Thoracoscopic Atrial Fibrillation Ablation Research Articles

Effectiveness of Maze IV procedure versus thoracoscopic ablation for atrial fibrillation: a propensity score-matched analysis.

Thoracoscopic ablation (TA) has emerged as a promising treatment for atrial fibrillation (AF), with the Cox-Maze IV Procedure (CMP-IV) as the current gold-standard intervention. This study aims to evaluate and compare the outcomes of TA and CMP-IV in treating AF. Patients with AF underwent either CMP-IV or TA through a left-side chest approach. The CMP-IV entailed bi-atrium ablation, whereas the TA involved creating three circular plus three linear ablations in the left atrium. We analyzed baseline characteristics, perioperative outcomes and recurrence rates using propensity score matching (PSM) at a 1:1 ratio, to ensure comparability between the two treatment groups. A total of 459 patients underwent either CMP-IV (n=93) or TA via left chest (n=366) and 174 patients were deemed eligible for 1:1 PSM. The TA group experienced significantly shorter intensive care unit (ICU) and hospital stays. The mean follow-up period was 31.5±22.1 months. Pre- and post-matching analysis showed that CMP-IV had a higher rate of freedom from recurrence compared to TA, particularly in non-paroxysmal AF patients. Multivariable Cox regression analysis revealed that CMP-IV was associated with a reduced risk of recurrence, while an increased left atrial size emerged as an independent predictor of postoperative recurrence, regardless of the use of CMP-IV or TA. Our study suggests that while the therapeutic efficacy of TA for "lone" AF may fall short of the classic CMP-IV, its less invasive nature results in significantly shorter ICU and hospital stays. To enhance patient outcomes following TA, it is essential to improve the quality of ablation, refine the ablation route, and focus on careful patient selection.

Clinical Implication of Left Atrial Appendage Emptying Velocity in Thoracoscopic Ablation of Atrial Fibrillation.

There are limited data about predictors of atrial fibrillation (AF) recurrence after totally thoracoscopic ablation (TTA). This study investigated the clinical implication of left atrial appendage emptying velocity (LAAV) in patients undergoing TTA.Methods and Results: Patients who underwent TTA between 2012 and 2015 at a tertiary hospital were prospectively enrolled in this study. LAAV was measured and averaged over five heart beats from preoperative transesophageal echocardiography. The primary outcome was a freedom from recurrent AF or atrial flutter (AFL) detected on 24-h Holter monitoring or an electrocardiogram over a 3-year period after TTA. In all, 129 patients were eligible for analysis in this study. The mean (±SD) patient age was 54.4±8.8 years, and 95.3% were male. During the 3 years after TTA, the overall event-free survival rate was 65.3%. LAAV was an independent predictor of recurrent AF/AFL during the 3-year period after TTA (per 1-cm/s increase, adjusted hazard ratio [aHR] 0.95; 95% confidence interval [CI] 0.91-0.99; P=0.016). Event-free survival was significantly lower among patients with a low LAAV (<20 cm/s; n=21) compared with those with a normal (≥40 cm/s; n=38; aHR 6.11; 95% CI 1.42-26.15; P=0.015) or intermediate (LAAV ≥20 and <40 cm/s; n=70; aHR 2.74, 95% CI 1.29-5.83; P=0.009) LAAV. In patients with AF, LAAV was significantly associated with the risk of long-term recurrence of AF after TTA.

Left atrial strain predicts fibrosis of left atrial appendage in patients with atrial fibrillation undergoing totally thoracoscopic ablation

Abstract Background Left atrial (LA) fibrosis is related with development and severity of atrial fibrillation (AF). The aim of this study was to investigated factors associated with LA fibrosis in patients undergoing totally thoracoscopic ablation (TTA) for AF. Methods Between February 2012 and March 2015, a total of 128 patients who underwent TTA were enrolled from a tertiary hospital. Left atrial appendage (LAA) was harvested during surgery to determine the degree of fibrosis. LAA fibrosis was classified as mild (1st quartile), moderate (2nd and 3rd quartile), or severe (4th quartile). Clinical outcome was 5-year recurrence rate of AF detected in electrocardiogram or 24-hour Holter monitoring. Results The mean age was 54.3 ± 8.8 years and 18.8% had paroxysmal AF. Patients with mild LAA fibrosis had a significantly lower rate of recurrent AF (23.3%) at 5 years after TTA compared with those with moderate (51.4%; hazard ratio [HR] 2.69; 95% confidence interval [CI] 1.19─6.12) or severe (53.2%; HR 2.84; 95% CI 1.16─6.97) fibrosis. Among clinical and echocardiographic parameters, peak LA strain was the only predictor of mild LAA fibrosis (coefficient 0.10, p=0.005) with the best cutoff value of 14.7% (area under the curve 0.732). The prevalence of mild LAA fibrosis was 40.6% in patients with peak LA strain ≥14.7%, but only 6.8% in those with peak LA strain &amp;lt;14.7%. Conclusions In patients undergoing thoracoscopic ablation for AF, mild LAA fibrosis was associated with a lower risk of 5-year AF recurrence. LA strain is the only predictor of mild LAA fibrosis that reflects a lower risk of 5-year AF recurrence.

Long-term outcomes of thoracoscopic ablation for atrial fibrillation

The aim of this work is to analyze the effectiveness of thoracoscopic ablation (TSA) of atrial fibrillation (AF) and to define the risk factors for the return of atrial tachyarrhythmias after TSA in the long-term follow-up period.Methods. From January 2019 to December 2021, 150 patients with symptomatic atrial fibrillation (persistent 29.3% monitoring at the control points of the study, the results of which evaluated the effectiveness of the procedure.Results. The overall efficiency of TSA in the long-term follow-up period was 72.5%. After off-antiarrhythmic drugs, freedom from any atrial tachyarrhythmias was 79.2%, 70.5% and 68.9% after 6, 12 and 24 months, respectively. Additional catheter ablations after 3 months increase the effectiveness of the procedure to 82.9%. Important risk factors for the return of arrhythmia after TSA should be considered the patient’s age, duration of AF, previous catheter ablations and the left atria diameter of more 40 mm.Conclusion. The hybrid approach significantly improves the effectiveness of TSA for patients with non-paroxysmal forms of AF. The results obtained require further study of this problem in order to improve the quality of TSA and determine the optimal set of ablation lines, considering the risk factors for the return of arrhythmia.

EVOLUTION OF THORACOSCOPIC TREATMENT OF ATRIAL FIBRILLATION: FROM INCEPTION TO CONTEMPORARY APPROACHES

HighlightsThe development and implementation of video-assisted thoracoscopic atrial fibrillation ablation since 2005 by R. Wolf and colleagues have undergone a number of modifications for improvement and simplification. A study of the evolutionary development of thoracoscopic ablation of atrial fibrillation is necessary to optimize ablation recruitment and surgical technique for different forms of atrial fibrillation. AbstractThere is a variety of treatments for atrial fibrillation (AF): therapeutic, interventional and surgical. The effectiveness of these methods varies significantly depending on the form of AF. For a long time, surgery was considered the only highly effective treatment for AF. In modern arrhythmology, «Maze IV» and its modifications are considered only as a simultaneous procedure in cardiac surgery. The work of M. Haïssaguerre et al. has established that the main focus of catheter ablation (CA) in AF should be the pulmonary veins, but their isolation in non-paroxysmal AF is questionable. This discovery has stimulated the development of alternative treatment modalities for resistant AF. Recently, video-assisted thoracoscopic epicardial ablation (TSA), which does not require sternotomy, cardiopulmonary bypass and cardioplegia, has been increasingly preferred. TSA of AF is an alternative surgical treatment for isolated forms of AF on the working heart. This procedure may include: pulmonary vein ablation, posterior left atrial wall and pulmonary vein ablation and left atrial appendage exclusion, but its effectiveness varies considerably due to the heterogeneity of patients, surgical technique and follow-up period. The aim of this review is to provide data on the evolutionary development of thoracoscopic ablation of AF depending on the choice of surgical access, ablation line set and ablation device.

Women Have More Recurrences of Atrial Fibrillation than Men after Thoracoscopic Ablation and Suffer More from Established Risk Factors

Atrial fibrillation (AF) is more prevalent in men than in women. However, women with AF are more symptomatic, have a worse quality of life, a higher stroke risk and may therefore benefit most from ablation. In this study we aim to identify the risk of recurrent AF after thoracoscopic ablation, and assess the differential impact of the risk factors for recurrence between women and men. This is a single center cohort study, including patients undergoing thoracoscopic ablation for advanced AF between 2008 and 2019. All patients were clinically followed up for two years with quarterly 24 h Holter monitoring and ECGs for the detection of recurrent AF. Left atrial appendage (LAA) tissue was collected for collagen analysis. We included 571 patients, of whom 143 (25%) were women. Women were older than men (63 ± 8.3 y vs. 59 ± 8.5, p < 0.001), but had fewer cardiovascular risk factors, myocardial infarctions (1.4% vs. 6.5%, p = 0.03) and, in particular, vascular disease (7.0% vs. 16.1%, p = 0.01). Women suffered more from AF recurrence, driven by more atrial tachycardias, and sex was an independent risk factor for recurrence (HR1.41 [1.04-1.91], p = 0.028]). The presence of vascular disease was associated with an increased risk for AF recurrence in women, but not in men. In LAA histology, women had more collagen than men, as had patients with persistent compared to paroxysmal AF. Women had 15% more recurrences, driven by more atrial tachycardias, which may be explained by a more fibrotic atrial substrate. What's new? Women undergoing thoracoscopic AF ablation have a higher risk of recurrent AF, driven by more atrial tachycardias. Among patients with left atrial enlargement or persistent AF, women have worse outcomes than men. Vascular disease was a risk factor for recurrence in women, but not in men. In a histopathologic analysis of the left atrial appendage, women had more collagen than men, as had patients with persistent compared to paroxysmal AF.

Left atrial appendage exclusion using a stapler with thoracoscopic ablation of atrial fibrillation

Highlights. Stroke prevention in patients with atrial fibrillation is extremely important and difficult. Lifelong anticoagulant therapy is not always an effective way of preventing thrombosis in the left atrial appendage in this group of patients. In this regard, one of the most urgent problems of modern surgical arrhythmology and cardiac surgery is the search for new open and minimally invasive surgical methods of excluding the left atrial appendage from the blood flow.Aim. To investigate the safety and efficacy of using the left atrial appendage stapler for video-guided thoracoscopic ablation (TSA) of non-valvular atrial fibrillation (AF).Methods. The retrospective, single-center study included 100 patients with non-valvular AF who underwent video-guided thoracoscopic ablation of AF with single-stage left atrial appendage exclusion using an Endo GIA stapler (Medtronic, Minneapolis, Minnesota, USA).Results. The mean age of the patients was 56,2±8,8 years, the majority of the patients (73 patients, 73%) were male. Patients with persistent 50 (50%) AF and longstanding AF 50 (50%) were included in the study. The duration of atrial fibrillation was 4 (1,7–7) years. The median CHA2DS2-VASc and HAS-BLED scores were 2 (1–1,5) and 1 (0-1), respectively. The mean anticoagulation therapy-to-ablation time was 4,2±1,9 years. Thirty-eight (38%) patients were prescribed warfarin preoperatively. The completeness of left atrial appendage (LAA) exclusion was confirmed by intraoperative transesophageal echocardiography. The average length of the staple lines was 48 (35–75). A single left atrial appendage exclusion was performed using a 60 mm staples. In 12 (12%) patients, stapler exclusions were performed using two 45 mm staples due to insufficient staple length. None of the patients had ruptures, punctures along the staple lines or rupture of the surrounding epicardial tissue. Anticoagulant therapy was discontinued 6 months after TSA in 70 (70%) patients with sustained sinus rhythm observed on 24-h Holter Monitoring, satisfactory CHA2DS2-VASc scores and after confirmation of absence of left atrial thrombus by transesophageal echocardiography and contrast-enhanced MSCT. No strokes were reported within 1,2±0,7 years after discontinuing anticoagulation therapy.Conclusion. Exclusion of LAA using a stapler for TSA is a highly effective and safe technique for patients with non-valvular atrial fibrillation compared to alternative methods of excluding the LAA from the systemic blood flow.

The Minimum Number of Ablation Lines for Complete Isolation of the Pulmonary Veins during Thoracoscopic Ablation for Atrial Fibrillation.

Total thoracoscopic ablation has been recommended as a class IIa indication for atrial fibrillation. However, the optimal number of ablation lines for pulmonary vein isolation has not yet been proposed. This study aimed to report the minimum number of ablation lines required to achieve an intraoperative conduction block. This study included a total of 20 patients who underwent total thoracoscopic ablation from December 2020 to July 2021. The epicardial conduction block was checked after each ablation line of pulmonary vein antral clamping. The median age was 61 years old. The median duration of atrial fibrillation since the first diagnosis was 78 months. Pulmonary vein isolation with bidirectional conduction block was confirmed in 90% of patients. A median of six ablation lines around each pulmonary vein antrum were performed according to our protocol even after the conduction block was verified. The median number of ablations to achieve an exit block was two on the right side and 3.5 on the left side. We found that most conduction blocks were achieved within three ablations around the pulmonary vein antrum. Our results may provide evidence to reduce the number of unnecessary ablation lines in the future.

El fracaso de la ablación por catéter de la fibrilación auricular se asocia con mayor remodelado y menos eficacia de una posterior ablación toracoscópica

Introduction and objectivesRecent observations suggest that patients with a previous failed catheter ablation have an increased risk of atrial fibrillation (AF) recurrence after subsequent thoracoscopic AF ablation. We assessed the risk of AF recurrence in patients with a previous failed catheter ablation undergoing thoracoscopic ablation. MethodsWe included patients from 3 medical centers. To correct for potential heterogeneity, we performed propensity matching to compare AF freedom (freedom from any atrial tachyarrhythmia> 30 s during 1-year follow-up). Left atrial appendage tissue was analyzed for collagen distribution. ResultsA total of 705 patients were included, and 183 had a previous failed catheter ablation. These patients had fewer risk factors for AF recurrence than ablation naïve controls: smaller indexed left atrial volume (40.9± 12.5 vs 43.0±12.5 mL/m2, P=.048), less congestive heart failure (1.5% vs 8.9%, P=.001), and less persistent AF (52.2% vs 60.3%, P=.067). However, AF history duration was longer in patients with a previous failed catheter ablation (6.5 [4-10.5] vs 4 [2-8] years; P<.001). In propensity matched analysis, patients with a failed catheter ablation were at a 68% higher AF recurrence risk (OR, 1.68; 95%CI, 1.20-2.15; P=.034). AF freedom was 61.1% in patients with a previous failed catheter ablation vs 72.5% in ablation naïve matched controls. On histology of the left atrial appendage (n=198), patients with a failed catheter ablation had a higher density of collagen fibers. ConclusionsPatients with a prior failed catheter ablation had fewer risk factors for AF recurrence but more frequently had AF recurrence after thoracoscopic AF ablation than ablation naïve patients. This may in part be explained by more progressed, subclinical, atrial fibrosis formation.

Changes in cognitive function after thoracoscopic and catheter ablation for atrial fibrillation.

Comparative data regarding the effect of percutaneous and thoracoscopic ablation of atrial fibrillation (AF) on cognitive function are very limited. The aim of the study was to determine and compare the effect of both types of ablations on patient cognitive functions in the mid-term. Patients with AF indicated for ablation procedure were included. Forty-six patients underwent thoracoscopic, off-pump ablation using the COBRA Fusion radiofrequency system, followed by a catheter ablation three months afterward (Hybrid group). A comparative cohort of 53 AF patients underwent pulmonary vein isolation only (PVI group). Neuropsychological examinations were done before and nine months after the surgical or catheter ablation procedure. Neuropsychological testing comprised 13 subtests of seven domains, and the results were expressed as post-operative cognitive dysfunction (POCD) nine months after the procedure. Patients in both groups were similar with respect to the baseline clinical characteristics; only non-paroxysmal AF was more common in the hybrid group (98%vs. 34%). Major POCD was present in eight (17.4%) of hybrid patients versus three (5.7%) of PVI patients (p=0.11), combined (major/minor) worsened cognitive decline was present in 10 (21.7%) hybrid patients versus three (5.6%) PVI patients (p=0.034). On the other hand, combined (major/minor) improvement was present in 15 (32.6%) hybrid patients versus nine (16.9%) patients in the PVI group (p=0.099). Hybrid ablation, a combination of thoracoscopic and percutaneous ablation, is associated with a higher risk of cognitive decline compared to sole percutaneous ablation.

Electrophysiological findings after bilateral thoracoscopic atrial fibrillation ablation using irrigated bipolar radiofrequency energy - a pilot study

Úvod: Torakoskopická ablace fibrilace síní (TARAFS) s použitím bipolární radiofrekvenční energie (Medtronic Cardioblate Gemini-S) by měla vést k antrální izolaci plicních žil (PŽ) a izolaci zadní stěny levé síně (LS). Elektrofyziologické nálezy po ablaci touto technikou ale nejsou známy. Metody a výsledky: U 22 pacientů s recidivou fibrilace síní (FS) po oboustranné TARAFS provedené pro perzistující FS byla zvolena radiofrekvenční katetrizační ablace s odstupem alespoň tří měsíců po TARAFS. Výsledky: Z 22 pacientů nebyla izolace zadní stěny LS nalezena u 15 (68,2 %) pacientů. U 12 pacientů nebyly endokardiálně zjištěny známky žádné předchozí ablace, u dvou pacientů byly izolovány pravé PŽ a u jednoho pacienta byly izolovány levé PŽ. Na konci ablace byla izolace zadní stěny LS dokončena u všech 15 pacientů. U 18 z celkových 22 pacientů bylo katetrizační ablací dosaženo nevyvolatelnosti FS. Závěr: U značného počtu pacientů s recidivou FS po TARAFS není izolace plicních žil ani zadní stěny LS dokončena a na elektroanatomické voltážové mapě nejsou nalezeny žádné známky předchozí ablace, které by usnadnily následnou katetrizační ablaci. U většiny pacientů je k dosažení nevyvolatelnosti FS kromě izolace zadní stěny LS nutná další ablace.

Short-term results of two strategies in thoracoscopic ablation for lone atrial fibrillation

Background: Thoracoscopic ablation is an effective treatment of patients with atrial fibrillation. Nowadays, 2 types of ablative devices are available in clinical practice allowing one to perform the thoracoscopic procedure Medtronic and AtriCure. However, the contemporary clinical literature does not have enough data that would compare these two approaches. Aims: to perform a comparative analysis of the short-term results of two minimally invasive strategies in thoracoscopic ablation for atrial fibrillation. Methods: 232 patients underwent thoracoscopic ablation for atrial fibrillation in two clinical centers for the period from 2016 to August 2021. The patients were divided into 2 groups. The first group was represented by those patients to whom a Medtronic device was applied (n=140), the second group was treated with an AtriCure device (n=92). The patients were comparable in their age, gender, initial severity of the condition. The follow-up consisted of laboratory tests, chest Х-ray, electrocardiography, 24-hour Holter monitor, echocardiography. The structure and prevalence of postoperative and intraoperative complications, specifics of the postoperative period were compared between the two groups. Results: According to the structure and prevalence of intraoperative complications the 2 groups are comparable to each other: 4.3% and 1.1% for the 1st group and 2nd group, respectively (p 0.05). The postoperative complications had developed in 6 (4.3%) and 5 (5.4%) patients in groups 1 and 2, respectively (p 0.05). At the time of discharge from hospital, a sinus rhythm was registered in 93.6% of patients (1st group), and 85.9% (2nd group) (p 0.05). Conclusions: Both strategies have demonstrated comparable short-term results in patients with lone atrial fibrillation. A further research is needed to evaluate the effectiveness of this strategy in a long-term period.

A failed catheter ablation of atrial fibrillation is associated with more advanced remodeling and reduced efficacy of further thoracoscopic ablation

Introduction and objectivesRecent observations suggest that patients with a previous failed catheter ablation have an increased risk of atrial fibrillation (AF) recurrence after subsequent thoracoscopic AF ablation. We assessed the risk of AF recurrence in patients with a previous failed catheter ablation undergoing thoracoscopic ablation. MethodsWe included patients from 3 medical centers. To correct for potential heterogeneity, we performed propensity matching to compare AF freedom (freedom from any atrial tachyarrhythmia> 30 s during 1-year follow-up). Left atrial appendage tissue was analyzed for collagen distribution. ResultsA total of 705 patients were included, and 183 had a previous failed catheter ablation. These patients had fewer risk factors for AF recurrence than ablation naïve controls: smaller indexed left atrial volume (40.9± 12.5 vs 43.0±12.5 mL/m2, P=.048), less congestive heart failure (1.5% vs 8.9%, P=.001), and less persistent AF (52.2% vs 60.3%, P=.067). However, AF history duration was longer in patients with a previous failed catheter ablation (6.5 [4-10.5] vs 4 [2-8] years; P<.001). In propensity matched analysis, patients with a failed catheter ablation were at a 68% higher AF recurrence risk (OR, 1.68; 95%CI, 1.20-2.15; P=.034). AF freedom was 61.1% in patients with a previous failed catheter ablation vs 72.5% in ablation naïve matched controls. On histology of the left atrial appendage (n=198), patients with a failed catheter ablation had a higher density of collagen fibers. ConclusionsPatients with a prior failed catheter ablation had fewer risk factors for AF recurrence but more frequently had AF recurrence after thoracoscopic AF ablation than ablation naïve patients. This may in part be explained by more progressed, subclinical, atrial fibrosis formation.

Unilateral left-sided thoracoscopic ablation of atrial fibrillation concomitant to minimally invasive bypass grafting of the left anterior descending artery.

OBJECTIVESThoracoscopic ablation for atrial fibrillation (AF) and minimally invasive direct coronary artery bypass (MIDCAB) with robot-assisted left internal mammary artery (LIMA) harvesting may represent a safe and effective alternative to more invasive surgical approaches via sternotomy. The aim of our study was to describe the feasibility, safety and efficacy of a unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB surgery.METHODSRetrospective analysis of a prospectively gathered cohort was performed of all consecutive patients with AF and at least a critical left anterior descending artery (LAD) stenosis that underwent unilateral left-sided thoracoscopic AF ablation and concomitant off-pump MIDCAB surgery in the Maastricht University Medical Centre between 2017 and 2021.RESULTSTwenty-three patients were included [age 69 years (standard deviation = 8), paroxysmal AF 61%, left atrial volume index 42 ml/m2 (standard deviation = 11)]. Unilateral left-sided thoracoscopic isolation of the left (n = 23) and right (n = 22) pulmonary veins and box (n = 21) by radiofrequency ablation was succeeded by epicardial validation of exit- and entrance block (n = 22). All patients received robot-assisted LIMA harvesting and off-pump LIMA-LAD anastomosis through a left mini-thoracotomy. The perioperative complications consisted of one bleeding of the thoracotomy wound and one aborted myocardial infarction not requiring intervention. The mean duration of hospital stay was 6 days (standard deviation = 2). After discharge, cardiac hospital readmission occurred in 4 patients (AF n = 1; pleural- and pericardial effusion n = 2, myocardial infarction requiring the percutaneous intervention of the LIMA-LAD n = 1) within 1 year. After 12 months, 17/21 (81%) patients were in sinus rhythm when allowing anti-arrhythmic drugs. Finally, the left atrial ejection fraction improved postoperatively [26% (standard deviation = 11) to 38% (standard deviation = 7), P = 0.01].CONCLUSIONSIn this initial feasibility and early safety study, unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB for LIMA-LAD grafting is a feasible, safe and efficacious for patients with AF and a critical LAD stenosis.

Minimally invasive atrial fibrillation ablation and left anterior descending bypass grafting

Abstract Funding Acknowledgements Type of funding sources: None. Background Minimally invasive direct coronary artery bypass (MIDCAB) with robotic left internal mammary artery (LIMA) harvesting for a critical left anterior descending (LAD) stenosis and thoracoscopic ablation for atrial fibrillation (AF) may represent safe and effective alternatives to more invasive surgical approaches via sternotomy. Purpose To evaluate the feasibility, safety and efficacy of a MIDCAB procedure with concomitant thoracoscopic AF ablation. Methods We prospectively analysed all patients who underwent a minimally invasive, off-pump, MIDCAB through a left mini-thoracotomy with concomitant left-sided thoracoscopic AF ablation using a bipolar radio frequent clamp between 2017 and 2021. Results Twenty-three patients were included (age 69±8 years, BMI 29±4kg/m2, paroxysmal AF 61%, LAVI 42±11 ml/m2). All patients received an off-pump LIMA-LAD anastomosis. Ablation of the left (n=23) and right (n=22) pulmonary veins and box (n=21) was succeeded by epicardial validation of exit- and entrance block (n=22). No procedural complications were observed and complications during hospital admission and after discharge were: bleeding of the LIMA-LAD anastomosis n=1; myocardial infarction requiring percutaneous intervention of the LIMA-LAD n=1, respiratory insufficiency due to pleural effusion or atelectasis n=3, hospital readmission due to pleural- and pericardial effusion n=2. Duration of hospital stay was 6±2 days. After 12 months, 16/20 (80%) patients were in sinus rhythm when allowing anti-arrhythmic drugs and 18/20 (90%) patients were free from myocardial infarction. Conclusion Robot-assisted MIDCAB surgery for LIMA-LAD grafting concomitant with left-sided thoracoscopic AF ablation is a feasible, safe and efficacious minimally invasive treatment strategy for patients with a critical LAD stenosis and AF suitable for minimally invasive surgery.

Change in health related quality of life is different in obese versus non-obese patients with atrial fibrillation after thoracoscopic ablation

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Received research grants (through institution) from Atricure Inc, Bayer, Boston Scientific, Daiichi Sankyo, Johnson&amp;Johnson, Medtronic Received honoraria/speaker/consultancy fees from Abbott, AtriaN Medical, Atricure Inc, Bayer, Biotronik, CVOI, Daiichi Sankyo, IPP Med, Itreas, Medtronic, Novartis, Servier Background Obesity is an important risk factor for atrial fibrillation (AF), and negatively affects health-related quality of life (QoL) and treatment efficacy. The impact of obesity on the improvement of QoL and on AF recurrence in patients undergoing thoracoscopic AF ablation is unknown. Purpose To assess the change in QoL and the risk of AF recurrence in obese and non-obese patients with atrial fibrillation undergoing thoracoscopic ablation Methods Patients undergoing thoracoscopic AF ablation were prospectively included. Holters were performed before and at 3, 6, 9 and 12 months after the procedure. AF recurrence was defined as any atrial tachyarrhythmia episode &amp;gt;30 seconds during one year of follow-up. QoL and AF recurrence rate were assessed for normal weight (BMI ≤ 24,9 kg/m2), overweight (25,0 – 29,9 kg/m2) and obese (≥ 30,0 kg/m2) patients. QoL was measured by the Short Form 36 questionnaire at baseline and at one year follow-up. Results Four hundred and eight patients were included for analysis. Six out of eight QoL domains scored lower in obese versus non-obese patients before the procedure. In all patients, six out of eight domains increased after the procedure (p&amp;lt;0.01 for most domains). Obese patients showed a larger improvement of emotional related QoL (p=0.01) and a trend towards a larger improvement of mental QoL (p=0.07), while physical QoL increased similarly to non-obese patients (figure). In obese patients, QoL increased similarly for those with and without AF recurrence (p=0.78), whereas in non-obese patients, AF recurrence was associated with less improvement in mental QoL. AF recurrence at 1-year was similar in all groups (normal weight 72.4%, overweight 68%, obese 70.4%, p=0.692). Conclusion After thoracoscopic ablation, obese patients have a similar AF freedom rate as non-obese patients, but a greater improvement in mental quality of life, irrespective of AF recurrence status, after thoracoscopic ablation.

Long-Term Efficacy and Anticoagulation Strategy of Left Atrial Appendage Occlusion During Total Thoracoscopic Ablation of Atrial Fibrillation to Prevent Ischemic Stroke.

ObjectivesAtrial fibrillation (AF) is associated with an increased ischemic stroke, and the left atrial appendage (LAA) represents the main source of thrombus formation. We evaluated the long-term efficacy of surgical thoracoscopic LAA occlusion during total thoracoscopic ablation of AF to prevent the stroke and anticoagulation strategy after surgery.MethodsPatients who underwent total thoracoscopic ablation for AF, from February 2012 to May 2020, were included; Patients who did not receive LAA occlusion were excluded. We evaluated the development of thromboembolism in these patients.ResultsThe total number of 460 patients [mean age, 57.1 ± 9.2 years; 400 (87.0%) males] were included in the study. The mean follow-up duration was 44.8 months. The mean CHA2DS2-VASc score was 1.9 ± 1.6. Median OAC duration was 109.5 days after the surgery, and the final number of patients who discontinued OAC were 411 (89.3%) in total. Anticoagulation discontinuation rate according to CHA2DS2-VASc score are as follows; (i) 0 = 99.0%; (ii) 1 = 98.2%; and (iii) ≥2 = 81.3%. The annualized incidence rate of ischemic stroke was 0.78%/year, showing a 73% risk reduction compared with the CHA2DS2-VASc predicted rate without anticoagulation. The hazard ratio for ischemic stroke according to previous stroke history was 1.5 [95% confidential interval (CI) 0.3–7.3, p = 0.62], and that of remnant LAA was 5.1 (1.2–20.9, p = 0.02).ConclusionsThoracoscopic LAA occlusion during total thoracoscopic ablation of AF was effective to prevent ischemic stroke. Most patients could discontinue OAC therapy after the procedure. Patients who had a residual trabeculated LAA, or peri-occluder pouch in follow-up CT need to maintain OAC therapy even after LAA occlusion.

Does left atrial epicardial conduction time reflect atrial fibrosis and the risk of atrial fibrillation recurrence after thoracoscopic ablation? Post hoc analysis of the AFACT trial

ObjectivesTo determine the association between left atrial epicardial conduction time (LAECT), fibrosis and atrial fibrillation (AF) recurrence after thoracoscopic surgical ablation of persistent AF.SettingSingle tertiary care centre in the Netherlands.ParticipantsPatients...

New Oral Anticoagulant Versus Vitamin K Antagonists for Thoracoscopic Ablation in Patients With Persistent Atrial Fibrillation: A Randomized Controlled Trial

Anticoagulation could not be currently stopped even after successful thoracoscopic ablation of atrial fibrillation for at least 2 months. The aim of this study is to compare the safety and efficacy outcomes between a new oral anticoagulant and warfarin after thoracoscopic ablation. This trial was a single-center, prospective, randomized controlled study comparing edoxaban and warfarin in patients undergoing thoracoscopic ablation of atrial fibrillation. This study enrolled 60 patients randomly assigned into 2 groups. The primary endpoint was efficacy outcomes, including stroke and systemic thromboembolic events. The secondary endpoint was safety outcomes including major bleeding and pericarditis. The patients were evaluated at discharge, 2 weeks, 3 months, and 6 months postoperatively. No stroke and thromboembolic events were noted in both treatment groups during the follow-up period. During the 6 months follow-up period, 4 (13%) of 30 patients in the edoxaban group experienced minor bleeding events, whereas none were noted in the warfarin group. Five anticoagulation-related events (bleeding, and prolongation of international normalized ratio), including pericarditis, were noted in both the edoxaban and warfarin groups. No statistically significant difference existed between the 2 groups. In conclusion, this study showed the comparable results of edoxaban to warfarin during the window period of post-thoracoscopic ablation of atrial fibrillation. Moreover, anticoagulation-related events were rather affected by patient factors and not by the anticoagulant type.

Abstract 11973: Women Have Less Success of Thoracoscopic AF Ablation Than Men and Suffer More From Established Risk Factors

Background: Women have more recurrent atrial fibrillation (AF) after AF ablation compared with men and are underrepresented in studies. What determines this worse outcome is incompletely understood. Objective: To explore the differential impact of established risk factors for AF recurrence in women and men. Methods: Consecutive patients (n=571) underwent thoracoscopic AF ablation. AF recurrence was defined as any atrial tachyarrhythmia &gt;30s on ECG or Holter, during 2 years of follow-up with exclusion of the first 90 days blanking period. Holters were performed at 3, 6, 9, 12, 15, 18, and 24 months. Predictors of AF recurrence were assessed and compared by sex using the Cox proportional hazards model. Risk ratios (RR) of predictors for AF recurrence were assessed by sex. Results: At thoracoscopic ablation, women were older (63±8 vs. 59±9 years, p&lt;0.001), had higher median [IQR] serum CRP (2.00 [0.90, 4.28] vs. 1.30 [0.65, 2.90] mg/ml p=0.006), but fewer cardiovascular risk factors (myocardial infarction (1.4% vs. 8.6%, p=0.03) and vascular disease (7.0% vs. 16.1%, p=0.01)). There was no difference in the prevalence of hypertension, heart failure, or diabetes mellitus. Freedom of AF recurrence until 2-year follow-up was 42.9% for women vs. 58.3% in men (p=0.002). The added risk for women was highest in patients with persistent AF (RR 1.4, p=0.001) (figure), aged &gt;67y (RR 1.43, p=0.04), and moderate left atrial dilatation (&gt;34 ml/m 2 ) (RR 1.32, p=0.01). Conclusion: Persistent AF, old age, and moderate left atrial enlargement more negatively affect AF freedom in women than in men. Meanwhile, women had similar or fewer cardiovascular risk factors compared to men, underscoring sex as an important contributor to AF recurrence.