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Editorial
. 2024 Jan 30;13(1):91-98.
doi: 10.21037/acs-2023-afm-21. Epub 2024 Jan 23.

Concomitant atrial fibrillation ablation in minimally invasive cardiac surgery

Andrew Tjon Joek Tjien  1 , Ferdi Akca  1 , Kayan Lam  1 , Jules Olsthoorn  1 , Lukas Dekker  2   3 , Pepijn van der Voort  2 , Niels Verberkmoes  1 , Thomas J van Brakel  1
Affiliations
Editorial

Concomitant atrial fibrillation ablation in minimally invasive cardiac surgery

Andrew Tjon Joek Tjien et al. Ann Cardiothorac Surg. .

Abstract

Concomitant atrial fibrillation (AF) ablation in cardiac surgery effectively restores sinus rhythm and may reduce morbidity and mortality. Cardiac surgery has witnessed the transition from the historical Cox Maze procedure to more modern and less invasive approaches for concomitant AF treatment. As minimally invasive cardiac surgery gains traction, ablation methods and careful patient selection become crucial to optimize results. Emerging techniques, including bipolar epicardial radiofrequency and endo/epicardial cryoablation, are central to these advances, targeting specific arrhythmogenic areas within the atria. While pulmonary vein isolation (PVI) is essential, it may be insufficient for patients with persistent or longstanding persistent AF. In such cases, left atrial posterior wall isolation has proven beneficial. Furthermore, recent studies emphasize the significance of left atrial appendage occlusion in concurrent AF treatments, highlighting its role in stroke risk reduction. Notably, the left atrium remains the focal point for concomitant AF surgery over the right, primarily due to concerns like high pacemaker implantation rates and complexities of right atrial ablation sets. Although guidelines support its widespread use, concomitant AF ablation outcomes vary based on patient selection, surgeon's expertise, and clinical context and thus the Heart Team's input is crucial for individualized decisions. In the upcoming sections, we present our patient selection and a visual guide to our techniques for concomitant AF surgery in minimally invasive mitral valve, coronary artery bypass and aortic valve surgery.

Keywords: Atrial fibrillation (AF); cardiac surgery; minimally invasive ablation.

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Conflict of interest statement

Conflicts of Interest: F.A., T.J.B. and N.V. are proctor for Medtronic. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Patient position and set-up.
Figure 2
Figure 2
Left atrial lesion set.
Figure 3
Figure 3
Endocardial lesion set with cryoprobe for inferior box line.
Figure 4
Figure 4
Mitral isthmus line. (A) Epicardial lesion; (B) endocardial lesion. IVC, inferior vena cava.
Figure 5
Figure 5
Closure of the left atrial appendage. SVC, superior vena cava.
Figure 6
Figure 6
Left sided set-up ENDO-Cab and mini-maze. ENDO-Cab, endoscopic coronary bypass. LIMA, left internal mammary artery.
Figure 7
Figure 7
Right sided set-up ENDO-Cab and mini-maze. ENDO-Cab, endoscopic coronary bypass.
Figure 8
Figure 8
Introduction of bipolar radiofrequency ablation clamp from the right side. Intrathoracic view. PA, pulmonary artery; IVC, inferior vena cava; SVC, superior vena cava; RPA, right pulmonary artery; RSPV, right superior pulmonary vein; RIPV, right inferior pulmonary vein.
Figure 9
Figure 9
Posterior view of the heart with the guides, the bipolar clamp from the left and the lesion set (in green).
Figure 10
Figure 10
Bipolar ablation from the left. LAA, left atrial appendage.
Figure 11
Figure 11
Closure of the left atrial appendage through mini sternotomy, J-incision in the 3rd intercostal space. RPA, right pulmonary artery; LAA, left atrial appendage.
See this image and copyright information in PMC

References

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