Krul Sébastien P J, Pison Laurent, La Meir Mark, Driessen Antoine H G, Wilde Arthur A M, Maessen Jos G, De Mol Bas A J M, Crijns Harry J G M, de Groot Joris R
Heart Center, Department of Cardiology, Cardiothoracic Surgery and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
Department of Cardiology, Academic Hospital Maastricht and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
Int J Cardiol. 2014 May 1;173(2):229-35. doi: 10.1016/j.ijcard.2014.02.043. Epub 2014 Feb 28.
Patients with atrial fibrillation (AF) with enlarged atria or previous pulmonary vein isolation (PVI) are challenging patients for catheter ablation. Thoracoscopic surgery is an effective treatment for these patients but comes at the cost of an increase in adverse events. Recently, electrophysiological (EP) guided approaches to thoracoscopic surgery have been described which consist of EP guidance by measurement of conduction block across ablation lines. In this study we describe the efficacy and safety of EP-guided thoracoscopic surgery for AF in patients with enlarged atria and/or prior failed catheter ablation.
METHODS & RESULTS: A total of 72 patients were included. Two different approaches to EP-guided thoracoscopic surgery were implemented: epicardial or endocardial EP-guidance at the time of surgery. Residual intraoperative conduction requiring additional ablation was detected with epicardial or endocardial mapping techniques in 50% and 11%, respectively. Additional epicardial or endocardial ablation was performed until bidirectional block was confirmed. Follow-up consisted of an ECG and a 24h Holter at 3, 6 and 12 months after the procedure. A total of 57 patients (79%) had freedom of AF and were off anti-arrhythmic drugs at one year follow-up (30 paroxysmal (83%), 27 persistent AF (75%)). Adverse events occurred in 13 patients (6 major). None of our patients died and all events were reversible.
EP-guidance of thoracoscopic surgery can be safely performed both epicardially and endocardially and is associated with a high rate of long-term maintenance of sinus rhythm in patients with enlarged atria and/or a previously failed ablation.
心房扩大或既往接受过肺静脉隔离术（PVI）的心房颤动（AF）患者是导管消融治疗的挑战性患者。胸腔镜手术是治疗这些患者的有效方法，但会增加不良事件的发生风险。最近，已经描述了电生理（EP）引导的胸腔镜手术方法，该方法包括通过测量消融线两侧的传导阻滞进行EP引导。在本研究中，我们描述了EP引导的胸腔镜手术治疗心房扩大和/或既往导管消融失败的AF患者的有效性和安全性。
共纳入72例患者。实施了两种不同的EP引导胸腔镜手术方法：手术时的心外膜或心内膜EP引导。分别使用心外膜或心内膜标测技术在50%和11%的患者中检测到需要额外消融的残余术中传导。进行额外的心外膜或心内膜消融，直到确认双向阻滞。随访包括术后3、6和12个月的心电图和24小时动态心电图。在一年随访时，共有57例患者（79%）无房颤且停用抗心律失常药物（30例阵发性房颤（83%），27例持续性房颤（75%））。13例患者发生不良事件（6例为严重不良事件）。我们的患者均未死亡，所有事件均可逆转。
胸腔镜手术的EP引导在心外膜和心内膜均可安全进行，并且与心房扩大和/或既往消融失败患者的窦性心律长期维持率高相关。
