Stand alone totally endoscopic epimyocardial ablation in patients with persistent atrial fibrillation and significant atrial dilatation

BACKGROUND: To analyze safety and efficacy of surgical totally endoscopic epimyocardial ablation in patients (pts) turned down for interventional catheter therapy due to long-standing persistent atrial fibrillation (pAF) combined with significant atrial dilatation (> 5 cm).

METHODS: Since December 2010, 15 pts were referred for surgical ablation due to persistent AF combined with biatrial dilatation (left atrium [LA] 5.0 ± 0.6 cm). Mean age was 52 ± 6 years, body mass index (BMI) 38 ± 6, duration of AF 2.8 ± 1.2 years, left ventricular end diastolic diameter (LVEDD) 5.8 cm ± 0.6 cm. Ablation was performed via a bilateral endoscopic approach using bipolar RF energy application. Monitoring was achieved by an event recorder (Reveal XT Medtronic, Inc., Minneapolis, MN, USA) or repeated 24-hours Holter electrocardiogram.

RESULTS: All pts successfully received bilateral pulmonary vein isolation + box lesion + trigonal lesion + left atrial appendage resection. Mean duration of procedure was 235 ± 70 minutes. There was no intraoperative complication; however, one patient had persistent left phrenic nerve palsy. Mean hospital stay was 4 ± 2 days, mean follow-up time was 21 ± 11 months. Incidence of sinus rhythm (SR) was 67, 73, and 80% at discharge, three months, and 12 months follow-up. Mean LA diameter was reduced from 58.1 mm ± 6.0 mm preoperative to 49.7 mm ± 5.4 mm (p = 0.004) at 12 months follow-up. Incidence of SR was 86% at latest follow-up (mean time 21 months). All pts currently in SR (13/15 = 86%) are of class I or III antiarrhythmic drugs.

CONCLUSION: Totally endoscopic left atrial ablation including left atrial resection can safely be performed. It achieved excellent rates of SR restoration in patients with long-standing persistent AF combined with significant atrial dilatation.