Stand-alone Atrial Fibrillation Surgery by Totally Thoracoscopic Ablation: We are Good, but why aren't we better?

Objectives: Stand-alone atrial fibrillation (AF) ablation surgery has been advocated by an increasing number of surgeons, yet for the majority of electrophysiologists, it remains a weak indication for the treatment of atrial arrhythmias. Among the reasons for its niche presence, stand-alone AF surgery is associated with considerable invasiveness and non-superior effectiveness as compared with repeated catheter ablations. This study documents current results of totally thoracoscopic ablation (TTA) as a closed-chest, beating heart approach. The rationale is to help stimulate future developments in the field.

Methods: Between 2010 and June 2014, 42 patients (14 females, mean age 63 years) underwent TTA in our institution. Indications were symptomatic paroxysmal (n = 19) or persistent (n = 23) AF despite prior catheter ablation (n = 35) or medical treatment (n = 7). Lesions sets included bilateral pulmonary vein isolation and connecting lines at the left atrial (LA) backwall, ganglionated plexus ablation, as well as LA appendectomy. Follow up was by insertable cardiac monitors (n = 36), pacemakers (n = 4), or serial Holter EKG (n = 2).

Results: There was no perioperative or late mortality, and all patients were discharged in good condition. Six patients (14%) were converted to thoracotomy due to bleeding (n = 3) or adhesions (n = 3), predominantly at the beginning of our experience. Major morbidities included phrenic nerve palsy (n = 1), mild pulmonary vein stenosis (n = 1), and acute renal failure (n = 1). During follow up, 8 (19%) underwent repeat catheter ablation for LA flutter (n = 3) or AF (n = 5). Among the patients with continuous rhythm monitoring, 35 of 40 (83%) were in sinus rhythm as defined by an AF burden of < 0,1% during the latest 2 months of follow up. The 2 remaining patients without continuous monitoring had no documented AF in any Holter EKG nor did they ever require another treatment for cardiac arrhythmias.

Conclusions: TTA represents the latest iteration of stand-alone AF surgery with lowest surgical trauma and acceptable morbidity. Most but not all patients with refractory AF can be cured, although staged-hybrid catheter ablation is required in select cases. Therefore, future developments should target additional as well as consistently transmural ablation lines. Only if TTA replicates the electrophysiologic effects of an open chest Cox Maze procedure while maintaining its low invasiveness, it can gain wide spread acceptance among the medical community and patients.