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Ann Thorac Surg 2004;78:e24-e25
© 2004 The Society of Thoracic Surgeons

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Case report

First robotic endoscopic epicardial isolation of the pulmonary veins with microwave energy in a patient in chronic atrial fibrillation

^a Division of Cardiac Surgery, Lenox Hill Hospital, New York, New York, USA
^b Division of Electrophysiology, Lenox Hill Hospital, New York, New York, USA

Accepted for publication November 20, 2003.

^* Address reprint requests to Dr Loulmet, Lenox Hill Hospital, Division of Cardiac Surgery, New York, NY, USA 10021
e-mail: loulmetd{at}aol.com

	Abstract

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The pulmonary veins have been demonstrated to play an important role in generating atrial fibrillation. We report the first successful endoscopic epicardial isolation of the pulmonary veins in a patient with permanent atrial fibrillation, along with a 1-year follow-up. The procedure consisted of making a conduction block around the pulmonary veins with a flexible microwave energy delivery probe. The probe was placed endoscopically on the left atrial epicardium with the aid of robotic instruments.

	Introduction

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The pulmonary veins have been demonstrated to play an important role in generating atrial fibrillation [1]. Experience has grown in isolating the pulmonary veins using catheter-based techniques [2]. Results with the percutaneous approaches have shown that patients often require multiple procedures because of recurrent atrial fibrillation. Moreover, the risks of pulmonary vein stenosis, stroke, and pericardial effusion have not been negligible [3]. Surgeons have challenged catheter-based techniques by developing minimally invasive epicardial techniques with the aim of obtaining more consistent results with a lower risk of pulmonary vein stenosis [4, 5]. We report the first successful endoscopic epicardial isolation of the pulmonary veins in a patient with permanent atrial fibrillation, along with a 1-year follow-up. The procedure consisted of making a conduction block around the pulmonary veins with a flexible microwave energy delivery probe (Flex10 [Afx Inc]) (Fig 1). The probe was placed endoscopically on the left atrial epicardium with the aid of robotic instruments (daVinci [ISI]).

View larger version (82K): [in this window] [in a new window]   Fig 1. The FLEX 10 (Afx, Inc) provides a total ablation zone of 20 cm. The system consists of ten adjacent ablation segments of 2 cm long that are activated separately. The microwave energy is emitted only into the targeted tissue.

The patient was proposed endoscopic epicardial isolation of the pulmonary veins and signed informed consent (Institutional Review Board Protocol, No. L03.03.016). Surgery was performed on October 23, 2002. A double lumen endotracheal tube was used for ventilation. Intraoperative transesophageal echocardiogram did not show any thrombus in the left appendage and confirmed severe left ventricular dysfunction. External defibrillator patches were applied to the chest. The patient was placed in the supine position. Single left lung ventilation was initiated. The arms and instruments of the daVinci (ISI) were placed in triangulation into the right chest, the endoscope was placed in the 4th intercostal space at the midclavicular line, and the left and right instruments were placed in the 3rd and 5th intercostal spaces at the anterior axillary line, respectively. The pericardium was opened longitudinally above the right phrenic nerve. The superior vena cava and the inferior vena cava were dissected. The interatrial groove was largely dissected. The plane between the right pulmonary artery and the roof of the left atrium was also largely dissected. This extensive dissection aimed at facilitating the introduction of the Flex 10 (Afx Inc) into the transverse sinus and at keeping it away from the sinus node and left main coronary artery.

The Flex 10 (Afx Inc) was introduced into the chest through a port placed in the 4th right intercostal space at the anterior axillary line. Its tip was passed below the superior vena cava, in the space between the right pulmonary artery and left atrium. It was pushed through the transverse sinus until it came back above the inferior vena cava, between the right ventricle and the diaphragm. It was then repositioned below the inferior vena cava in such a way that the Flex 10 (Afx Inc) encircled the four pulmonary veins. The daVinci was temporarily removed from the right chest. The patient was switched to single right lung ventilation. Working from the patient's left side, conventional endoscopic instruments were placed in triangulation into the left chest. The pericardium was opened longitudinally above the left phrenic nerve. The Flex 10 (Afx Inc) was found between the left appendage and the left ventricle. It was repositioned between the left appendage and the upper left pulmonary vein. The instruments were removed from the chest, and the patient was switched back to single left lung ventilation.

The daVinci (ISI) was placed back into the right chest. Under vision control, microwave energy was delivered at 65 watts during 90 seconds for each of the Flex 10 (Afx Inc) ablation segments.

A chest tube was place in each pleural cavity using the lower ports for introduction. The total operative time was 4 hours 15 minutes.

The patient converted spontaneously to sinus rhythm at his arrival in the intensive care unit. He went back to atrial fibrillation on postoperative day 1. He was discharged from the hospital in atrial fibrillation with oral amiodarone. Two weeks after surgery he converted to sinus rhythm again. One month after surgery, Holter monitoring confirmed stable sinus rhythm with occasional atrial premature contractions and couplets. Three months after surgery cardiac magnetic resonance imaging demonstrated synchronic atrioventricular contraction with a left atrial ejection fraction of 35% and a left ventricular ejection fraction of 52%. The patient was able to resume normal work and sports activities and was taken off amiodarone. Eight months after surgery he started experiencing palpitations again and was diagnosed with intermittent flutter. He subsequently underwent successful transcatheter ablation of the tricuspid isthmus. One year after surgery he is in stable sinus rhythm with rare episodes of palpitations on ß-blockers and no anticoagulation medicine.

	Comment

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In this reported case, the daVinci system (ISI) allowed for a precise endoscopic placement of the Flex 10 (Afx Inc). The risk of pulmonary vein stenosis was reduced because only a fourth of the circumference of each pulmonary vein ostium was included in the isolation line. However, three arteries were at risk of injury during the procedure: (1) the sinus node, (2) the left main coronary artery, and (3) the circumflex arteries. Dissecting the virtual space between the right pulmonary artery and the left atrium allowed for placing the Flex 10 (Afx Inc) away from the sinus node and left main coronary artery. Controlling the position of the Flex 10 (Afx Inc) relatively to the left appendage from the left side of the chest avoided any damage to the circumflex artery.

Ablation lines at the level of the tricuspid and mitral valve isthmi were not performed in this case because of the limitations of the current technology. This explains the recurrence of atrial flutter 8 months postoperatively. Minor technological developments will allow surgeons to perform epicardial ablation of the mitral and tricuspid valve isthmi in combination with the isolation of the pulmonary veins.

In summary, isolation of the pulmonary veins from the left atrium can be successful using a totally endoscopic technique. This technique offers an alternative that may prove to be more effective and safer in treating patients with chronic atrial fibrillation than using the transcatheter techniques.

	References

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1. Haissaguerre M., Jais P., Shah D.C., et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998;339:659-666.[Abstract/Free Full Text]
2. Marrouche N.F., Dresing T., Cole C., et al. Circular mapping and ablation of the pulmonary vein for treatment of atrial fibrillation: impact of different catheter technologies. J Am Coll Cardiol 2002;40:464-474.[Abstract/Free Full Text]
3. Deisenhofer I., Schneider M.A., Bohlen-Knauf M., et al. Circumferential mapping and electric isolation of pulmonary veins in patients with atrial fibrillation. Am J Cardiol 2003;91:159-163.[Medline]
4. Prasad S.M., Maniar H.S., Moustakidis P., Schuessler R.B., Damiano R.J., Jr Epicardial ablation on the beating heart: progress towards an off-pump maze procedure. Heart Surg Forum 2002;5:100-104.[Medline]
5. Manasse E., Infante M., Ghiselli S., et al. A video-assisted thoracoscopic technique to encircle the four pulmonary veins: a new surgical intervention for atrial fibrillation. The Heart Surg Forum 2002;5:337-339.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Didier F. Loulmet Nirav C. Patel Nilesh U. Patel Valavanur A. Subramanian Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Loulmet, D. F. Articles by Subramanian, V. A. Search for Related Content PubMed PubMed Citation Articles by Loulmet, D. F. Articles by Subramanian, V. A. Related Collections Electrophysiology - arrhythmias