Alaaddin Yilmaz.
St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands.
OBJECTIVE: Radiofrequency (RF) pulmonary vein isolation via sternotomy or bilateral mini-thoracotomy as treatment for atrial fibrillation (AF) has already been porven to be effective. Here we describe a minimal invasive totally endoscopic closed chest surgical technique which leads to better patient tolerance.
METHODS: Twenty closed chest thoracoscopic procedures for treatment of AF was performed from January to July 2007. Patients were in supine position after general anesthesia. Both arms were raised and fixed in 90 degree flexion above the head. The operation was performed from both side consiquitively. Two 5 mm thoracoports were inserted in the fourth intercostal space, midaxillary and midclavicular. A third thoracoport of 10 mm was inserted in the sixth intercostal space midaxillary. Bilateral pulmonary vein isolation was accomplished with the Atricure isolator bipolar RF clamp. The isolator multifunctional pen was used to check conduction block, ablate ganglionic plexi when present and perform connecting lines over the atrial roof. Left atrial appendage was amputated by using an endostapling device. Both hemithoraces were drained. Patients were extubated in the operation room.
RESULTS: Mean operation time improved from 145 minutes (range 112-175) in the first five operations to 100 minutes (range 75-140) in the last five. Two conversions to median sternotomy were performed, due to massive adhesions and bleeding from the pulmonary vein. Despite a high INR (2.2+ 0.6) bloodloss was minimal (80 to 120 cc). Mean hospital stay decreased from 7 days in the first five procedures to 2.5 days in the last five patients. After a mean follow up of 7.4 months (range 6-11) 86% were in sinus rhythm.
CONCLUSIONS: We present the first series of completely endoscopic bilateral pulmonary vein isolation with the bipolar RF ablation clamp. This approach has already contributed to a shorter hospital stay with it's high success rate and truly minimal invasiveness. In the future this concept can compete with percutaneous procedures.
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