A Surgical Approach to Treat Atrial Fibrillation

Emory’s cardiothoracic surgeons have successfully performed nearly 500 “Totally Thoracoscopic Mini-Maze” procedures which involve totally endoscopic bilateral pulmonary vein isolation using bipolar radiofrequency energy and stapled occlusion of the left atrial appendage procedures.

The patient, a 46-year-old woman, had a history of 7 years of disabling symptoms of paroxysmal atrial fibrillation (AF). Her symptoms were interfering with her personal life and career performance as an executive resulting in “zero quality of life.” The patient was in AF approximately 50% of each day. She had failed numerous medication trials, having a variety of negative reactions to various anti-arrhythmic medications. She had undergone two percutaneous catheter ablation procedures performed out-of-state.

The patient was not interested in a third catheter procedure. She sought information online and interviewed several regional surgeons. We told her about Emory's comprehensive follow-up program and various surgical and percutaneous options. We also discussed efforts to reduce the size of the incisions and to progress to a totally endoscopic approach. She agreed to be the first patient for a trial of the totally endoscopic approach.

The Totally Thoracoscopic Mini-Maze

On February 14, we inserted three 11 mm trocars into the chest on each side under the axilla (arm pit). No other incision was made. A thoracscopic camera provided our only visualization. We measured exit and entry conduction across the pulmonary veins (PVs) on each side at the beginning of the procedure. Intraoperative electrophysiology measurements confirmed conduction block across the PV on each side.

The left atrial appendage (LAA) was stapled shut with a "no-knife" endoscopic stapling device. The device safely occludes the base of the LAA with three rows of staples and no incision in the appendage, thereby reducing the risk of hemorrhage. Blood loss was negligible. The cosmetic results were very pleasing, as the three trocar sites are small (approximately ½ inch) and located under the arm pit.

No AF at the Hospital or at Follow up

The patient showed no AF on telemetry postoperatively and was discharged home 3 days after surgery. Although she reported a single brief episode of irregular rhythm at home, she has had no AF at her 1-month and 3-month follow-up visits.  As part of Emory’s comprehensive follow-up, the patient was provided with a small, portable cardiac rhythm monitor for 2 weeks on the 3-month anniversary of her minimally invasive surgery. This monitor recorded every heart beat for 2 weeks, documenting complete absence of AF.

We are pleased with the procedural success and safety and with the impressive relief of AF in this first pioneering patient who was disabled by her AF symptoms prior to surgery. We believe that this approach offers a new and important option for carefully selected patients.

Atrial Fibrillation