非瓣膜性房颤患者行胸腔镜下射频消融联合左心耳闭合术预防卒中

(2) 对抗心律失常药物无效的症状性非瓣膜性房颤患者。(3) 具有明确的出血病史或出血倾向。(4) 在规范抗凝的情况下仍发生血栓栓塞事件。(5) 对长期口服抗凝药物依从性差 ...

对于高卒中风险同时存在不适合长期规范抗凝治疗或者在长期规范抗凝治疗的基础上仍发生卒中的非瓣膜性房颤患者,射频消融联合左心耳封堵术(一站式手术)是安全,有效的[2].

Objectives Totally thoracoscopic left atrial appendage closure (TT-LAAC) with or without the MAZE procedure is an LAA management technique that prevents cardioembolic events by closing the LAA in patients with atrial fibrillation (AF). Additionally, it facilitates rhythm control with a concurrent a mini-maze procedure. Here we present TT-LAAC outcomes without the MAZE procedure (TT-LAAC) and with the maze procedure (TT-MAZE). Methods LAAC and/or bilateral pulmonary vein isolation were performed under complete thoracoscopy, with ablation performed using a radiofrequency device. Patients undergoing both LAAC and ablation were classified as TT-MAZE, whereas those undergoing only closure were classified as TT-LAAC. Successful closure was defined as a stump <10 mm as assessed via intraoperative transesophageal echocardiography. Results Between March 2018 and January 2025, 200 patients (155 males, 45 females; mean age, 70.4 ± 9.6 years) underwent TT-MAZE (n = 151) or TT-LAAC (n = 49). AF subtypes included paroxysmal in 62 patients, persistent in 105 patients, and permanent in 33 patients. Closure of the LAA was successful in all patients. No in-hospital mortality was observed. Anticoagulant therapy was discontinued in 96.5% of the patients (n = 193) of patients after 3 months. No postoperative strokes were observed during the mean follow-up of 3 years. In the TT-MAZE group, sinus rhythm was maintained in 72% of patients at 4 years postoperatively. Conclusions TT-LAAC procedures effectively prevent cardioembolic stroke even after discontinuation of anticoagulant therapy, regardless of whether sinus rhythm was restored after surgery. These procedures remain a valuable treatment strategy for AF.

BACKGROUND Tanscatheter left atrial appendage (LAA) closure and minimally invasive thoracoscopic LAA occlusion are local interventions of LAA for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). However, the safety and efficacy of these methods have not been compared. This prospective cohort study aimed to assess the safety and efficacy of those two treatment approaches for stroke prevention in NVAF patients. METHODS Two hundred and nine recurrent NVAF patients who received radiofrequency ablation were enrolled. These patients were treated with transcatheter LAA closure or thoracoscopic LAA occlusion. The patients were followed up from the first postoperative day and evaluated for efficacy endpoints (stroke/transient ischemic attack (TIA), systemic embolism (SE), and death) and a safety endpoint (bleeding events). Perioperative complications were recorded. RESULTS After a median follow-up of 1.8 years (383 patient-years), the overall rate of the composite efficacy endpoints was similar between the two groups (3.8 vs. 2.7 events per 100 patient-years; HR = 0.71; 95% CI: 0.225−2.237; P = 0.559). However, regarding primary safety endpoint, there were 1.5 bleeding events per 100 patient-years in the thoracoscopic LAA occlusion group, compared with 6.4 in transcatheter LAA closure group (HR = 0.246; 95% CI: 0.074−0.819; P = 0.022). The incidence of operative complications was 3/138 (2.17%) in thoracoscopic LAA occlusion group and 1/71 (1.41%) in transcatheter LAA closure group. CONCLUSIONS Thoracoscopic LAA occlusion and transcatheter LAA closure have similar efficacy in preventing stroke in NVAF patients. However, the thoracoscopic group had fewer bleeding events than the transcatheter group, but the former group required a longer hospital stay.

In this article we describe the modified technique of a unilateral closed chest thoracoscopic ablation and left atrial appendage closure including a box lesion that is made by radiofrequency clamps only for the treatment of atrial fibrillation. By abandoning the unidirectional pen devices and replacing these by radiofrequency clamps, we aim to further improve the procedural efficacy and shorten operation time while minimizing surgical exposure for the patient.

Left atrial appendage occlusion (LAAO) in the treatment of atrial fibrillation (AF) has become a hot topic in clinical research in recent years. We report a 68‐year‐old female with a 3‐year history of paroxysmal atrial fibrillation refractory to antiarrhythmic therapy and unable to tolerate anticoagulation therapy who underwent successful atrial fibrillation radiofrequency ablation combined with left atrial appendage occlusion guided by 3D printing technology. There was no recurrence of her atrial fibrillation and there was continued complete occlusion of her left atrial appendage at 3‐month and 1‐year follow‐ups.This case supports the potential advantage of 3D printing technology to guide a “one‐stop combined AF radiofrequency ablation and left atrial appendage occlusion procedure.” But whether it can improve the prognosis and quality of life of patients, further multi‐center research and large data statistics are required.

We present the first report of concomitant convergent ablation, left atrial appendage (LAA) closure, and minimally invasive direct coronary artery bypass (MIDCAB) procedures during a single operation. Three patients had coronary artery disease of the left anterior descending artery and atrial fibrillation. All were offered concomitant convergent ablation and LAA closure during the MIDCAB procedure. There were no intra- or postoperative events. At one-year follow-up, no serious adverse events had occurred. One patient had experienced a relapse of paroxysmal atrial fibrillation, and one patient, with a well-functioning graft, had been medically optimized for angina. Our report shows that combining convergent ablation, LAA closure, and MIDCAB can be done feasibly and safely, enabling efficient minimally invasive approaches to future complex cases.

Background Atrial fibrillation (AF) is a major risk factor for ischemic stroke, with >90% of thrombi in nonvalvular AF originating in the left atrial appendage (LAA). Thoracoscopic LAA occlusion (LAAO), with or without ablation, is a minimally invasive alternative to endocardial devices or anticoagulation, but multicenter data are limited. Methods and Results The Totally Thoracoscopic Left Atrial Appendage Occlusion Study (TT-LAAOS) is a multicenter Japanese registry of thoracoscopic LAAO in nonvalvular AF. From March 2018 to December 2024, 567 patients underwent the procedure at 6 institutions using stapler excision or epicardial clip. Outcomes included procedural success, anatomic closure, cerebrovascular events, and anticoagulant withdrawal. Mean age was 72 years; 63.5% had long-standing persistent AF. Median CHADS2 and CHA2DS2 VASc scores were 2 and 4, respectively. Success was 99.8% with no intraoperative deaths; residual stumps >10 mm were found in 1.5%. At discharge, sinus rhythm was present in 45%. Anticoagulants were stopped in 15% immediately and 63% within 1 month. During 875.8 patient years of follow-up (median 13 months), freedom from stroke or transient ischemic attack was 99.5% (0.34/100 patient years), with no thromboembolic deaths. Conclusions Thoracoscopic LAAO, with or without ablation, is safe and effective for stroke prevention in AF, with high success, reliable closure, and very low midterm events.

BACKGROUND Trans-thoracoscopic atrial fibrillation (AF) ablation combined with left atrial appendage excision (LAAE) is an alternative treatment approach for non-valvular AF patients with a history of thromboembolic events. The primary objective of this research is to investigate the electrophysiological characteristics of recurrent atrial tachyarrhythmias and rhythm outcome in patients receiving repeat catheter ablation after surgical AF ablation plus LAAE. METHODS Nonvalvular AF patients with previous thromboembolic events who underwent trans-thoracoscopic AF ablation plus LAAE and then received radiofrequency catheter ablation were enrolled. During the procedure, the reconnection of the left atrium (LA) and pulmonary veins (PVs) was investigated, and three-dimensional activation mapping of the left and/or right atrium during atrial tachyarrhythmias was performed. RESULTS From January 2014 to December 2021, 173 patients without a history of prior ablation underwent concurrent trans-thoracoscopic AF ablation and LAAE. A total of 74 patients experienced recurrent atrial tachyarrhythmias during a median follow-up period of 3.5 years (interquartile range [IQR]: 2.0 to 5.0 years) after the surgical procedure. A total of 22 patients with atrial tachyarrhythmias recurrence (11 males, aged 60±9 years) underwent radiofrequency catheter ablation. Among them, 10 patients with recurrent AF were identified, and in two of them, non-PV triggers originated from the interatrial septum and the superior vena cava. Reconnected LA-PV conduction was detected in 12 patients, with a total of 27 PV gaps. Eighteen of these PV gaps were located at the roof or the bottom. Thirteen sustained atrial tachycardias (ATs) were mapped in 12 patients, including peri-mitral AT (n=7), cavotricuspid isthmus-dependent AT (n=3), remnant LAA-related microreentrant AT (n=1), roof-dependent reentry AT (n=1), and focal AT (n=1). At a median follow-up of 9 months (IQR: 3-20 months) after the ablation procedure, the freedom rate from atrial tachyarrhythmias was 77%. CONCLUSION Reconnection of LA-PVs and macro-reentry ATs are common in repeat catheter ablation after surgical treatment for AF, with peri-mitral AT being the most frequently observed AT. PV gaps are most often located at the roof or bottom. Additionally, LAAE may contribute to arrhythmogenesis in certain patients. Catheter ablation targeting these mechanisms resulted in a favorable short- to mid-term rhythm outcome.

The authors present surgical treatment of a 52-year-old female patient diagnosed with giant left atrial appendage aneurysm (LAAA) after examination for paroxysmal atrial fibrillation. Thoracoscopic resection of LAAA without cardiopulmonary bypass and epicardial radiofrequency isolation of pulmonary vein collectors and posterior wall of the left atrium (“box lesion set”) were performed. There were no postoperative complications and rhythm disturbances. The patient was discharged after 5 days.

Purpose: In totally endoscopic off-pump left atrial appendage (LAA) closure and surgical ablation, securing the operative field is sometimes difficult in some patients because of a narrow working space caused by an elevated diaphragm or ventricles. In this study, we aimed to investigate the effectiveness of a method that facilitates securing the operative field using an artificial pneumothorax. Methods: We analyzed 71 consecutive patients who underwent totally endoscopic off-pump LAA closure and bilateral pulmonary vein isolation. The factors contributing to the reduction in operative time were examined. The patients were divided into the following 2 groups according to whether or not an artificial pneumothorax was used: Group C comprised 24 patients without an artificial pneumothorax and Group A comprised 47 patients with an artificial pneumothorax. Results: There were no hospital deaths or major complications. The operative time was significantly shorter in Group A (108 ± 26 minutes) than in Group C (198 ± 77 minutes) (p <0.0001). Conclusions: In totally endoscopic off-pump LAA closure and surgical ablation, an artificial pneumothorax may be useful in reducing the operative time.

Background and aims Hybrid atrial fibrillation (AF) ablation is a therapeutic option in non-paroxysmal AF. Our study examines cardiac mechanics changes after hybrid AF ablation plus epicardial closure of left atrial appendage (LAA). Methods All consecutive patients undergoing hybrid AF ablation at UZ Brussel were evaluated. They received pulmonary vein isolation (PVI), posterior wall isolation (LAPWI), and epicardial LAA closure. Left atrium (LA) and Left ventricle (LV) mechanics were analyzed, with the following measures obtained at baseline, post-ablation, and follow-up: 1) volumes (EDV, ESV); 2) ejection fraction (EF); 3) strain (ENDO GCS, ENDO GLS); 4) forces (LVLF, LVsysLF, LVim, LVs). Results A total of 50 patients were included. At follow-up, LAEDV decreased from baseline [44.7 mL vs 53.8 mL, P = 0.025]. LA ENDO GCS and GLS increased post-ablation, with further GLS improvement at follow-up. LV ENDO GCS and LV ENDO GLS also rose post-ablation [-26.7% vs. −22.5%, P < 0.001] and [-20.57% vs. −16.6%, P < 0.001], respectively. LVEF increased post-ablation [54.6% vs 46.3%, P < 0.001]. There was an increase in all LV hemodynamic forces (HDFs) and in particular: LVLF and LVsysLF increased post-ablation [15.5% vs 10.4%, P < 0.001] and [21.5% vs 14.11%, P < 0.001], respectively. LVim also increased post-ablation [19.6% vs 12.8%, P < 0.001]. Finally, there was an increase in LVs post-ablation compared to baseline [10.6% vs 5.4%, P < 0.001]. Conclusion In patients undergoing hybrid AF ablation, there was a significant and persistent improvement in the mechanical and hemodynamic functions of both LA and LV.

A clinical case of successful radiofrequency thoracoscopic ablation of persistent atrial fibrillation after implantation of an occluder in the left atrium appendage is presented.

No abstract available

Introduction Non-valvular atrial fibrillation (NVAF) is a high-risk factor for ischaemic stroke. The 2016 European Society of Cardiology Atrial Fibrillation Management guidelines recommend oral anticoagulants (OACs) to prevent stroke in men with CHA2DS2-VASc scores ≥2 and women ≥3. However, in patients with a high risk of stroke and a high risk of bleeding (HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly) score≥3), OAC had a higher risk of bleeding. Left atrial appendage closure (LAAC) is non-inferior to OAC as a means of preventing stroke in several studies. As a minimally invasive intervention to prevent stroke, transthoracic LAAC (TS-LAAC) has a high successful closure rate, but there is a lack of literature reports directly comparing it with OAC. Our research compares TS-LAAC with novel oral anticoagulants (NOACs) and provides an appropriate programme for stroke prevention in a specific population. Methods and analysis This is a non-randomised controlled trial study protocol, and we will conduct this study from April 2022 to April 2025. The study included 186 patients with confirmed NVAF, 93 of whom completed thoracoscopic LAAC, and the control group treated with NOACs. The primary outcome was the incidence of stroke and systemic embolism, as well as the composite endpoint events (stroke, systemic embolism, myocardial infarction, bleeding, cardiovascular death, etc). Secondary outcomes were ischaemic stroke, haemorrhagic stroke, any bleeding events, death from cardiovascular causes, death from all causes, residual root rate in the surgery group, device-related thrombosis in the surgery group, changes in blood pressure, cardiac chamber size changes, etc. Each subject completed at least 1 year of follow-up. Ethics and dissemination The study has been approved by the Medical Ethics Committee of Beijing Tiantan Hospital, Capital Medical University, China (approval number: KY2022-013-02). The results from this study will be disseminated through manuscript publications and national/international conferences. Trial registration number ChiCTR2200058109.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is noncommercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

Objective: Atrial fibrillation management is rapidly evolving, particularly for patients who are intolerant to medical therapy. Several catheter-based, surgical, and hybrid approaches currently exist, each with unique benefits that may be harnessed to provide optimal outcomes for these patients. This review focuses on the use of a biatrial lesion set versus an isolated left atrial lesion set for ablation. Methods: Major representative articles for each ablation strategy were identified and included. Terms searched on PubMed, Google Scholar, and Scopus included “atrial fibrillation ablation,” “atrial fibrillation surgery,” and “maze procedure,” among others. Additional articles were included based on expert opinion. Results: The complete Cox maze biatrial lesion set has the highest efficacy but requires cardiopulmonary bypass. An isolated left atrial lesion set can also be performed, and these approaches are often less invasive but not as efficacious as the traditional complete maze operation. Conclusions: Although biatrial ablation may carry a higher risk of conduction abnormalities than isolated left atrial ablation in the setting of atrial fibrillation, biatrial ablation is more efficacious in maintaining sinus rhythm. Visual abstract

Atrial fibrillation remains the most frequent sustained arrhythmia, particularly in the elderly population, and is associated with increased risks of stroke, heart failure, and reduced quality of life. While catheter ablation is widely used for rhythm control, its efficacy is limited in persistent and long-standing atrial fibrillation. Over the past two decades, minimally invasive surgical strategies have emerged as effective alternatives, aiming to replicate the success of the Cox-Maze procedure while reducing surgical trauma. This overview critically summarizes the current minimally invasive techniques available for atrial fibrillation treatment, including mini-thoracotomy ablation, thoracoscopic ablation, and hybrid procedures such as the convergent approach. These methods offer the potential for durable sinus rhythm restoration by enabling direct visualization, transmural lesion creation, and left atrial appendage exclusion, with lower perioperative morbidity compared to traditional open surgery. The choice of energy source plays a key role in lesion efficacy and safety. Particular attention is given to the technical steps of each procedure, patient selection criteria, and the role of left atrial appendage closure in stroke prevention. Hybrid strategies, which combine epicardial surgical ablation with endocardial catheter-based procedures, have shown encouraging outcomes in patients with refractory or long-standing atrial fibrillation. Despite the steep learning curve, minimally invasive techniques provide significant benefits in terms of recovery time, reduced hospital stay, and fewer complications. As evidence continues to evolve, these approaches represent a key advancement in the surgical management of atrial fibrillation, deserving integration into contemporary treatment algorithms and multidisciplinary heart team planning.

No abstract available

BACKGROUND Mid- and long-term rhythm outcomes of catheter ablation (CA) for atrial fibrillation (AF) are reported to be suboptimal. Minimally invasive surgical off-pump ablation (MISOA), including both thoracoscopic and trans-diaphragmatic approaches, has been developed to reduce surgical invasiveness and overcome on-pump surgery drawbacks. We sought to compare the efficacy and safety of MISOA and CA for AF treatment. METHODS A systematic review and meta-analysis of the literature was performed including studies comparing MISOA and CA. The primary endpoint was survival freedom from AF at follow-up after a 3-month blanking period. Subgroup analysis of the primary endpoint was performed according to the type of surgical incision and hybrid approach. RESULTS Freedom from AF at 4 years was 52.1% ± 3.2% vs 29.1% ± 3.5%, between MISOA and CA respectively (log-rank p < 0.001; Hazard Ratio: 0.60 [95%Confidence Interval (CI):0.50-0.72], p < 0.001). At landmark analysis, a significant improvement in rhythm outcomes was observed in the MISOA group after the 5th month of follow-up (2 months from the blanking period). The Odds Ratio between MISOA and CA of postoperative cerebrovascular accident incidence and postoperative permanent pacemaker implant (PPM) were 2.00 (95%CI:0.91-4.40, p = 0.084) and 1.55 (95%CI:0.61-3.95, p = 0.358), respectively. The incidence rate ratio of late CVA between MISOA and CA was 0.86 (95%CI:0.28-2.65, p = 0.787), while for late PPM implant was 0.45 (95%CI:0.11-1.78, p = 0.256). CONCLUSIONS The current meta-analysis suggests that MISOA provides superior rhythm outcomes when compared to CA in terms of sinus rhythm restoration. Despite the rhythm outcome superiority of MISOA, it is associated to higher postoperative complications compared to CA.

Purpose. To analyze long-term outcomes of minimally invasive epicardial video-assisted radiofrequency ablation (RFA) of the pulmonary veins (PV) and the posterior wall of the left atrium “box lesion” using Cobra technology in patients with various forms of isolated atrial fibrillation (AF). Materials and methods. From September 2011 to November 2021, 85 patients (70 male, 15 female) suffering from various forms of idiopathic AF underwent surgery on the basis of the Republican Scientific and Practical Center of Cardiology, Republic of Belarus. The patients were operated on using epicardial video-assisted RFA of the PV and posterior wall of the left atrium “box lesion” using Cobra Adhere (45 patients) and Cobra Fusion (40 patients) devices. Mean age 53.8±8.80 years (28–71). History of AF – the burden of fibrillation before the surgery was 58.6±32.50 months. 35.3% (30 patients) had previously undergone ineffective PV catheter ablation. Results. There were no lethal cases, as well as conversions to sternotomy, acute cerebrovascular accidents during the hospital period. The follow-up period was studied in 100.0% of patients, the average follow-up period was 7.1+2.1 years. To evaluate the results, Holter monitoring was used after 3, 6, 12 months. after surgery, then annually, the readings of event monitors and the results of pacemaker programming. Positive results included sinus rhythm (SR) without AF/Atrial paroxysms for more than 30 s, as well as atrial (AAI) or dual-chamber DDD(R) pacing. The effectiveness of RFA of the PV and the posterior wall of the left atrium “box lesion” using Cobra Adhere and Cobra Fusion devices, depending on the initial type of AF in the long-term period (3 years), was: 56.3% /70.6% for paroxysmal AF, 28.0% / 44.4% for persistent AF, 0%/0% for long-standing persistent AF. Conclusion. The Cobra technology proved to be the most effective in paroxysmal AF, less optimal results were obtained in persistent AF. In general, more consistent results were obtained with the Fusion technology. Efficacy also depended on the length of the follow-up, with the number of patients with sustained sinus rhythm decreasing over time and requiring additional catheter procedures in symptomatic patients.

No abstract available

Abstract OBJECTIVES Thoracoscopic ablation for atrial fibrillation (AF) and minimally invasive direct coronary artery bypass (MIDCAB) with robot-assisted left internal mammary artery (LIMA) harvesting may represent a safe and effective alternative to more invasive surgical approaches via sternotomy. The aim of our study was to describe the feasibility, safety and efficacy of a unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB surgery. METHODS Retrospective analysis of a prospectively gathered cohort was performed of all consecutive patients with AF and at least a critical left anterior descending artery (LAD) stenosis that underwent unilateral left-sided thoracoscopic AF ablation and concomitant off-pump MIDCAB surgery in the Maastricht University Medical Centre between 2017 and 2021. RESULTS Twenty-three patients were included [age 69 years (standard deviation = 8), paroxysmal AF 61%, left atrial volume index 42 ml/m2 (standard deviation = 11)]. Unilateral left-sided thoracoscopic isolation of the left (n = 23) and right (n = 22) pulmonary veins and box (n = 21) by radiofrequency ablation was succeeded by epicardial validation of exit- and entrance block (n = 22). All patients received robot-assisted LIMA harvesting and off-pump LIMA-LAD anastomosis through a left mini-thoracotomy. The perioperative complications consisted of one bleeding of the thoracotomy wound and one aborted myocardial infarction not requiring intervention. The mean duration of hospital stay was 6 days (standard deviation = 2). After discharge, cardiac hospital readmission occurred in 4 patients (AF n = 1; pleural- and pericardial effusion n = 2, myocardial infarction requiring the percutaneous intervention of the LIMA-LAD n = 1) within 1 year. After 12 months, 17/21 (81%) patients were in sinus rhythm when allowing anti-arrhythmic drugs. Finally, the left atrial ejection fraction improved postoperatively [26% (standard deviation = 11) to 38% (standard deviation = 7), P = 0.01]. CONCLUSIONS In this initial feasibility and early safety study, unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB for LIMA-LAD grafting is a feasible, safe and efficacious for patients with AF and a critical LAD stenosis.

Objective Surgical closure of the left atrial appendage (LAA) in patients with atrial fibrillation undergoing cardiac surgery can decrease the risk of stroke and thromboembolism and should therefore be considered. In minimally invasive, thoracoscopic, or robotic-assisted mitral valve surgery, however, external procedures such as clip application or epicardial resection are not feasible due to anatomic limitations and the reduced size of the access port. Internal suture closing techniques bear the risk of recurrent LAA reperfusion, so far. We present a novel surgical technique of LAA excision and subsequent defect closure from the interior aspect of the atrium. Methods We developed this novel technique during robotic-assisted cardiac surgeries. In short, the LAA is invaginated into the left atrium, excised completely at the base using scissors and the stump is then closed from the inside with a two-layer looped PTFE suture. We give a detailed step-by-step description of the technique. Results A total of 20 patients received intra-atrial LAA excision so far. Complete resection of the LAA without any residual stump or bleeding was achieved in all cases. There were no procedure-related complications. Conclusion The intra-atrial LAA excision technique shows promising preliminary results regarding efficacy, safety, and reproducibility during robotic-assisted cardiac operations and could be recommended for all right-sided minimally invasive cardiac surgical procedures.

No abstract available

OBJECTIVES The aim of this study was to evaluate in-hospital outcomes and long-term survival of patients undergoing cardiac surgery with preoperative atrial fibrillation. We compared different strategies, including no atrial fibrillation treatment, left atrial appendage occlusion alone, concomitant surgical ablation alone or both. METHODS A retrospective analysis using the KROK registry included all patients with preoperative diagnosis of atrial fibrillation who underwent cardiac surgery in Poland between between January 2012 and December 2022. Risk adjustment was performed using regression analysis with inverse probability weighting of propensity scores. We assessed six-year survival with Cox proportional hazards models. Sensitivity analysis was performed based on index cardiac procedure. RESULTS Initially, 42,510 patients with preoperative atrial fibrillation were identified, and, after exclusion, 33,949 included in the final analysis. 1,107 (3.26%) received both surgical ablation and left atrial appendage occlusion, 1,484 (4.37%) received left atrial appendage occlusion alone, 3,921 (11.55%) surgical ablation alone and the remaining 27,437 (80.82%) had no atrial fibrillation directed treatment. As compared to no treatment, all strategies were associated with survival benefit over 6-years follow-up. A gradient of treatment was observed with the highest benefit associated with surgical ablation + left atrial appendage occlusion followed by surgical ablation alone and left atrial appendage occlusion alone (log-rank P < 0.001). Mortality benefits were reflected when stratified by surgery type with the exception of aortic valve surgery where left atrial appendage occlusion alone fare worse than no treatment. CONCLUSIONS Among patients with preoperative atrial fibrillation undergoing cardiac surgery, surgical management of atrial fibrillation, particularly surgical ablation+ left atrial appendage occlusion, was associated with lower six-year mortality. These findings support the benefits of incorporating surgical ablation and left atrial appendage occlusion in the management of atrial fibrillation during cardiac surgery.

No abstract available

Pericardial-esophageal fistula is a rare complication after radiofrequency ablation for atrial fibrillation. A 52-year-old man developed pneumopericardium, which was revealed by echocardiogram and computed tomography, after a combined ablation and left atrial appendage occlusion procedure for atrial fibrillation. He was diagnosed with a pericardial-esophageal fistula and underwent surgical pericardial and mediastinal drainage tube placement. However, the patient developed constrictive pericarditis 2 months after the first surgery and subsequently underwent pericardiolysis. A month after the second surgery, the patient's condition was significantly improved and he was allowed home.

Objectives Atrial fibrillation (AF) is associated with an increased ischemic stroke, and the left atrial appendage (LAA) represents the main source of thrombus formation. We evaluated the long-term efficacy of surgical thoracoscopic LAA occlusion during total thoracoscopic ablation of AF to prevent the stroke and anticoagulation strategy after surgery. Methods Patients who underwent total thoracoscopic ablation for AF, from February 2012 to May 2020, were included; Patients who did not receive LAA occlusion were excluded. We evaluated the development of thromboembolism in these patients. Results The total number of 460 patients [mean age, 57.1 ± 9.2 years; 400 (87.0%) males] were included in the study. The mean follow-up duration was 44.8 months. The mean CHA2DS2-VASc score was 1.9 ± 1.6. Median OAC duration was 109.5 days after the surgery, and the final number of patients who discontinued OAC were 411 (89.3%) in total. Anticoagulation discontinuation rate according to CHA2DS2-VASc score are as follows; (i) 0 = 99.0%; (ii) 1 = 98.2%; and (iii) ≥2 = 81.3%. The annualized incidence rate of ischemic stroke was 0.78%/year, showing a 73% risk reduction compared with the CHA2DS2-VASc predicted rate without anticoagulation. The hazard ratio for ischemic stroke according to previous stroke history was 1.5 [95% confidential interval (CI) 0.3–7.3, p = 0.62], and that of remnant LAA was 5.1 (1.2–20.9, p = 0.02). Conclusions Thoracoscopic LAA occlusion during total thoracoscopic ablation of AF was effective to prevent ischemic stroke. Most patients could discontinue OAC therapy after the procedure. Patients who had a residual trabeculated LAA, or peri-occluder pouch in follow-up CT need to maintain OAC therapy even after LAA occlusion.

One third of the population will develop atrial fibrillation in their lifetime and 12.1 million people in the United States are expected to be affected by 2030. A long-standing gap exists in traditional pharmacologic and nonpharmacologic treatments for persistent atrial fibrillation. An innovative, hybrid treatment, commonly referred to as the Convergent Procedure, combines surgical ablation of the posterior left atrium through a minimally invasive subxiphoid incision with traditional endocardial ablation techniques. When the procedure includes ligament of Marshall ligation and epicardial occlusion of the left atrial appendage using a video-assisted thoracoscopic approach, it is termed the Convergent 'Plus' Procedure. Evidence indicates that the procedure is twice as effective as endocardial ablation alone, reducing the need for atrial fibrillation medications by half. Consequently, demand for the procedure has surged, and anesthesia providers are now caring for patients in cardiac operating rooms and hybrid cardiology suites nationwide. Successful execution of the Convergent Plus Procedure demands close coordination among interdisciplinary teams, including surgery, cardiology, and anesthesiology. Anesthetic management is complex, requiring certified registered nurse anesthetists to understand procedural stages, ensure proper patient positioning, manage lung isolation, and be prepared for numerous complications such as hemodynamic instability, hemorrhage, and stroke.

Totally thoracoscopic ablation for symptomatic atrial fibrillation (AF) refractory to drug or catheter based therapy is indicated as a Class 2A recommendation according to latest guidelines. Evidence for long-term rhythm control and stroke reduction is limited. The aim of this study was to report on long-term outcome after totally thoracoscopic ablation. In total 82 consecutive patients were included that underwent totally thoracoscopic ablation including left appendage closure (2012-2013). The primary outcome was freedom from atrial arrhythmia recurrence. Secondary outcomes were survival, freedom from cerebrovascular events, freedom from reablation and definite pacemaker implantation. The mean age was 59.9 ± 8.6 years and 71% were male. The mean CHA Totally thoracoscopic ablation is an effective sustainable rhythm control therapy for AF with a reasonable recurrence rate and low stroke rate when performed in dedicated AF centers.

Catheter and surgical ablation of atrial fibrillation (AF) can be associated with a risk of thromboembolic events. The goal of this study was to assess optimal anticoagulation management during thoracoscopic ablation of AF. Fifty-two patients with persistent or long-standing persistent AF underwent hybrid ablation consisting of thoracoscopic ablation followed by electrophysiologic (EP) evaluation and consecutive ablation if indicated. The thoracoscopic ablation was performed using three different anticoagulation protocols: (1) without periprocedural heparin and without occlusion of the left atrial appendage; (2) with periprocedural heparin but without left atrial appendage occlusion; and (3) with periprocedural heparin and left atrial appendage occlusion. Transesophageal echocardiography (TEE) was obligatorily used to screen for intraatrial thrombi before the surgical and EP procedure and before hospital discharge for patients in protocols 2 and 3. In group 1 (n = 20), 1 patient (5%) had a postoperative stroke with persistent neurologic deficit, and 6 other patients (30%) had a new thrombus in the left atrial appendage seen on the pre-EP TEE. In group 2 (n = 6), 3 left atrial appendage thrombi occurred (50%; 2 on predischarge TEE and 1 on pre-EP TEE). In group 3 (n = 26), no intracardiac thrombi were found on predischarge and pre-EP TEE, and there were no strokes in this group of patients, namely, the rates of thrombus or stroke were significantly reduced when compared with groups 1 and 2 (p = 0.001). Thoracoscopic ablation of AF can be associated with a risk of left atrial appendage thrombus formation and possibly also stroke. With administration of heparin during the ablation, followed by occlusion of the left atrial appendage as a part of the procedure, this risk can be effectively reduced.

The aim of this article is to describe a unilateral approach for totally thoracoscopic ablation and left atrial appendage closure for the treatment of atrial fibrillation to simplify the procedure, avoid a technically more demanding thoracoscopy on the left side and potentially reduce postoperative pain without compromising the lesion set.

Besides mechanical and anatomical changes of the left atrium, epicardial closure of the left atrial appendage has also possible homeostatic effects. The aim of this study was to assess whether epicardial clipping of the left atrial appendage has different biochemical effects compared with complete removal of the left atrial appendage. Eighty-two patients were included and underwent a totally thoracoscopic AF ablation procedure. As part of the procedure, the left atrial appendage was excluded with an epicardial clip (n = 57) or the left atrial appendage was fully amputated with an endoscopic vascular stapler (n = 25). From all patients' preprocedural and postprocedural blood pressure, electrolytes and inflammatory parameters were collected. The mean age and left atrial volume index were comparable between the epicardial clip and stapler group (64 ± 8 years vs. 60 ± 9 years, P = non-significant; 44 ± 15 mL/m vs. 40 ± 13 mL/m, P = non-significant). Patients receiving left atrial appendage clipping had significantly elevated C-reactive protein levels compared with patients who had left atrial appendage stapling at the second, third, and fourth postoperative day (225 ± 84 mg/L vs. 149 ± 76 mg/L, P = 0.002, 244 ± 78 vs. 167 ± 76, P = 0.004, 190 ± 74 vs. 105 ± 48, P < 0.001, respectively). Patients had a significant decrease in sodium levels, systolic, and diastolic blood pressure at 24 and 72 hours after left atrial appendage closure. However, this was comparable for both the left atrial appendage clipping and stapling group. Increased activation of the inflammatory response was observed after left atrial appendage clipping compared with left atrial appendage stapling. Furthermore, a significant decrease in blood pressure was observed after surgical removal of the left atrial appendage. Whether the inflammatory response affects the outcome of arrhythmia surgery needs to be further evaluated.

Thoracoscopic atrial fibrillation ablation seeks to replicate the electrophysiological effects of more invasive, open surgical procedures. The authors present a lesion concept that includes isolation of the pulmonary veins, the left atrial posterior wall, and the superior vena cava, respectively, lines to inhibit perimitral and periauricular flutter circuits, and left atrial appendage closure. All lesions are tested for bidirectional block.

The convergent procedure is a hybrid ablation treatment for atrial fibrillation. It is increasingly considered as a management option for patients with persistent and long-standing atrial fibrillation. It consists of surgical ablation of the posterior left atrium through a minimally invasive closed-chest approach followed by endocardial catheter ablation. It is increasingly performed with concurrent epicardial occlusion of the left atrial appendage with a video-assisted thoracoscopic technique to physically and electrically isolate the left atrial appendage. This article provides an overview of a multidisciplinary approach to the convergent procedure, with concurrent thoracoscopic closure of the left atrial appendage, with an emphasis on perioperative management at a single institution. It provides a literature review of procedural outcomes, current data limitations, and future considerations.

Atrial tachycardia (AT) originating from the distal left atrial appendage (LAA) is rare, especially in older adult patients. A 64-year-old man was admitted for heart failure due to drug- and ablation-resistant AT. The arrhythmia was traced to the distal LAA. Owing to high risk of recurrence and complications with repeat catheter ablation, the patient underwent total thoracoscopic en bloc isolation of the left pulmonary veins and LAA, followed by LAA resection. Sinus rhythm was restored intraoperatively and was maintained postoperatively without antiarrhythmic medication. Left ventricular ejection fraction improved from 20% to 51% over 12 months. No recurrence of AT or heart failure was observed at the 12-month follow-up. This case highlights the efficacy and safety of combining thoracoscopic LAA resection with en bloc isolation in treating AT originating from the LAA in older adult patients.

The contemporary trends in catheter ablation (CA) and surgical ablation (SA) utilization and surgical techniques [open vs. thoracoscopic, with or without left atrial appendage closure (LAAC)] are unclear. In addition, the in-hospital outcomes of stand-alone SA compared with CA are not well-described. The National Inpatient Sample 2010-18 was queried for atrial fibrillation (AF) hospitalizations with CA or stand-alone SA. Complex samples multivariable logistic and linear regression models were used to compare the association between stand-alone SA vs. CA and the primary outcomes of in-hospital mortality and stroke. Of 180 243 hospitalizations included within the study, 167 242 were for CA and 13 000 were for stand-alone SA. Catheter ablation and stand-alone SA hospitalizations decreased throughout the study period (Ptrend < 0.001). Surgical ablation had higher rates of in-hospital mortality [adjusted odds ratio (aOR) 2.26; 95% confidence interval (CI) 1.41-3.61; P = 0.001] and stroke (aOR 4.64; 95% CI 3.25-6.64; P < 0.001) compared with CA. When examining different surgical approaches, thoracoscopic SA was associated with similar in-hospital mortality (aOR 1.53; 95% CI 0.60-3.89; P = 0.369) and similar risk of stroke (aOR 1.75; 95% CI 1.00-3.07; P = 0.051) compared with CA. Stand-alone SA comprises a minority of AF ablation procedures and is associated with increased risk of mortality, stroke, and other in-hospital complications compared to CA. However, when a thoracoscopic approach was utilized, the risks of mortality and stroke appear to be reduced.

Hybrid catheter and surgical ablation has emerged as an effective therapy for patients with persistent atrial fibrillation (AF). The aims of this study were to evaluate the relationship between intraprocedural arrhythmia termination and the long-term outcomes of hybrid ablation in patients with long-standing persistent AF. From May 2015 through April 2019, 50 patients with persistent AF with a mean duration of 73.3 ± 62.1 (median 54) months underwent single-step hybrid ablation. Pulmonary vein isolation, left atrial posterior wall isolation and left atrial appendage excision or closure were performed through a left-sided thoracoscopic approach. Subsequently, all patients underwent high-density endocardial mapping and electrogram-based ablation with the end point of AF termination. We achieved intraprocedural AF termination in 84% (42/50) patients; this end point was reached in 16 patients during surgical ablation and in 26 patients during catheter ablation. Seven patients underwent repeat catheter ablation. After a mean follow-up period of 29 ± 13 months, the freedom from atrial tachyarrhythmia of a single procedure without the use of antiarrhythmic drugs was 70% (35/50). In the Cox regression model, intraprocedural termination of AF (hazard ratio 0.205, 95% confidence interval 0.058-0.730; P = 0.014) was the sole predictor of success. The 2-year outcomes of a one-stop hybrid ablation with an end point of AF termination are promising in patients with long-standing persistent AF.

Atrial fibrillation is a challenging pathologic process. There continues to be a great need for the development of a reproducible, durable cure when medical management has failed. An effective, minimally invasive, sternal-sparing intervention without the need for cardiopulmonary bypass is a promising treatment approach. In this article, we describe a hybrid technique being refined at our center that combines a thoracoscopic epicardial surgical approach with an endocardial catheter-based procedure. We also discuss our results and review the literature describing this unique treatment approach.

Minimally invasive Maze procedure via right mini-thoracotomy approach is reportedly a promising option for paroxysmal and non-paroxysmal atrial fibrillation (AF), although it is not widely performed. This study aimed to validate feasibility and safety of minimally invasive stand-alone Maze procedure in an institutional first case series. This study enrolled an institutional consecutive series of 20 cases who underwent minimally invasive Maze procedure between November 2018 and January 2021. Concomitant tricuspid annuloplasty was performed in five cases who showed moderate tricuspid regurgitation preoperatively. Minimally invasive Maze procedure using cryo-energy source was successfully accomplished with sinus rhythm being restored at the intensive care unit entry in all cases without conversion to the sternotomy approach. All cases were discharged home, while one case was complicated with stroke postoperatively. Nineteen cases (95%) showed sinus rhythm at the last follow-up, whereas one case, who had large left atrium, showed recurrent persistent AF despite optimum medical therapy. Catheter ablations were performed for residual conductions at box lesions and/or mitral/tricuspid isthmus in three cases, who showed medically refractory atrial tachycardia post-Maze procedure. Consequently, these three cases showed sinus rhythm restoration at the last follow-up Conclusions: Minimally invasive stand-alone Maze procedure with or without tricuspid annuloplasty was feasible and safe for AF in the institutional first case series. Catheter ablations for recurrent AF post-Maze procedure would be warranted.

Mapping of the unorganized activation patterns of atrial fibrillation requires a high-resolution mapping approach to diagnose substrate-mediated pathophysiological mechanisms. At present, epicardial mapping is the only approach that is able to acquire electrograms of >200 high-density sites simultaneously. This study introduces a technique to perform high-resolution mapping in minimally invasive surgery. In 3 patients with mitral valve disease, epicardial mapping of the right atrium, Bachmann's bundle and parts of the left atrium was safely performed via minimal right thoracotomy.

The Convergent procedure comprises epi- and endocardial ablation of the left atrium and represents an effective alternative to conventional endocardial ablation in patients with therapy-resistant atrial fibrillation. The LARIAT approach allows the epi- and endocardial closure of the left atrial appendage and effectively reduces the risk of stroke in patients with atrial fibrillation. In this video tutorial, we provide step-by-step guidance through the concomitant Convergent and LARIAT procedures.

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In the last several years, a number of procedures have been conceived that have attempted to treat atrial fibrillation (AF) by creating a limited set of lesions modeled after those of the Maze operation. These lesions have been created by a variety of means, including the traditional cut-and-sew method, but also by nonincisional techniques. These have included cryoablation as well as several thermal techniques, using radiofrequency, microwave, laser, and focused ultrasound energy. One reason for the development of these nonincisional techniques has been the desire to develop less invasive operations for the treatment of AF. The specific goal of our center has been to utilize these energy sources as well as other minimally invasive tools, such as surgical robots, to develop a closed chest, off-pump procedure for AF. The development of such a procedure is outlined in this article.

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Fundamental procedure of arrhythmia surgery is to bock conduction of macro-reentry or focal activation. Traditional "cut and sew" technique is effective to make a conduction block without any special devices although it is time consuming and there is some bleeding risk. Surgical ablation devices are easily able to make a conduction block during surgery. It could undergo the minimally invasive cardiovascular surgery (MICS) -maze procedure through the right mini thoracotomy. It is most important to make complete conduction block because incomplete ablation causes residual conduction, resulting in recurrence of atrial fibrillation or atrial tachycardia. Moreover, the left atrial clip is new surgical treatment for atrial fibrillation. This device could avoid thrombus formation and make a conduction block arising from the left atrial appendage.

The Cox maze surgical ablation operation is a highly effective treatment for patients with atrial fibrillation, but adoption has been limited by procedure complexity and invasiveness. Minimally invasive approaches using nonsternotomy limited access and eliminating cardiopulmonary bypass have been developed. All published series of minimally invasive surgical ablation for isolated, atrial fibrillation were reviewed. Series were analyzed for method of access, energy source, procedure success, and complications. Outcomes were compiled based on type of atrial fibrillation, method and length of follow-up, and freedom from atrial fibrillation with and without antiarrhythmic drugs. There are 14 published series with outcomes reported in 604 unique patients. Most procedures are performed through bilateral minithoracotomies with video assistance, although in later series a totally thoracoscopic approach is more commonly used. Bipolar radiofrequency is the predominant energy source used, and bilateral pulmonary vein isolation the most common lesion set, with some reports adding ganglionic plexi ablation and more extensive ablation lines. Approximately 53% of the procedures were performed for paroxysmal and 47% for persistent/long-standing persistent atrial fibrillation. Overall freedom from atrial fibrillation at 6-12 months is 84% (59%-91%), with 89% (79%-100%) in paroxysmal and 62% (25%-87%) in persistent/long-standing persistent patients. Overall freedom from atrial fibrillation off of antiarrhythmic drugs is 65% (57%-87%). Results approximating those of the Cox maze procedure are achieved with minimally invasive surgical ablation of atrial fibrillation in patients with paroxysmal atrial fibrillation. Further developments are necessary to further simplify and standardize the procedure, to replicate the results in larger series from more centers, to standardize the reporting of results, and to define a more effective procedure for persistent and long-standing persistent atrial fibrillation.

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Both catheter left atrial appendage occlusion combined with ablation (COA) and thoracoscopic surgical left atrial appendage clipping combined with ablation (TCA) have shown favorable outcomes in management of patients with atrial fibrillation (AFib). However, studies comparing the endpoints of both techniques are still lacking. Herein, a meta-analysis of safety and efficacy outcomes of COA versus TCA was performed in patients with AFib. Pubmed, Embase, Cochrane, and Web of Science databases were searched for retrieving potential publications. The primary outcome was the incidence of stroke during follow-up period of at least 12 months. Secondary outcomes were acute success rate of complete left atrial appendage (LAA) closure by COA or TCA, postprocedural mortality and complications, and all-cause mortality during follow-up period of at least 12 months. 19 studies of COA containing 1,504 patients and 6 studies of TCA with 454 patients were eligible for analysis. No significant difference in stroke and all-cause mortality was found in patients undergoing COA versus TCA after at least a 12-month follow-up (stroke: This meta-analysis showed that COA and TCA did not differ in stroke prevention and all-cause mortality in patients with AFib after a follow-up of at least 12 months. Postprocedural complications and mortality were almost comparable between the two groups. In the near future, high-quality randomized controlled trials exploring the optimal surgical strategies for AFib and endpoints of different procedures are warranted. [https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42022325497].

Concomitant left atrial appendage occlusion (LAAO) during surgical ablation has emerged as a potential treatment strategy to reduce stroke and perioperative mortality in patients with atrial fibrillation (AF). The present meta-analysis aims to assess current evidence on the efficacy and safety between LAAO and LAA preservation cohorts for patients undergoing cardiac surgery. Electronic searches were performed using six electronic databases from their inception to November 2013, identifying all relevant comparative randomized and observational studies comparing LAAO with non-LAAO in AF patients undergoing cardiac surgery. Data were extracted and analysed according to predefined endpoints including mortality, stroke, postoperative AF and reoperation for bleeding. Seven relevant studies identified for qualitative and quantitative analyses, including 3653 patients undergoing LAAO (n = 1716) versus non-LAAO (n = 1937). Stroke incidence was significantly reduced in the LAAO occlusion group at the 30-day follow-up [0.95 vs 1.9%; odds ratio (OR) 0.46; P = 0.005] and the latest follow-up (1.4 vs 4.1%; OR 0.48; P = 0.01), compared with the non-LAAO group. Incidence of all-cause mortality was significantly decreased with LAAO (1.9 vs 5%; OR 0.38; P = 0.0003), while postoperative AF and reoperation for bleeding was comparable. While acknowledging the limitations and inadequate statistical power of the available evidence, this study suggests LAAO as a promising strategy for stroke reduction perioperatively and at the short-term follow-up without a significant increase in complications. Larger randomized studies in the future are required, with clearer surgical and anticoagulation protocols and adequate long-term follow-up, to validate the clinical efficacy of LAAO versus non-LAAO groups.