Position of totally thoracoscopic surgical ablation in the treatment of atrial fibrillation: an alternative method of conduction testing

Abstract

Recent advances in surgical techniques and understanding of the pathophysiology of atrial fibrillation has led to the development of a less invasive thoracoscopic surgical treatment including video-assisted bilateral pulmonary vein isolation using bipolar radiofrequency ablation clamps. More recently, the same operation became possible via a totally thoracoscopic approach. In this paper we describe technical aspects of the thoracoscopic approach to surgical treatment of AF and discuss its features, benefits and limitations. Furthermore, we present a new alternative technique of conduction testing using endoscopic multi-electrode recording catheters. An alternative electrophysiological mapping strategy involves a multi-electrode recording catheter designed primarily for percutaneous endocardial electrophysiologic mapping procedure. According to our initial experience, the recordings obtained from the multi-electrode catheters positioned around the pulmonary veins are more accurate than the recordings obtained from the multifunctional ablation and pacing pen. The totally thoracoscopic surgical ablation approach is a feasible and efficient treatment strategy for atrial fibrillation. The conduction testing can be easily and rapidly performed using a multifunctional pen or multi-electrode recording catheter.

Figure 1

Three ports are placed in order to gain access and visualize the surgical ablation area. A 10-mm port is placed into the 4^th intercostal space (ICS) on the mid-axillary line and CO₂ insufflation is started immediately. An additional 5-mm port is then inserted into the 3^rd ICS on the mid-clavicular line. The final 10-mm port is placed into 7^th ICS on the mid-axillary line.

Figure 2

The pen is placed sequentially on the superior and inferior pulmonary veins.

Figure 3

During the ablation cycle a graph of tissue conductance (current/voltage) versus time is displayed on the ablation and sensing unit (ASU) monitor (AtriCure, Inc., Ohio, USA).

Figure 4

The multielectrode recording catheter is placed around the pulmonary veins for simultaneous conduction testing at multiple locations.