title: Feasibility and outcome of epicardial pulmonary vein isolation for lone atrial fibrillation using minimal invasive surgery and high intensity focused ultrasound.
abstract: OBJECTIVE
  Transvenous pulmonary vein isolation (PVI) is the cornerstone of non-pharmacological rhythm control therapy in symptomatic atrial fibrillation (AF). Success and complications rates are, however, still not optimal. New techniques and energy sources are therefore being developed.
  
  
  RESULTS
  Fifteen patients with lone AF refractory for antiarrhythmic drugs (AADs) underwent PVI by minimal invasive epicardial off-pump monolateral right-sided video-assisted thoracic surgery (VATS) using the UltraCinch with high-intensity focused ultrasound (HIFU). Primary endpoint was successful ablation defined as absence of AF or atrial flutter/tachycardia after 6 months assessed by complaints, 12 lead electrocardiogram, and 96 h Holter monitoring. Secondary endpoints were ablation success at the end of follow-up irrespective of AADs use or re-ablation and complications related to the procedure. Mean age was 47 +/- 10 years and 14 (93%) were male. Eleven (73%) had paroxysmal, and 4 (27%) patients had persistent AF. Median AF history was 5 (1-12) years. At 6 months, six (40%) patients had sinus rhythm after one epicardial PVI (four on AADs). After 1.3 +/- 0.6 years, four (27%) patients had sinus rhythm after one epicardial PVI (two on AADs) and in six (40%) patients endocardial radiofrequency re-ablation was performed, which was successful in three patients (20%). Two patients (13%) were planned for re-ablation. Three others (20%) refused re-ablation. Two major complications occurred (one late tamponade and one bleeding during surgery, necessitating sternotomy).
  
  
  CONCLUSIONS
  Epicardial PVI using monolateral right-sided VATS with the UltraCinch delivering HIFU is feasible, but is associated with substantial complications. Furthermore, the success rate was low. More research is therefore warranted to assess optimal ablation techniques and energy sources to perform PVI.
authors.affiliation: Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
authors.forename: Theo J
authors.initials: TJ
authors.lastname: Klinkenberg
authors.forename: Sheba
authors.initials: S
authors.lastname: Ahmed
authors.forename: Anita
authors.initials: A
authors.lastname: Ten Hagen
authors.forename: Ans C P
authors.initials: AC
authors.lastname: Wiesfeld
authors.forename: Eng S
authors.initials: ES
authors.lastname: Tan
authors.forename: Felix
authors.initials: F
authors.lastname: Zijlstra
authors.forename: Isabelle C
authors.initials: IC
authors.lastname: Van Gelder
mesh_terms: D001281:Atrial Fibrillation / Q000601:surgery*; D003131:Combined Modality Therapy; D005240:Feasibility Studies; D005260:Female; D006329:Heart Conduction System / Q000601:surgery*; D057086:High-Intensity Focused Ultrasound Ablation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D010496:Pericardium / Q000601:surgery*; D011667:Pulmonary Veins / Q000601:surgery*; D016896:Treatment Outcome