Page 24 - ADD-ON ABLATION SURGERY IN PATIENTS WITH ATRIAL FIBRILLATION

Chapter 1
the advantage of shortening operative times while maintaining the efficacy of the traditional cut-and-sew Cox–Maze III.
Minimally invasive surgery
Bilateral thoracoscopic approach
The most widely employed minimally invasive approach to LAF has been the video-assisted bilateral mini-thoracotomy or thoracoscopic PV island creation and left atrial appendage (LAA) removal or exclusion, usually with ganglionic plexus evaluation and destruction. Most surgeons prefer this approach to avoid the difficult passage of the ablation device around the PVs (through the transverse and the oblique sinus) when performing a monolateral thoracoscopic approach. The percentage of success with this technique ranged from 42 to 91% in published papers (excluding case reports) at follow-up ranging from 6 and 40 months.
Right-side thoracoscopic approach
Several authors have described a right-sided port approach with two or three ports. Initially, microwave (MW) technology was employed followed by laser and unipolar suction-assisted radiofrequency. Unfortunately, significant published assessments are lacking and the only substantial reports available are for MW technology.
This approach is promising, although a limitation potentially includes the inability to remove the LAA. For this reason, Balkhy et al.135 combined the right thoracoscopic MW ablation with the incorporation of a new device for LAA exclusion (Surg-ASSIST computer-mediated thoracoscopic stapling system [Power Medical Intervention, New Hope, PA, USA]).
More recently, Solinas et al.136 employed a bipolar irrigated radiofrequency (RF) source through a monolateral right thoracotomy for left atrial ablation during minimally invasive mitral surgery. No data exist in the current literature about the feasibility of bipolar RF ablation through a right-side monolateral access in patients with LAF, which would combine the benefits for patients of a less-invasive procedure with the advantages of bipolar technology.
Right-side thoracotomy approach
A full maze lesion set using a right thoracotomy and a beating heart on cardiopulmonary bypass has been performed clinically with cryotherapy. More recently, Lee et al.137 published their results in 22 consecutive LAF patients
22