Minimally invasive atrial fibrillation ablation combined with a new technique for thoracoscopic stapling of the left atrial appendage: case report

Surgical therapy for atrial fibrillation (AF) is becoming increasingly popular in the concomitant setting. Minimally invasive techniques are being developed for management of the patient with stand-alone AF. We report on our first case of a patient undergoing thoracoscopic microwave epicardial AF ablation combined with the incorporation of a new device for left atrial appendage (LAA) exclusion. The patient is a 62-year-old man with a 10-year history of drug-resistant paroxysmal AF. He had failed multiple electrical cardioversions, as well as a percutaneous attempt at left and right superior pulmonary vein (PV) isolation. On October 8, 2003, he was admitted to undergo an off-pump thoracoscopic epicardial microwave ablation. While the patient was under general anesthesia, 3 thoracoscopic access ports were created in the right chest. The pericardium was widely opened. Red rubber catheters were positioned in the transverse and oblique sinuses. The 2 catheters were retrieved on the left side and tied together, forming a guide to the Flex 10 microwave ablation probe (Guidant Corporation, Fremont, CA, USA). The Flex 10 sheath was positioned to encircle all 4 pulmonary veins. The position of the ablation catheter was confirmed visually to be behind the LAA. Sequential ablation was then performed in the segments of the Flex 10 to create a continuous ablation line around the PVs. A connecting lesion to the base of the LAA was then performed. The LAA was then stapled using the SurgASSIST computer-mediated thoracoscopic stapling system (Power Medical Intervention, New Hope, PA, USA). The procedure was uneventful and lasted for a total of 2.5 hours. The patient was discharged home on postoperative day 2 in rate-controlled AF. He was successfully electrically cardioverted to normal sinus rhythm (NSR). At latest follow-up he remained in NSR and continued to take dofetilide (Tikosyn). Thoracoscopic epicardial microwave ablation of AF is a technically feasible procedure with minimal risk. The computer deployment and motion controlled stapling system that we used in this case has the potential to become a safe and reliable alternative to conventional stapling instruments.