Management of recurrent atrial arrhythmias after minimally invasive surgical pulmonary vein isolation and ganglionic plexi ablation for atrial fibrillation

Abstract

Background: Minimally invasive thoracoscopic procedures have evolved for surgical treatment of atrial fibrillation (AF). The spectrum and management of arrhythmias after minimally invasive epicardial radiofrequency ablation of the pulmonary vein (PV) antrum have not been well studied.

Objective: The aim of this study was to describe the spectrum and treatment of recurrent atrial tachyarrhythmias (AT) after minimally invasive AF surgery.

Methods: Fifty patients underwent bipolar radiofrequency (RF) ablation of the PV antrum, parasympathetic ganglionated plexi, and ligament of Marshall. Twenty patients (40%) had recurrent AT, and 13 underwent electrophysiology study 100 to 948 days postoperatively (mean 383 +/- 234).

Results: Fourteen arrhythmias were identified in 13 patients 90 to 666 days (mean 214 +/- 162) after AF surgery. The most common arrhythmias were AF (N = 8) and atrial flutter (N = 3). Of 44 PVs examined, 22 (50%) had reconnected. Seven of 8 patients with recurrent AF had either 2 or 3 veins reconnected, and 6 of 8 had reconnection of the left superior PV. On average, 25.6% of each PV reconnected and showed conduction delay between the left atrium and PV. Two of 4 postoperative atrial flutters were due to isthmus-dependent re-entry. After catheter ablation, 2 patients had symptomatic recurrence of AT.

Conclusion: Recurrent AT occurs in up to 40% of patients after minimally invasive thoracoscopic AF surgery during a minimal follow-up of 12 months. PV reconnection accounts for most recurrences. Postoperative AT appears amenable to catheter ablation, often in conjunction with medical therapy, with high intermediate-term success.

Trial registration: ClinicalTrials.gov NCT00747838.