Minimally Invasive Atrial Fibrillation Ablation Combined with a New Technique for Thoracoscopic Stapling of the Left Atrial Appendage: Case Report
Background: Surgical therapy for atrial fibrillation (AF) is becoming increasingly popular in the concomitant setting. Minimally invasive techniques are being developed for management of the patient with stand-alone AF. We report on our first case of a patient undergoing thoracoscopic microwave epicardial AF ablation combined with the incorporation of a new device for left atrial appendage (LAA) exclusion.
Methods: The patient is a 62-year-old man with a 10-year history of drug-resistant paroxysmal AF. He had failed multiple electrical cardioversions, as well as a percutaneous attempt at left and right superior pulmonary vein (PV) isolation. On October 8, 2003, he was admitted to undergo an off-pump thoracoscopic epicardial microwave ablation. While the patient was under general anesthesia, 3 thoracoscopic access ports were created in the right chest. The pericardium was widely opened. Red rubber catheters were positioned in the transverse and oblique sinuses. The 2 catheters were retrieved on the left side and tied together, forming a guide to the Flex 10 microwave ablation probe (Guidant Corporation, Fremont, CA, USA). The Flex 10 sheath was positioned to encircle all 4 pulmonary veins. The position of the ablation catheter was confirmed visually to be behind the LAA. Sequential ablation was then performed in the segments of the Flex 10 to create a continuous ablation line around the PVs. A connecting lesion to the base of the LAA was then performed. The LAA was then stapled using the SurgASSIST computer-mediated thoracoscopic stapling system (Power Medical Intervention, New Hope, PA, USA).
Results: The procedure was uneventful and lasted for a total of 2.5 hours. The patient was discharged home on postoperative day 2 in rate-controlled AF. He was successfully electrically cardioverted to normal sinus rhythm (NSR). At latest follow-up he remained in NSR and continued to take dofetilide (Tikosyn).
Conclusion: Thoracoscopic epicardial microwave ablation of AF is a technically feasible procedure with minimal risk. The computer deployment and motion controlled stapling system that we used in this case has the potential to become a safe and reliable alternative to conventional stapling instruments.
Williams RM, Knaut M, Berube D, Oz MC. 2002. Application of microwave energy in cardiac tissue ablation: from in vitro analysis to clinical use. Ann Thorac Surg 74:1500-5.nWolf PA, Mitchell JB, Baker CS, Kannel WB, D'Agostino RB. 1998. Impact of atrial fibrillation on mortality, stroke, and medical costs. Arch Intern Med 158:229-34.nBenjamin EJ, Wolf PA, D'Agostino RB, Silbershatz H, Kannel WB, Levy D. 1998. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation 98:946-52.nBlackshear JL, Johnson WD, Odell JA, et al. 2003. Thoracoscopic extra cardiac obliteration of the left atrial appendage for stroke risk reduction in atrial fibrillation. J Am Coll Cardiol 42:1249-52.nChen SA, Hsieh MH, Tai CT, et al. 1999. Initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation 100:1879-86.nCox JL. 1991. The surgical treatment of atrial fibrillation, IV: surgical technique. J Thorac Cardiovasc Surg 101:584-92.nCox JL, Jaquiis R, Schuessler R, Boineau J. 1995. Modification of the maze procedure for atrial flutter and atrial fibrillation, I: rational and surgical results. J Thorac Cardiovasc Surg 110:473-84.nGillinov AM, Blackstone EH, McCarthy PM. 2002. Atrial fibrillation: current surgical options and their assessment. Ann Thorac Surg 74:2210-7.nHaissaguerre M, Jais P, Shah DC, et al. 1998. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 339:659-66.nManasse E, Colombo PG, Barbone A, et al. 2003. Clinical histopathology and ultrastructural analysis of myocardium following microwave energy ablation. Eur J Cardiothorac Surg 23:573-7.nManasse E, Infante M, Ghiselli S, et al. 2002. A video-assisted thoracoscopic technique to encircle the four pulmonary veins: a new surgical intervention for atrial fibrillation ablation. Heart Surg Forum 5(4):337-9.nNattel S, Lummer G, Talajic M, Roy D. 2003. Cost evaluation of rhythm control methods for atrial fibrillation evidence from CTAF. Card Electrophysiol Rev 7(3):211-4.nOdell JA, Blackshear JL, Davies E, et al. Thoracoscopic obliteration of the left atrial appendage: potential for stroke reduction? Ann Thorac Surg 1996;61:565-9.nSaltman AE, Rosenthal LS, Francalancia NA, Lahey SJ. 2003. A completely endoscopic approach to microwave ablation for atrial fibrillation. Heart Surg Forum 6(3):E38-41.n
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).