Minimally Invasive Surgical Pulmonary Vein Isolation for Atrial Fibrillation: A Multicenter Experience
James R. Edgerton1, James McClelland2, David Duke2, Marc Gerdisch3, Bryan Steinberg4, Scott H. Bronleewe5, Tara A. Weaver6, Syma L. Prince6, Michael J. Mack1; 1Medical City Dallas Hospital, Dallas, TX; 2Endovascular Research, Eugene, OR; 3Central Dupage Hospital, Winfield, IL; 4Washington Adventist Hospital, Takoma Park, MD; 5University Community Hospital, Tampa, FL; 6CRSTI, Dallas, TX
Objective: The development of enabling technologies has allowed surgical ablation of atrial fibrillation (AF) to be accomplished in a minimally invasive manner. We conducted a prospective five center registry of patients undergoing minimally invasive surgical ablation of AF by a standardized technique to determine if the procedure is effective.
Methods: The study consisted of 150 consecutive patients, treated at 5 centers. The mean age was 60.83 (range 32-82) years with the duration of AF > one year in 87.3%. Sixty-six percent were male. Paroxysmal AF was present in 83 (55.3%), persistent in 30 (20.0%), and long-standing persistent in 37 (24.7%) Surgical indications included failure of antiarrhythmic drug (AAD) therapy (46.7%), Coumadin intolerance or noncompliance (20.0%), and failure of previous catheter ablation (24.0%). The procedure consisted of bilateral pulmonary vein antral electrical isolation with a bipolar radiofrequency clamp, targeted autonomic denervation of the left atrium, and selective left atrial appendectomy (LAA) performed through small bilateral thoracotomy incisions. Patients were followed for six months and outcomes reported using Heart Rhythm Society guidelines. Follow-up at six months included ECG and longer term monitoring (LTM). Longer term monitoring consisted of pacemaker interrogation (16 patients) or 14 - 30 day event monitors (72 patients). When patient circumstances dictated, a 24 hour Holter monitor was used (33 patients).
Results: There were two (1.3%) operative mortalities and one (0.7%) late unrelated mortality. The LAA was excised or excluded in 134 (89.4%) patients. Mean hospital stay was 4.8 (range 0-34) days. Other complications included new heart block in 4 (2.7%) and phrenic nerve palsy in two (1.3%) patients. Six-month follow up was complete in 121 (80.7%) patients. Normal sinus rhythm (NSR) at six months by LTM was 88/121 (72.7%) with 70/121 (57.9%) off of AADs. NSR was 61/71 (85.9%) in paroxysmal and 27/50 (54.0%) in persistent/long-standing persistent patients.
Conclusion: Minimally invasive surgical ablation of atrial fibrillation is effective treatment of paroxysmal AF with less optimal results in persistent/long-standing persistent AF. Rhythm analysis by ECG alone overestimates success by approximately15%.
Six Month Follow-up
| Paroxysmal Patients (n=71) | Persistent/Long-Standing Persistent Patients (n=50) | All Patients (n=121) |
| NSR by ECG | 65 (91.5%) | 38 (76.0%) | 103 (85.1%) |
| NSR by LTMOn or off AAD | 61 (85.9%) | 27 (54.0%) | 88 (72.7%) |
| NSR by LTM Off AAD | 50 (70.4%) | 20 (40.0%) | 70 (57.9%) |
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