Salzberg Sacha P, van Boven Wim-Jan, Wyss Christophe, Hürlimann David, Reho Ivano, Zerm Thomas, Noll Georg, Emmert Maximilian Y, Corti Roberto, Grünenfelder Jürg
HeartClinic, Klinik Hirslanden, Zurich, Switzerland.
Albertinen Krankenhaus, Hamburg, Germany.
J Atr Fibrillation. 2019 Feb 28;11(5):2039. doi: 10.4022/jafib.2039. eCollection 2019 Feb-Mar.
Traditional surgical treatment for patients with atrial fibrillation (AF) is performed via sternotomy and on cardiopulmonary bypass. It is very effective in regard to rhythm control, but remains unpopular due to its invasiveness. Truly endoscopic AF treatments have decreased the threshold for electrophysiologists (and cardiologists) to refer, and the reluctance of patients to accept a standalone surgical approach. Practice guidelines from around the world have recognized this as an acceptable therapeutic approach. Current guidelines recommend the HeartTeam approach in treating these complex AF cases. In this study we report our experience with AF HeartTeam approach for surgical stand-alone AF ablation.
The AF HeartTeam Program began in 2013, patients qualified for inclusion if either of the following was present: failed catheter ablation and/or medication, not suitable for catheter ablation, contraindication to anticoagulation, or patients preferring such an approach. All patients with a complex AF history were assessed by the AF HeartTeam, from which 42 patients were deemed suitable for a totally endoscopic AF procedure (epicardial ablation and LAA closure). Endpoints were intraoperative bidirectional block of the pulmonary veins and closure of left atrial appendage confirmed by transesophageal echocardiography (TEE). Post discharge rhythm follow-up was performed after 3 and 12, 24 and 36 months. Anticoagulation was discontinued 6 weeks after the procedure in patients after documented LAA closure.
In total 42 patients underwent the endoscopic procedure (Median CHA2DS2-VASC=3 (1-6), HAS-BLED=2 (1-6)) for paroxysmal (15/42) and non-paroxysmal AF (27/42) respectively. Bidirectional block was obtained in all patients and complete LAA closure was obtained in all but one Patient on TEE (41/42). In one patient the LAA was not addressed due to extensive adhesions. Two patients underwent median sternotomy because of bleeding during the endoscopic surgery early in the series. There were no deaths. Procedure duration was a median of 124min (Range 83-211) and duration of hospitalization was median of 5 days (Range 3-12). During 36 months follow-up survival free of mortality, thromboembolic events or strokes was 100%. Twelve month freedom from atrial arrhythmia off anti-arrhythmic medication was 93% and 89% for paroxysmal and non-paroxysmal patients respectively. 6/42 patients who had an AF recurrence during the follow-up underwent touch-up catheter ablation.
Atrial fibrillation heart team approach provides excellent outcomes for patients with AF. This approach is beneficial for patients after failed catheter ablation or not candidates for such and offers a very effective mid-term outcome data. In addition to effective rhythm control the protective effect of epicardial LAA closure may play an important role in effectively reducing stroke. The creation of an AF HeartTeam as recommended by the guidelines insures unbiased therapies and provides access to this minimally invasive but effective therapeutic option for AF patients.
心房颤动（AF）患者的传统外科治疗是通过胸骨切开术并在体外循环下进行。在节律控制方面非常有效，但由于其侵入性，仍然不太受欢迎。真正的内镜下房颤治疗降低了电生理学家（和心脏病专家）转诊的门槛，以及患者接受独立手术方法的抵触情绪。世界各地的实践指南已将其视为一种可接受的治疗方法。当前指南推荐采用心脏团队方法来治疗这些复杂的房颤病例。在本研究中，我们报告了我们采用心脏团队方法进行单独外科房颤消融的经验。
房颤心脏团队项目始于2013年，符合以下任一情况的患者有资格纳入：导管消融和/或药物治疗失败、不适合导管消融、抗凝禁忌证，或患者倾向于这种方法。所有有复杂房颤病史的患者均由房颤心脏团队进行评估，其中42例患者被认为适合完全内镜下房颤手术（心外膜消融和左心耳封闭）。终点指标是经食管超声心动图（TEE）确认肺静脉双向阻滞和左心耳封闭。出院后在3、12、24和36个月进行节律随访。在记录到左心耳封闭后，患者在术后6周停用抗凝药。
共有42例患者分别接受了内镜手术（CHA2DS2-VASC中位数=3（1-6），HAS-BLED中位数=2（1-6）），其中阵发性房颤患者15例（共42例），非阵发性房颤患者27例（共42例）。所有患者均实现了双向阻滞，除1例患者外（41/42），TEE显示所有患者左心耳均完全封闭。1例患者因广泛粘连未处理左心耳。系列手术早期有2例患者因内镜手术期间出血而接受了正中胸骨切开术。无死亡病例。手术时间中位数为124分钟（范围83-211分钟），住院时间中位数为5天（范围3-12天）。在36个月的随访期间，无死亡、血栓栓塞事件或中风的生存率为100%。阵发性和非阵发性患者在停用抗心律失常药物后12个月无房性心律失常的比例分别为93%和89%。42例患者中有6例在随访期间房颤复发，接受了补充导管消融。
房颤心脏团队方法为房颤患者提供了优异的治疗效果。这种方法对导管消融失败或不适合导管消融的患者有益，并提供了非常有效的中期结果数据。除了有效的节律控制外，心外膜左心耳封闭的保护作用可能在有效降低中风方面发挥重要作用。按照指南建议组建房颤心脏团队可确保无偏倚的治疗，并为房颤患者提供这种微创但有效的治疗选择。
