Endoscopic approach for epicardial bipolar radiofrequency ablation in the surgical treatment of lone atrial fibrillation

Objectives: The Cox-Maze procedure has achieved high cure rates in the surgical therapy of atrial fibrillation (AF) while becoming progressively less invasive. However, percutaneous catheter ablation has been the preferred choice of treatment for many patients with symptomatic drug-refractory AF, although incomplete ablation lines and varying long-term success rates remain a problem. The development of an endoscopic approach using bipolar radiofrequency ablation can provide an attractive and safe alternative. This report evaluates the feasibility and efficacy of this procedure. Methods: Epicardial bipolar radiofrequency ablation was performed beating heart via a bilateral endoscopic approach on 22 consecutive patients with lone AF. The pulmonary veins were isolated, a complete box-lesion set was performed including a trigonal-line to the aortic non-coronary sinus and the left atrial appendage was excluded. Bi-directional conductance block was documented and ganglionic plexus were detected and ablated. Pre-, peri- and postoperative data were collected prospectively for all patients. Mean follow-up was 204±137 days and included questionnaires and a 24-hour-ECG. Results: Mean duration of preoperative AF was 10.4±7.8 years with 73% paroxysmal and 27% persistent or long-standing persistent AF. Median operation-time was 165 minutes (121–275), median hospital-stay was 8 days (5–12). There was no death, no conversion to sternotomy and no early or late stroke. Freedom from AF was obtained in 91% of patients. Conclusions: Epicardial bipolar radiofrequency ablation beating heart can be performed endoscopically with high success rates and might develop to a good alternative to percutaneous catheter ablation in the treatment of lone AF.