ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Mark La Meir
Michel Buche
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by La Meir, M.
Right arrow Articles by Buche, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by La Meir, M.
Right arrow Articles by Buche, M.
Related Collections
Right arrow Electrophysiology - arrhythmias

Ann Thorac Surg 2007;83:2244-2245
© 2007 The Society of Thoracic Surgeons

How To Do It

Treatment of Lone Atrial Fibrillation With a Right Thoracoscopic Approach

Mark La Meir, MDa,*, Luc De Roy, MDb, Dominique Blommaert, MDb, Michel Buche, MDa

a Department of Cardiovascular and Thoracic Surgery, UCL Mont-Godinne, Yvoir, Belgium
b Department of Cardiology, UCL Mont-Godinne, Yvoir, Belgium

Accepted for publication August 1, 2006.

* Address correspondence to Dr La Meir, Department of Cardiovascular and Thoracic Surgery, UCL Mont-Godinne, Yvoir, 5530, Belgium. (Email: mark.lameir{at}chex.ucl.ac.be).


Dr. La Meir discloses that he has a financial relationship with Guidant.

 

   Abstract
Top
 Abstract
Introduction
 Technique
 Comment
 References
 
A simplified technique to treat patients in stand-alone atrial fibrillation with a right thoracoscopic approach is described. An electrical isolation of the four pulmonary veins (box lesion) is achieved with a microwave antenna.

Recently, Cox [1] defined the characteristics of the ideal technique required for the development and wide adoption of a surgical procedure for the treatment of atrial fibrillation. He reported that this procedure should be minimally invasive (preferably thoracoscopic), epicardial, and without cardiopulmonary bypass. A possible technique is the creation of a line of electrical conduction block around the four pulmonary veins (PVs) using the Flex 10 microwave ablation device (Guidant Cardiac Surgery, Santa Clara, CA). Actually most surgeons performing this operation prefer a right and left thoracoscopic approach to avoid the difficult passage of the ablation device around the PVs (through the transverse and oblique sinus) when performing a monolateral thoracoscopic approach. The bilateral approach also enables the surgeon to exclude the left atrial appendage (LAA).

We present a technique that facilitates passage of the antenna with a monolateral right thoracoscopic approach in those patients for whom an exclusion of the LAA is not necessary. In patients with a history of emboli, thrombus formation, or important stases in the LAA, we perform a monolateral left thoracoscopic approach and exclude the LAA with a stapling device.

Data collection was in accordance with institutional review board recommendations. Informed consent was obtained.


   Technique
Top
 Abstract
 Introduction
 Technique
Comment
 References
 
The procedure may be divided into four steps: (1) patient positioning and port placement, (2) pericardial reflection dissection, (3) device positioning, and (4) ablation.

Patient Positioning and Port Placement
The patient is ventilated with a double lumen endotracheal tube in the supine position with a rotation of the chest 30 degrees to the left. A transesophageal echocardiography examination is performed to rule out the presence of thrombus in the LAA. The right chest is entered with three working ports consisting of a 10-mm port for the camera in the fifth intercostal space at the midaxillary line, a 5-mm port for instruments in the fourth intercostal space at the anterior axillary line, and a 10-mm port for instruments in the sixth intercostal space at the anterior axillary line. Based on the patient’s anatomy, the locations of these ports may be one intercostal space higher. A CO2 insufflation is connected, and insufflation is started at a pressure of 8 mm Hg.

Pericardial Reflection Dissection
The pericardium is grasped and pulled away from the right atrium. It is opened with an endoscopic coagulation hook and scissors longitudinally (2 cm anterior to the phrenic nerve towards the superior and inferior caval vein). To improve visibility, the posterior part of the pericardium is retracted with two sutures that are pulled outside the chest under the camera port using a suture hook. The pericardial reflection of the superior caval vein is bluntly dissected with an endoscopic peanut (Ethicon, Somerville, NJ) until the opening of the transverse sinus and the visualization of the tip of the LAA. This opening is created by gently rubbing off the fat in the triangle created by the right pulmonary artery, the superior caval vein, and the right atrium. It is important to direct the dissection away from the pulmonary artery toward the transverse sinus (Fig 1). The same technique is applied to dissect the pericardial reflection of the inferior caval vein to gain access to the oblique sinus, pushing the atriocaval region upward with a grasper and pushing the underlying pericardium downward to facilitate the dissection (Fig 2).


Figure 1
View larger version (154K):
[in this window]
[in a new window]

  		Fig 1. Opening of the transverse sinus.

 

Figure 2
View larger version (143K):
[in this window]
[in a new window]

  		Fig 2. Opening of the oblique sinus. (RIPV = right inferior pulmonary vein.)

 
Placement of the FLEX 10 Around the Pulmonary Veins
A flexible triangular endoscopic retractor (Diamond-Flex 60-mm liver retractor [Genzyme, Cambridge, MA]) is used to facilitate the placement for the Flex ablation device around the PVs. The proximal section of this retractor is flexible and can be bent to form a triangular shape by a turning a knob on the device handle. To avoid entanglement of cardiac tissue when closing the flexible portion around the pulmonary veins, the articulations of the flexible portion are covered with a Penrose Ch6 (Sherwood, St Louis, MO). The Flex 10 microwave ablation device is attached to the proximal end of the introducer with a suture. The port in the sixth intercostal space is removed, and the introducer and the Flex 10 are directed into the chest and pushed under the superior caval vein into the transverse sinus. At this point it is very important to position the introducer and the Flex 10 behind the LAA thus avoiding the risk of energy application over the circumflex artery. The introducer is pushed against the pericardium of the left side and should be directed toward the inferior and most importantly toward the posterior aspect of the left atrium. As soon as the end of the flexible portion reaches the transverse sinus, the introducer is activated by turning the actuating knob clockwise until the flexible portion forms its predetermined triangular shape. Once it reaches its desirable shape, it will come back below the inferior caval vein, encircling the four PVs. The suture joining the Flex 10 to the introducer is cut. The introducer is then deactivated and pulled outside the chest. The Flex 10 is slowly pulled until the proximal active segment reaches the level of the superior caval vein.

Microwave Ablation
Before starting the ablation, the fat pad in the intraatrial groove is bluntly dissected using an endo-peanut to provide a better placement of the Flex 10. Furthermore, this maneuver will enhance microwave penetration in the atrial tissue, and burn the preganglionated plexi located inside this fat pad. The orientation of the device is confirmed at the level of the LAA. Sequential ablations are then performed to create a continuous transmural lesion around the PVs. Each ablation is performed with a power setting of 65 W for 90 seconds per lesion. After completing a satisfactory lesion based on visual inspection, electrical isolation of the PVs is assessed by pacing the right PV and verifying noncapture on the right atrium. If the right atrium is captured, a second ablation is performed around the four PVs and an electrical block is reassessed.

The patient is extubated in the operating room. Antiarrhythmic drugs are started postoperatively, and oral anticoagulant therapy is started on day 1.


   Comment
Top
 Abstract
 Introduction
 Technique
 Comment
References
 
From January 2005 until September 2005, 16 patients were operated on using this technique. Mean duration of atrial fibrillation was 8.3 ± 6.7 years. Mean operating time was 89 minutes (range, 46–179 mins). There were no conversions. Intraoperative conduction block was achieved in 7 patients after one ablation and in another 4 patients after two ablations. The remaining 5 patients did not have an acute conduction block. Failure to achieve a perioperative block is probably due to incomplete transmural lesions immediately after ablation; with microwave energy the lesion thickness will evolve and can become transmural after several days. A patient with emphysema had a left-sided pneumothorax when starting single-lung ventilation. One patient had a hemothorax treated by drainage, and 1 patient had a transitory paresis of the right phrenic nerve. Mean follow-up is 4.9 ± 2.1 months (range, 0.5–9 mos). Sinus rhythm was obtained in 60% of the patients with continuous atrial fibrillation after 3 and 6 months; this was 100% in patients with intermittent atrial fibrillation.


   References
Top
 Abstract
 Introduction
 Technique
 Comment
 References
 

  1. Cox JL. Atrial fibrillation II: rationale for surgical treatment J Thorac Cardiovasc Surg 2003;126:1693-1699.[Free Full Text]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
Y. Inoue
Treatment of Atrial Fibrillation With a Right Thoracoscopic Approach
Ann. Thorac. Surg., November 1, 2007; 84(5): 1795 - 1795.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Mark La Meir
Michel Buche
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by La Meir, M.
Right arrow Articles by Buche, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by La Meir, M.
Right arrow Articles by Buche, M.
Related Collections
Right arrow Electrophysiology - arrhythmias

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS