OBJECTIVES: Minimally invasive surgery for atrial fibrillation (AF) has rapidly evolved recently. The long-term efficacy of most of these procedures is poorly known. METHODS: Between 2006 and 2010, 38 drug-resistant, symptomatic patients with stand-alone AF underwent unilateral, thoracoscopic, off-pump ablation. The mean age was 60 ± 8.2 (range 42-75) years and the mean AF duration was 46 ± 62 (range 3-240) months. Sixteen patients (42%) had paroxysmal, 9 (24%) had persistent and 13 (34%) had long-standing persistent AF. A box lesion was created using a microwave (26 patients) or monopolar radiofrequency (12 patients) system. Patients were prospectively followed with repeat electrocardiograms (ECGs) and ECG Holters. Additional catheter ablation was offered to patients with recurrence of arrhythmia. RESULTS: All procedures were completed as planned with one conversion to sternotomy, zero mortality and minimal in-hospital complications. The mean follow-up duration was 70 ± 19 (range 20-88) months. Arrhythmia-free survival rates after the procedure were 50, 44.4, 24.1 and 10.8% at 6, 12, 36 and 60 months, respectively, with most recurrences in the first 6 months. Twelve patients underwent additional catheter ablation(s); from the last intervention, 75% of them were in sinus rhythm (SR) with a mean follow-up of 31 ± 23 (range 4-86) months. Overall, at the end of follow-up, only 3 patients were still in SR without any arrhythmia recurrence. Major complications (cerebral, peripheral embolism or bleeding) occurred in 5 patients. CONCLUSIONS: Unilateral, thoracoscopic AF ablation is safe and technically feasible. However, the results of the microwave and monopolar radiofrequency devices were less than satisfactory, with a gradual decline in arrhythmia-free survival over a very long-term follow-up.

Cardiocenter 3rd Faculty of Medicine Charles University Prague Prague Czech Republic Department of Cardiac Surgery University Hospital Kralovské Vinohrady Prague Czech Republic

Cardiocenter 3rd Faculty of Medicine Charles University Prague Prague Czech Republic Department of Cardiology University Hospital Kralovské Vinohrady Prague Czech Republic

National Institute of Public Health Prague Czech Republic

Interact Cardiovasc Thorac Surg. 2016 Jun;22(6):768. doi: 10.1093/icvts/ivw109. PubMed

See more in PubMed

European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery; Camm AJ, Kirchhof P, Lip GY, Schotten U et al. . Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010;31:2369–429. PubMed

Chugh SS, Blackshear JL, Shen WK, Hammill SC, Gersh BJ. Epidemiology and naturalhistory of atrial fibrillation: clinical implications. J Am Coll Cardiol 2001;37:371–8. PubMed

Zhang L, Gallagher R, Neubeck L. Health-related quality of life in atrial fibrillation patients over 65 years: a review. Eur J Prev Cardiol 2015;22:987–1002. PubMed

Shen J, Bailey MS, Damiano RJ Jr. The surgical treatment of atrial fibrillation. Heart Rhythm 2009;6(8 Suppl.):S45–50. PubMed PMC

Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA et al. . 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design. Europace 2012;14:528–606. PubMed

Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH et al. . 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 2012;33:2719–47. PubMed

La Meir M, Gelsomino S, Lucà F, Pison L, Colella A, Lorusso R et al. . Minimal invasive surgery for atrial fibrillation: an updated review. Europace 2013;15:170–82. PubMed

La Meir M, De Roy L, Blommaert D, Buche M. Treatment of lone atrial fibrillation with a right thoracoscopic approach. Ann Thorac Surg 2007;83:2244–5. PubMed

Straka Z, Budera P, Osmančík P, Herold M, Brůček P, Vaněk T. The endoscopic MAZE procedure—minimally invasive surgical treatment of isolated atrial fibrillation. Cor Vasa 2010;52(Suppl.):66–9 (in Czech).

Ganesan AN, Shipp NJ, Brooks AG, Kuklik P, Lau DH, Lim HS et al. . Long-term outcomes of catheter ablation of atrial fibrillation: a systematic review and meta-analysis. J Am Heart Assoc 2013;2:e004549. PubMed PMC

Stulak JM, Sundt TM III, Dearani JA, Daly RC, Orsulak TA, Schaff HV. Ten-year experience with the Cox–Maze procedure for atrial fibrillation: how do we define success? Ann Thorac Surg 2007;83:1319–24. PubMed

La Meir M. Surgical options for treatment of atrial fibrillation. Ann Cardiothorac Surg 2014;3:30–7. PubMed PMC

Budera P, Straka Z, Osmančík P, Vaněk T, Jelínek Š, Hlavička J et al. . Comparison of cardiac surgery with left atrial surgical ablation vs. cardiac surgery without atrial ablation in patients with coronary and/or valvular heart disease plus atrial fibrillation: final results of the PRAGUE-12 randomized multicentre study. Eur Heart J 2012;33:2644–52. PubMed PMC

Gillinov AM, Bhavani S, Blackstone EH, Rajeswaran J, Svensson LG, Navia JL et al. . Surgery for permanent atrial fibrillation: impact of patient factors and lesion set. Ann Thorac Surg 2006;82:502–13; discussion 513–4. PubMed

Voeller RK, Bailey MS, Zierer A, Lall SC, Sakamoto S, Aubuchon K et al. . Isolating the entire posterior left atrium improves surgical outcomes after the Cox Maze procedure. J Thorac Cardiovasc Surg 2008;135:870–7. PubMed

Lim TW, Koay CH, See VA, McCall R, Chik W, Zecchin R et al. . Single-ring posterior left atrial (box) isolation results in a different mode of recurrence compared with wide antral pulmonary vein isolation on long-term follow-up: longer atrial fibrillation-free survival time but similar survival time free of any atrial arrhythmia. Circ Arrhythm Electrophysiol 2012;5:968–77. PubMed

Pruitt JC, Lazzara RR, Ebra G. Minimally invasive surgical ablation of atrial fibrillation: the thoracoscopic box lesion approach. J Interv Card Electrophysiol 2007;20:83–7. PubMed

Zheng S, Li Y, Han J, Zhang H, Zeng W, Xu C et al. . Long-term results of a minimally invasive surgical pulmonary vein isolation and ganglionic plexi ablation for atrial fibrillation. PLoS ONE 2013;8:e79755. PubMed PMC

Weerasooriya R, Khairy P, Litalien J, Macle L, Hocini M, Sacher F et al. . Catheter ablation for atrial fibrillation: are results maintained at 5 years of follow-up? J Am Coll Cardiol 2011;57:160–6. PubMed

Ad N, Henry L, Friehling T, Wish M, Holmes SD. Minimally invasive stand-alone Cox-maze procedure for patients with nonparoxysmal atrial fibrillation. Ann Thorac Surg 2013;96:792–8; discussion 798–9. PubMed

Je HG, Shuman DJ, Ad N. A systematic review of minimally invasive surgical treatment for atrial fibrillation: a comparison of the Cox–Maze procedure, beating-heart epicardial ablation, and the hybrid procedure on safety and efficacy. Eur J Cardiothorac Surg 2015;48:531–41. PubMed

Takigawa M, Takahashi A, Kuwahara T, Okubo K, Takahashi Y, Watari Y et al. . Long-term follow-up after catheter ablation of paroxysmal atrial fibrillation: the incidence of recurrence and progression of atrial fibrillation. Circ Arrhythm Electrophysiol 2014;7:267–73. PubMed

Wynn GJ, Das M, Bonnett LJ, Panikker S, Wong T, Gupta D. Efficacy of catheter ablation for persistent atrial fibrillation: a systematic review and meta-analysis of evidence from randomised and non-randomised controlled trials. Circ Arrhythm Electrophysiol 2014;7:841–52. PubMed

Oral H, Veerareddy S, Good E, Hall B, Cheung P, Tamirisa K et al. . Prevalence of asymptomatic recurrences of atrial fibrillation after successful radiofrequency catheter ablation. J Cardiovasc Electrophysiol 2004;15:920–4. PubMed

Wudel JH, Chaudhuri P, Hiller JJ. Video-assisted epicardial ablation and left atrial appendage exclusion for atrial fibrillation: extended follow-up. Ann Thorac Surg 2008;85:34–8. PubMed