Abstract 11465: Epicardial and Endocardial Electrophysiological Guided Thoracoscopic Surgery for Atrial Fibrillation: A Multidisciplinary Approach of Atrial Fibrillation Ablation in Challenging Patients
Introduction: Thoracoscopic surgery is an effective treatment but associated with more procedural adverse events. Electrophysiological (EP) guided approaches to thoracoscopic surgery have been described which consist of EP guidance by measurement of conduction block across ablation lines. In this study we describe the efficacy and safety of EP-guided thoracoscopic surgery for AF in patients with enlarged atria and/or prior failed catheter ablation.
Hypothesis: The combination of surgical ablation and dedicated EP assessment of acute conduction block possibly increases the success rate of thoracoscopic surgery.
Methods: A total 72 patients were included. Of these, 33 (46%) had a previous catheter ablation, 48 (67%) had a left atrial diameter of ≥45 mm and 8 (11%) had a left atrial size of 40-44 mm with hypertension. Epicardial or endocardial peri-operative mapping and EP-guidance by the electrophysiologist at the time of surgery was implemented (n=36 each). Residual conduction of pulmonary veins was detected with epicardial or endocardial mapping techniques in 50% and 11%, respectively. The epicardial EP-guided measurements revealed residual conduction across additional ablations lines in all patients, and in 2 (7%) patients in the endocardial EP-guided approach. Follow-up consisted of an ECG and a 24h Holter at 3, 6 and 12 months after the procedure.
Results: Mean age was 59±8.7 years (range 38-78), 57 patients male (79%). A total of 57 patients (79%) had freedom of AF and were off anti-arrhythmic drugs at one year follow-up (30 paroxysmal (83%), 27 persistent AF (75%)). There were no significant differences in outcome between the approaches, neither overall nor for included subgroups. Adverse events occurred in 13 patients (6 major). None of our patients died and all events were reversible.
Conclusion: Thoracoscopic surgery with EP-guidance can be performed safely both epicardially and endocardially and is associated with a high rate of long-term maintenance of sinus rhythm in patients with enlarged atria and/or a previously failed ablation. A heart-team approach resulting in EP-guided surgical ablation provides a new and promising treatment modality for these, often difficult to treat, patients.
- © 2013 by American Heart Association, Inc.