Left Thoracoscopic Approach for Convergent AF Ablation: How to do Everything From the Same Side.
Atrial fibrillation (AF) is associated with increased risk
of stroke, heart failure and all-cause mortality [1]. When it comes to treating
persistent AF, the Cox-Maze procedure is the gold standard. However, it
presents significant morbidity and mortality rates. The classical endocardial
ablation approach appears to be safer but has limited efficacy to treat long
lasting persistent AF [2]. Thoracoscopic hybrid epicardial-endocardial ablation
technique proved to be effective and safe to treat long lasting persistent AF
patients with previous failed endocardial AF ablation [3,4].
This video illustrates the epicardial part of the convergent procedure with
application of a left atrial appendage clip all through a left thoracoscopic
approach.
The procedure was realized under general anesthesia with an arterial line,
intravenous access and a double lumen intratracheal tube. A transesophageal
echocardiogram (TOE) is performed to exclude left atrial appendage thrombus.
The patient was placed in the supine position. Left arm was slightly hanging
and an inflatable device was placed under the left scapula to elevate the left
hemi-thorax up to 45°. Sterile external defibrillator pads were placed out of
the operative field to facilitate cardioversion if necessary. Single right lung
ventilation was started. 3 thoracoscopic ports were placed. First, a
5-millimeter trocart was inserted through the fourth intercostal space in the
anterior axillary line allowing the insertion of the thoracoscope (0°, 5mm).
Working space was created using Carbon dioxide insufflation at 5-8mmHg. A
second 5-millimeter port was inserted through the second intercostal space,
also in the anterior axillary line. Through this port, an endoscopic pai r of
scissors was inserted. A third trocart, 12-millimeter, was inserted into the
left pleura in the mid axillary line. The endoscopic grasper was placed in the
thoracic cavity. Patient set-up is shown in figure 1. Then the pericardium was
widely opened approximately two centimeters beneath the phrenic nerve and
parallel to it. Pericardial stay sutures were placed on the medial pericardium
and brought through separate stab incisions for better exposure. This access
creates an excellent visualization to the lateral side of the left atrial
appendage (LAA), the anterior side of left pulmonary veins and the roof of the
left atrium. Endoscopic instruments were retrieved and the epicardial
radiofrequency suction ablation device (Episence Coagulation System, Atricure,
Inc.) was then inserted through the 12mm port. The 5mm port placed in the
second intercostal space was used to insert the grasper. After sectioning the
ligament of Marshall, the left atrial roof and the anterior part of the left
pulmonary veins were first ablated. Once this part of the ablation completed, a
line from the superior left pulmonary vein to on the tip of the LAA was carried
out under TOE control. Then, the LAA was measured with the AtriClip sizing
tool. An appropriately sized AtriClip device (AtriClip Pro2, Atricure) was used
for LAA exclusion. TOE was used to confirm the complete exclusion priori to
formal deployment. The clip wan be repositioned if incomplete exclusion was
witnessed on TOE. All trocarts were then retrieved. The incision in the 6th
intercostal space was slightly enlarged and the Subtle Cannula was brought into
the thorax among with the 5 mm 0° thoracoscope. The ablation of the posterior
wall and part of the right pulmonary veins was completed as usually. The
ablation device and cannula were retrieved. Incisions were closed and a
channeled drain is left in the left pleural space. Patients were extubated in
the operating room and transferred to the intensive care unit for overnight
monitoring.
References
1. Lippi G, Sanchis-Gomar F, Cervellin G. Global
epidemiology of atrial fibrillation: An increasing epidemic and public health
challenge. Int J Stroke. 2021 Feb;16(2):217-221.
2. Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C,
et al. 2020 ESC Guidelines for the diagnosis and management of atrial
fibrillation developed in collaboration with the European Association of
Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2020 Aug 29;ehaa612.
3. Zannis K, Alam W, Sebag FA, Folliguet T, Bars C, Fahed M, Ternacle J,
Bergoend E, Hamon D, Lellouche N. The convergent procedure: a hybrid approach
for long lasting persistent atrial fibrillation ablation. J Cardiovasc Surg
(Torino). 2020 Jun;61(3):369-375.
4. Downs EA, Ailawadi G. Hybrid thoracoscopic epicardial and catheter-based
endocardial ablation for atrial fibrillation. Multimed Man Cardiothorac Surg.
2015 Jul 22;2015:mmv015
