全胸腔镜下左心房后壁隔离治疗非瓣膜性心房颤动

目的 评价全胸腔镜下左心房后壁隔离法治疗非瓣膜性心房颤动(非瓣膜性房颤)的可行性和有效性.方法 2010年9月至2011年12月,应用全胸腔镜下左心房后壁隔离法治疗非瓣膜性房颤患者20例,其中男18例,女2例.年龄47 ～ 71岁,平均(61.5±5.6)岁.房颤病史2～ 25年,平均(6.2±4.0)年.术前心功能Ⅰ～Ⅱ级,左心室射血分数0.632±0.055.手术在全麻双腔气管插管下进行,胸腔镜下实施心外膜房颤射频消融术.术后应用胺碘酮和华法林3个月,术后1、3、6、12个月及每年随访患者并检查24 h动态心电图.结果 全组无死亡,无并发症,所有患者均顺利出院.平均手术(60.5±30.1) min,术后呼吸机使用(11.5±2.1)h.术后随访2.6～14.2个月,无阵发心悸、短脉、偏瘫等症状,无死亡或卒中,24 h动态心电图示患者均为窦性心律,房颤转复率100％.结论 初步经验显示全胸腔镜下左心房后壁隔离法治疗非瓣膜性房颤安全、有效.     

Midterm results of stand-alone thoracoscopic epicardial ablation with box lesion for atrial fibrillation

 Open in a separate windowOBJECTIVESThe short-term results of video-assisted thoracoscopic surgical ablation (VTSA) with box lesion have been highly variable, and the actual efficacy requires clarification through longer follow-ups. We aimed to report which patients might benefit more from VTSA with box lesion by longer follow-up.METHODSFrom September 2010 to November 2016, patients with atrial fibrillation (AF) who underwent VTSA with box lesion were screened. All enrolled patients visited the outpatient clinic and underwent 24-h Holter monitoring at 3, 6 and 12 months after surgery and annually thereafter.RESULTSA total of 91 consecutive patients [age, 58.0 (interquartile interval from 52.0 to 62.0) years; male, 71.4%] with paroxysmal (67%) or persistent/long-standing persistent (33%) AF were enrolled. After a median follow-up of 48 months (interquartile interval from 36 to 60 months), freedom from atrial tachyarrhythmias without antiarrhythmic drugs (AADs) was 76.5%, 66.0% and 66.0% for paroxysmal AF and 58.6%, 47.8% and 34.2% for persistent/long-standing persistent AF at 12, 36 and 60 months, respectively (P = 0.017). The preoperative left atrial diameter >40 mm (hazard ratio: 2.837, 95% confidence interval: 1.408–5.716; P = 0.004) and age >50 years (hazard ratio: 2.927, 95% confidence interval: 1.359–6.305; P = 0.006) were associated with recurrences of atrial tachyarrhythmias. In patients with paroxysmal AF and left atrial diameter ≤40 mm (n = 43), freedom from atrial tachyarrhythmias without AADs was 81.4%, 74.3% and 74.3% at 12, 36 and 60 months, respectively.CONCLUSIONSIn patients with paroxysmal AF and left atrial diameter ≤40 mm, 5-year freedom from atrial tachyarrhythmias without AADs was 74.3%, which was better than that in patients with left atrial diameter >40 mm. A larger sample size and improved study design are needed to confirm our conclusions.     

Box lesion or bi-atrial lesion set for atrial fibrillation during thoracoscopic epicardial ablation

 Open in a separate windowOBJECTIVESThoracoscopic epicardial ablation with a limited lesion set led to suboptimal results for advanced paroxysmal atrial fibrillation (AF) or persistent AF. Whether additional right atrial lesions improve the result is unclear.METHODSWe conducted a retrospective study involving 80 consecutive patients with paroxysmal or persistent AF, left atrial (LA) dilation (LA diameter >40 mm) and failed prior interventional ablation (40 patients, 50%) who underwent thoracoscopic epicardial ablation with box lesions (36 patients) or bi-atrial (BA) lesion (44 patients) in our institution. Freedom from atrial tachyarrhythmias after the procedures was compared between the box lesion group and BA lesion group.RESULTSBaseline differences included more patients with persistent AF (86.4% vs 47.2%) and larger left atrium [48.00 (44.00–50.75) vs 42.00 (41.25–44.00) mm] in the BA lesion group. There was no difference in procedural complications between the 2 groups. After a mean follow-up of 32 months, the freedom from atrial tachyarrhythmias off antiarrhythmic drugs at 6, 12 and 24 months was 77.2%, 77.2% and 77.2% in the BA lesion group and 69.4%, 50.0% and 40.6% in the box lesion group, respectively (P = 0.006). After adjustment for sex, age, body mass index, LA diameter, AF type, history of AF, and previous interventional ablation, BA lesion was an independent predictor of lower atrial tachyarrhythmia recurrence (hazard ratio 0.447, 95% confidential interval 0.208–0.963; P = 0.040).CONCLUSIONSCompared with the box lesion set, thoracoscopic epicardial ablation with BA lesion sets might provide better freedom from atrial tachyarrhythmias for paroxysmal or persistent AF with LA dilation. Randomized control trials are warranted to confirm the benefit of BA lesion sets in these patients.     

Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation

OBJECTIVE: Pulmonary vein isolation is curative in selected patients with atrial fibrillation. The objective of this study was to assess the feasibility and safety (midterm results) of video-assisted thoracoscopic epicardial pulmonary vein isolation. METHODS: Twenty-seven patients (22 male patients) with atrial fibrillation (18 paroxysmal, 4 persistent, and 5 permanent; average age, 57 years) underwent bilateral video-assisted thoracoscopic off-pump epicardial pulmonary vein isolation and exclusion of the left atrial appendage. All patients had had unsuccessful drug therapy or were intolerant to antiarrhythmic drug therapy or were intolerant to warfarin. The approach included two 10-mm ports and one 5-cm working port (non-rib spreading) bilaterally. Pulmonary vein isolation was achieved bilaterally by using a bipolar radiofrequency device. The left atrial appendage was excised with a surgical stapler. RESULTS: Bilateral pulmonary vein isolation and left atrial appendage excision was performed successfully in all patients. There were no conversions to sternotomy or thoracotomy. All patients were extubated in the operating room. Postoperative complications in 3 patients were minor and resolved within 48 hours. One morbidly obese patient had more serious complications related to comorbid conditions. Average postoperative follow-up is approximately 6 months (173.6 days). Twenty-three patients have been followed up for greater than 3 months, and 21 of these patients are free of atrial fibrillation (91.3%). The results of magnetic resonance angiography were normal (no pulmonary vein stenosis) in 12 of 12 patients evaluated 3 to 6 months postoperatively. CONCLUSIONS: Bilateral video-assisted thoracoscopic pulmonary vein isolation with excision of the left atrial appendage is feasible and safe and offers a promising, new, minimally invasive, beating-heart approach for curative surgical treatment of atrial fibrillation.     

Off-pump epicardial compartmentalization for ablation of atrial fibrillation

The Cox-Maze-III procedure still remains the gold standard in surgical treatment of atrial fibrillation. The major hazard of atrial fibrillation is thromboembolic event to the brain. Left atrial appendage (LAA) represents the source of thrombus and subsequent embolism although LAA obliteration is a key point to prevent thrombogenesis. We describe a simplified off-pump compartmentalization procedure using epicardial radiofrequency ablation of the left atrium and LAA stapling on the beating heart without cardiopulmonary bypass.     

双侧腋下小切口肺静脉隔离术治疗孤立性心房颤动

目的 总结双侧腋下小切口直视下肺静脉隔离及左心耳切除治疗孤立性心房颤动的临床经验.方法 对28例孤立性心房颤动患者通过腋下小切口径路,直视下用Atricure双极射频消融系统行双侧肺静脉隔离及左心耳切除、Marshall韧带切断.结果 无围术期死亡、Ⅲ度房室传导阻滞、脑卒中及大出血等严重并发症,气管插管时间（4.2±2.6）h,平均住院时间（5.8±3.2）d.24例患者术毕转复窦性心律,1例电复律后转复,3例5d内转复.平均随访16.5个月,1例心房颤动复发,2例出现阵发性房性早搏.结论 双侧腋下小切口直视下射频消融治疗孤立性心房颤动效果良好,无需特殊器械辅助,易于推广.     

Treatment of lone atrial fibrillation with a right thoracoscopic approach

A simplified technique to treat patients in stand-alone atrial fibrillation with a right thoracoscopic approach is described. An electrical isolation of the four pulmonary veins (box lesion) is achieved with a microwave antenna.     

分站式杂交消融术与微创迷宫消融术治疗长程持续性心房颤动随机对照研究的中长期随访结果

目的 评价并比较长程持续性心房颤动(房颤)患者接受分站式杂交消融术治疗的有效性是否优于单纯微创迷宫消融术.方法 纳入广东省人民医院南海医院2017～ 2018年行微创迷宫消融术术后3个月维持窦性心律患者108例,其中男82例、女26例,年龄(56.5±9.4)岁.其中50例为杂交手术(HA)组,补充行导管射频消融术;另...     

Standalone epicardial left atrial appendage exclusion for thromboembolism prevention in atrial fibrillation

Open in a separate window OBJECTIVESMost strokes associated with atrial fibrillation (AF) result from left atrial appendage thrombi. Oral anticoagulation can reduce stroke risk but is limited by complication risk and non-compliance. Left atrial appendage exclusion (LAAE) is a new surgical option to reduce stroke risk in AF. The study objective was to evaluate the safety and feasibility of standalone thoracoscopic LAAE in high stroke risk AF patients.METHODSThis was a retrospective, multicentre study of high stroke risk AF patients who had oral anticoagulation contraindications and were not candidates for ablation nor other cardiac surgery. Standalone thoracoscopic LAAE was performed using 3 unilateral ports access and epicardial clip. Periprocedural adverse events, long-term observational clinical outcomes and stroke rate were evaluated.RESULTSProcedural success was 99.4% (174/175 patients). Pleural effusion occurred in 4 (2.3%) patients; other periprocedural complications were <1% each. One perioperative haemorrhagic stroke occurred (0.6%). No phrenic nerve palsy or cardiac tamponade occurred. Predicted annual ischaemic stroke rate of 4.8/100 patient-years (based on median CHA₂DS₂-VASc score of 4.0) was significantly higher than stroke risk observed in follow-up after LAAE. No ischaemic strokes occurred (median follow-up: 12.5 months), resulting in observed rate of 0 (95% CI 0–2.0)/100 patient-years (P < 0.001 versus predicted). Six all-cause (non-device-related) deaths occurred during follow-up.CONCLUSIONSStudy proved that a new surgical option, standalone thoracoscopic LAAE, is feasible and safe. With this method, long-term stroke rate may be reduced compared to predicted for high-risk AF population.     

Minimally invasive epicardial left atrial ablation and appendectomy for refractory atrial tachycardia

Surgical removal or epicardial radiofrequency ablation of the left atrial appendage (LAA) is occasionally required when endocardial ablations fail. We report a modified minimally invasive surgical approach for elimination of recurrent atrial arrhythmias arising from the LAA, including both radiofrequency ablation and appendectomy. Ablation of the LAA base was performed using the Medtronic Cardioblate bipolar radiofrequency device (Medtronic, Minneapolis, MN), and left atrial appendectomy was then completed using the EndoGIA stapling system (US Surgical, Norwalk, CT). This procedure successfully isolated and removed the tachycardia focus, and normal sinus rhythm was restored. Elimination of LAA arrhythmias using a combination of epicardial radiofrequency ablation and appendectomy ensures electrical isolation while minimizing surgical invasiveness.     

Biatrial radiofrequency ablation for atrial fibrillation: epicardial and endocardial surgical approach

Radiofrequency energy applied by means of surgical probes permits the ablation of atrial fibrillation (AF). This study presents our initial experience on 55 consecutive cardiac patients with permanent AF with radiofrequency ablation through biatrial epicardial and endocardial surgical approach. At discharge, 8.1% of the patients had persistent AF-atrial flutter. Hospital incidence of arrhythmias were, 9% of paroxysmal atrial fibrillation, 10.9% of atrial flutter, and 34.5% of persistent atrial fibrillation. After a mean follow-up of 7 months, 83.6% patients have recovered sinus rhythm, and echocardiographic biatrial contraction was re-established in 73%. Biatrial radiofrequency ablation applied from the endocardium and the epicardium has achieved satisfactory results, without increasing the surgical risk.