box lesion with radiofrequency clamps only

In this article we describe the modified technique of a unilateral closed chest thoracoscopic ablation and left atrial appendage closure including a box lesion that is made by radiofrequency clamps only for the treatment of atrial fibrillation. By abandoning the unidirectional pen devices and replacing these by radiofrequency clamps, we aim to further improve the procedural efficacy and shorten operation time while minimizing surgical exposure for the patient.

Thoracoscopic ablation for the treatment of atrial fibrillation: a systematic outcome analysis of a multicentre cohort

AIMS

To perform a systematic outcome analysis in order to provide cardiologists and general pactitioners with more adequate information to guide their decision making regarding rhythm control. Totally thoracoscopic maze (TTmaze) for the treatment of atrial fibrillation (AF) is recommended as a Class 2a indication mainly based on single centre studies including small patient cohorts and inconsistent lesion sets.

METHODS AND RESULTS

We studied consecutive patients undergoing TTmaze in three European referral centres (2012-15). Primary outcome was freedom from atrial tachyarrhythmia (ATA). Secondary outcomes were 30-day complications, the composite endpoint of ischaemic stroke, haemorrhagic stroke or transient ischaemic attack (TIA), all-cause mortality, and predictors of ATA recurrence. Four hundred and seventy-five patients were included, with a mean age of 61 ± 9 years and 69.5% male. The mean CHA2DS2-VASc score was 1.7 ± 1.3. The overall freedom from ATA was 68.8% after a mean follow-up period of 20 ± 9 months. Freedom from ATA was 72.7% for paroxysmal AF, 68.9% for persistent AF, and 54.2% for longstanding persistent AF. Multivariate analysis revealed female gender [hazard ratio (HR): 1.87, P = 0.005], in-hospital AF (HR: 1.95, P = 0.040), longer duration of preoperative AF (HR: 1.06, P = 0.003) and mitral regurgitation (HR: 1.84, P = 0.025) as independent predictors of ATA recurrence. Overall 30-day freedom from any complication was 92.4%. Freedom from cerebrovascular events after mean follow-up of 30 ± 16 months was 98.7% and overall survival was 98.3%. The observed rate of ischaemic stroke, haemorrhagic stroke, or TIA was low (0.5 per 100 patient-years).

CONCLUSION

Totally thoracoscopic maze is a safe and effective rhythm control therapy.

Totally thoracoscopic ablation: a unilateral right-sided approach

The aim of this article is to describe a unilateral approach for totally thoracoscopic ablation and left atrial appendage closure for the treatment of atrial fibrillation to simplify the procedure, avoid a technically more demanding thoracoscopy on the left side and potentially reduce postoperative pain without compromising the lesion set.

Clamping versus nonclamping thoracoscopic box ablation in long-standing persistent atrial fibrillation

OBJECTIVE

To compare clinical outcomes of clamping devices and linear nonclamping devices for isolation of the posterior left atrium (box) in thoracoscopic ablation of long-standing persistent atrial fibrillation.

METHODS

Eighty patients who underwent thoracoscopic pulmonary vein and box isolation using a bipolar clamping device (42 patients) or bipolar nonclamping device (38 patients) to create the roof/inferior lesions for box isolation were included from 2 centers. Follow-up consisted of 24-hour Holter at regular intervals. Freedom from AF during 1-year follow-up and catheter repeat interventions were compared between groups.

RESULTS

Acute intraoperative electrical isolation of the box compartment was significantly higher in the clamping group than in the nonclamping group (100% and 79%, respectively, P < .01). At 1-year follow-up, 91% of the clamping group and 79% of the nonclamping group were in sinus rhythm. During 1-year follow-up, recurrence rates did not significantly differ between the 2 groups (P = .08). Repeat catheter interventions were required in 10% of the clamping group and 21% of the nonclamping group (P = .15). Conduction gaps in the roof or inferior lesions were found in 1 patient (2%) in the clamping group versus 4 patients (11%) in the nonclamping group (P = .13).

CONCLUSIONS

Thoracoscopic pulmonary vein and box isolation are highly effective in restoring sinus rhythm in long-standing persistent atrial fibrillation on short-term follow-up. Comparison of clamping and nonclamping devices revealed lower rates of intraoperative exit block of the box in the nonclamping group. However, this did not translate into a significant difference in atrial fibrillation freedom at short-term (1-year) follow-up.

Totally thoracoscopic ablation for atrial fibrillation: a systematic safety analysis

Aims

Thoracoscopic surgical ablation has evolved into a successful strategy for symptomatic atrial fibrillation (AF) refractory to other therapy. More widespread referral is limited by the lack of information on potential complications. Our aim was to systematically evaluate 30-day complications of totally thoracoscopic surgical ablation.

Methods and results

We retrospectively studied consecutive patients undergoing totally thoracoscopic surgical ablation at a referral centre in the Netherlands (2007-2016). Patients received pulmonary vein isolation, with additional lesion lines as needed, and left atrial appendage exclusion. The primary outcomes were freedom from any complications and freedom from irreversible complications at 30-days. Secondary outcomes included intra- and post-operative complications according to severity. Included were 558 patients with median age 62 years (interquartile range 56-68 years), 70% male and 53% with a previous failed catheter ablation. The cohort consisted of 43% paroxysmal AF, 47% persistent AF, and 10% long-standing persistent AF. Freedom from any 30-day complication was 88.2%, and from complications with life-long affecting consequences 97.5%. The intra-operative complication rate was 2.3% with no strokes or death observed. The median hospital length of stay was 4 days. The percentage of patients with major and minor complications at 30-days was 3.2% and 8.1%, respectively, with one patient dying of an ischaemic stroke. The only patient groups with excess complications were women aged ≥70 years and patients with a history of congestive heart failure.

Conclusions

Totally thoracoscopic ablation is associated with a low complication rate in a referral centre and may be a useful alternative to other rhythm control strategies.

Totally Thoracoscopic Pulmonary Vein Isolation: A Simplified Technique

Since the introduction of thoracoscopic ablation for atrial fibrillation (AF), the field of minimally invasive AF treatment has evolved toward an established treatment option for AF, with an overall 2-year antiarrhythmic drug free success rate of 77%. Complications are usually minor, and the incidence of bleeding needing conversion to sternotomy or (mini-)thoracotomy varies between 0% and 1.6%. Bleeding is often related to encircling the pulmonary veins, which is a blind maneuver that has to be done without direct camera vision. We propose here a modified surgical technique to simplify the procedure, shorten the operating time, and lower the risk of complications.