title: Epicardial and endocardial electrophysiological guided thoracoscopic surgery for atrial fibrillation: a multidisciplinary approach of atrial fibrillation ablation in challenging patients.
abstract: BACKGROUND
  Patients with atrial fibrillation (AF) with enlarged atria or previous pulmonary vein isolation (PVI) are challenging patients for catheter ablation. Thoracoscopic surgery is an effective treatment for these patients but comes at the cost of an increase in adverse events. Recently, electrophysiological (EP) guided approaches to thoracoscopic surgery have been described which consist of EP guidance by measurement of conduction block across ablation lines. In this study we describe the efficacy and safety of EP-guided thoracoscopic surgery for AF in patients with enlarged atria and/or prior failed catheter ablation.
  
  
  RESULTS
  A total of 72 patients were included. Two different approaches to EP-guided thoracoscopic surgery were implemented: epicardial or endocardial EP-guidance at the time of surgery. Residual intraoperative conduction requiring additional ablation was detected with epicardial or endocardial mapping techniques in 50% and 11%, respectively. Additional epicardial or endocardial ablation was performed until bidirectional block was confirmed. Follow-up consisted of an ECG and a 24h Holter at 3, 6 and 12 months after the procedure. A total of 57 patients (79%) had freedom of AF and were off anti-arrhythmic drugs at one year follow-up (30 paroxysmal (83%), 27 persistent AF (75%)). Adverse events occurred in 13 patients (6 major). None of our patients died and all events were reversible.
  
  
  CONCLUSIONS
  EP-guidance of thoracoscopic surgery can be safely performed both epicardially and endocardially and is associated with a high rate of long-term maintenance of sinus rhythm in patients with enlarged atria and/or a previously failed ablation.
authors.affiliation: Heart Center, Department of Cardiology, Cardiothoracic Surgery and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Sébastien P J
authors.initials: SP
authors.lastname: Krul
authors.affiliation: Department of Cardiology, Academic Hospital Maastricht and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
authors.forename: Laurent
authors.initials: L
authors.lastname: Pison
authors.affiliation: Department of Cardiac Surgery, Academic Hospital Maastricht and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
authors.forename: Mark
authors.initials: M
authors.lastname: La Meir
authors.affiliation: Heart Center, Department of Cardiology, Cardiothoracic Surgery and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Antoine H G
authors.initials: AH
authors.lastname: Driessen
authors.affiliation: Heart Center, Department of Cardiology, Cardiothoracic Surgery and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Arthur A M
authors.initials: AA
authors.lastname: Wilde
authors.affiliation: Department of Cardiac Surgery, Academic Hospital Maastricht and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
authors.forename: Jos G
authors.initials: JG
authors.lastname: Maessen
authors.affiliation: Heart Center, Department of Cardiology, Cardiothoracic Surgery and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Bas A J M
authors.initials: BA
authors.lastname: De Mol
authors.affiliation: Department of Cardiology, Academic Hospital Maastricht and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands.
authors.forename: Harry J G M
authors.initials: HJ
authors.lastname: Crijns
authors.affiliation: Heart Center, Department of Cardiology, Cardiothoracic Surgery and Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands. Electronic address: j.r.degroot@amc.uva.nl.
authors.forename: Joris R
authors.initials: JR
authors.lastname: de Groot
mesh_terms: D000328:Adult; D000368:Aged; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology* / Q000601:surgery*; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D015716:Electrocardiography, Ambulatory; D022062:Electrophysiologic Techniques, Cardiac; D004699:Endocardium / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D006327:Heart Block / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium / Q000503:physiopathology; D011183:Postoperative Complications / Q000517:prevention & control; D011446:Prospective Studies; D013906:Thoracoscopy / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome
keywords: Atrial fibrillation; Electrophysiological mapping; Thoracoscopic surgery