Pulmonary Vein Isolation and Autonomic Denervation for the Management of Paroxysmal Atrial Fibrillation by a Minimally Invasive Surgical Approach

Background: Advances in technology such as epicardial bipolar radiofrequency pulmonary vein isolation, ganglionated plexi identification, and isolation and thoracoscopic left atrial appendage exclusion have enabled less invasive surgical options for management of atrial fibrillation.

Methods: We performed a prospective, nonrandomized study of consecutive patients with symptomatic paroxysmal atrial fibrillation undergoing a video-assisted, minimally invasive surgical ablation procedure. The procedure consisted of bilateral, epicardial pulmonary vein isolation with bipolar radiofrequency, partial autonomic denervation, and selective excision of the left atrial appendage. Minimum follow-up was 1 year with long-term monitoring (24-hour continuous, 14-day event or pacemaker interrogation).

Results: Between March 2005 and January 2008, 52 patients (35 male), mean age 60.3 years (range, 42-79 years) underwent the procedure. The left atrial appendage was isolated in 88.0% (44/50). Average hospital stay was 5.2 days (range 3-10 days). There were no operative deaths or major adverse cardiac events. On long-term monitoring, freedom from atrial fibrillation/flutter/tachycardia was 86.3% (44/51) and 80.8% (42/52) at 6 and 12 months, respectively. Antiarrhythmic drugs were stopped in 33 of 37 patients and warfarin in 30 of 37 of the patients in whom ablation was successful at 12 months. Freedom from symptoms attributed to atrial fibrillation/flutter/tachycardia was 78.0% (39/50) at 6 months and 63.8% (30/47) at 12 months.

Conclusions: Minimally invasive surgical ablation is effective in the management of paroxysmal atrial fibrillation as evidenced by freedom from atrial arrythmias by long-term monitoring at 12 months. Measuring success using clinical symptoms underestimated clinical success as compared with long-term monitoring.