Full Endoscopic Treatment Of Lone Af In An Awake Patient With Epidural Anesthesia
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Bisleri G1, Manzato A2, Bottio T1, Piccoli P1, Muneretto C1.
1Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy, 2Section of Cardiothoracic Anesthesia, Spedali Civili di Brescia, Brescia, Italy.
Background: Percutaneous transcatheter ablation of atrial fibrillation (AF) holds several drawbacks as suboptimal success rates, arrhythmia recurrences, procedural duration and technical challenges. The development of minimally invasive approaches may nowadays expand arrhythmia surgery to patients with lone atrial fibrillation. We developed an innovative totally endoscopic monolateral approach with epidural anaesthesia in awake patients.
Methods: A 39 yrs. old male patient was scheduled for a full endoscopic ablation of lone AF, with epidural anaesthesia in consciousness and spontaneous breathing. The patient was suffering from paroxysmal AF since 32 months. The patient previously underwent electrical cardioversion unsuccessfully. Left atrial antero-posterior diameter was 49 mm. A catheter for high-thoracic epidural anesthesia was placed at the level of T1T2 and a solution of ropivacaine and sufentanyl was administered. Via a right monolateral thoracoscopic approach (3 ports), under mild CO2 insufflation (intrathoracic pressure: 5mmHg), the pericardial cavity was opened, the transverse and oblique sinuses were entered and a continuous linear epicardial isolation of the pulmonary veins (box lesion) was performed using a microwave endoscopic device.
Results: All endoscopic procedures were successfully performed in conscious, spontaneously breathing patients without any intraoperative complications. Oxygen saturation was maintained up to 90% by means of simple O2 administration. Mean ablation time was 18+6 minutes, while the mean procedural time was 77+18 minutes. There was no need for ICU stay nor any postoperative complications occurred. All patients showed a full functional recovery within 24 hours and were discharged within 48 hours. At a mean follow-up of 13.4+6 months, 8 patients are in stable sinus rhythm while 2 patients (1 paroxysmal and 1 permanent AF) recurrent bouts of AF.
Conclusions: Endoscopic surgical ablation of AF can be safely and successfully performed in awake patients. AF ablation under high thoracic epidural anaesthesia with spontaneous breathing allows a prompt patients' recovery and yields the potential to become a day-hospital procedure, thus competing with the transcatheter approach.
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