title: Thoracoscopic pulmonary vein isolation in patients with atrial fibrillation and failed percutaneous ablation.
abstract: OBJECTIVE
  Pulmonary vein isolation is indicated in patients with symptomatic isolated atrial fibrillation not controlled with antiarrhythmic therapy. We describe our surgical experience with thoracoscopic pulmonary vein isolation in patients in whom percutaneous ablation has failed.
  
  
  METHODS
  Thirty-four adult patients with unsuccessful catheter ablations (range 1-4, mean 2 +/- 1) underwent thoracoscopic bipolar-radiofrequency pulmonary vein isolation. Seventeen patients had paroxysmal atrial fibrillation, 12 with persistent and 5 with long-standing persistent fibrillation, for a mean of 6 years (range 3-10 years), 13 years (5-25 years), and 9 years (3-15 years), respectively.
  
  
  RESULTS
  There was no mortality during the procedure or follow-up (mean 16 +/- 11 months). Two patients needed conversion to thoracotomy owing to hemorrhage, and ablation could not be completed. Antiarrhythmic therapy was withdrawn 3 months postoperatively. Postoperative sinus rhythm was maintained in 82% of those with paroxysmal atrial fibrillation (13/15 at 6 months, 9/11 at 12 months), 60% had persistent atrial fibrillation (8/12 at 6 months and 6/10 at 12 months), and 20% had long-standing persistent atrial fibrillation (1/5 at 6 and 12 months). Preoperative left atrial diameter significantly differed between patients with paroxysmal fibrillation (mean 42 +/- 6 mm) and those with persistent and long-standing persistent fibrillation (means 50 +/- 4 and 47 +/- 2 mm). Left atrial size greater than 45 mm and atrial fibrillation type were preoperative factors that significantly influenced outcome in the univariate logistic regression analysis.
  
  
  CONCLUSIONS
  Thoracoscopic pulmonary vein isolation in patients with previously unsuccessful catheter ablations demonstrates satisfactory sinus rhythm maintenance rates in paroxysmal and persistent atrial fibrillation, but not in long-standing persistent atrial fibrillation. As with other minimally invasive surgical techniques, there is an important learning curve.
authors.affiliation: Department of Cardiovascular Surgery, Institut del Tòrax, Hospital Clínic, University of Barcelona, Barcelona, Spain. mcaste@clinic.ub.es
authors.forename: Manuel
authors.initials: M
authors.lastname: Castellá
authors.forename: Daniel
authors.initials: D
authors.lastname: Pereda
authors.forename: Carlos A
authors.initials: CA
authors.lastname: Mestres
authors.forename: Félix
authors.initials: F
authors.lastname: Gómez
authors.forename: Eduard
authors.initials: E
authors.lastname: Quintana
authors.forename: Jaume
authors.initials: J
authors.lastname: Mulet
mesh_terms: D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000503:physiopathology / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011667:Pulmonary Veins / Q000503:physiopathology / Q000601:surgery*; D018570:Risk Assessment; D012307:Risk Factors; D013030:Spain; D020775:Thoracic Surgery, Video-Assisted / Q000009:adverse effects; D013908:Thoracotomy; D013997:Time Factors; D017211:Treatment Failure