Minimally invasive epicardial posterior left atrial wall isolation: technique and results

Abstract

Atrial fibrillation (AF) is the most frequent arrhythmia in clinical practice. Catheter and surgical ablation has emerged as an alternative to maintain sinus rhythm and to avoid long-term AF complications. An ablation technique aims to target the triggers and the substrate of AF to prevent initiation and perpetuation of this arrhythmia. Surgical ablation is the gold standard in AF ablation; it has the best results in maintaining sinus rhythm in patients with persistent AF. Epicardial posterior left atrial wall isolation by right monolateral thoracoscopic approach is a minim invasive surgical technique that aims to eliminate major ganglionated plexi isolation influence on atrial myocardium in addition to pulmonary vein isolation. The exclusion of the left atrial posterior wall, including the pulmonary veins (considered as triggers or initiators) could be completed with an additional isolation/destruction of the adjacent major ganglionated plexi (considered as substrate modifiers) including the complex interconnection neural network which could add to influence the persistence of AF. Different hybrid surgical ablation lesions sets were developed, usually in a manner less than the full Cox-Maze IV lesion set. They are performed epicardially via minimally invasive (non-sternotomy) approaches without cardiopulmonary bypass, followed by catheter-based endocardial mapping, and if necessary additional ablation lines. The results of these innovative techniques are promising in persistent and long persistent AF. Epicardial right monolateral thoracoscopic approach to isolate the pulmonary vein and the major ganglionated plexi isolation in symptomatic refractory persistent AF patients is feasible and efficient.