The first experience of a hybrid approach in the surgical treatment of atrial fibrillation

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Abstract

Background: Atrial fibrillation (AF) is the most common arrhythmia in clinical practice and is associated with an increased risk of death, progression of heart failure, and the development of cardiogenic thromboemboli. Despite the significant success in the management of AF in the paroxysmal form, the results of the treatment for patients with persistent forms of AF remain unsatisfactory. Though the surgical approach provides higher rates of efficiency regarding the restoration of a sinus rhythm, transmural lesions are not always attainable, as a result, the rate of AF recurrence in the long-term period remains fairly high. It is also impossible to create ablative patterns to the mitral and tricuspid valves during thoracoscopic epicardial ablation, which can cause the development of recurrent AF, perimitral and typical atrial flutter. Therefore, the development of hybrid approaches combining the advantages of catheter and thoracoscopic techniques is an urgent task of contemporary surgical and interventional arrhythmology.

Aims: to estimate the immediate results of a hybrid approach in the management of patients with persistent AF.

Methods: We report the first experience of a hybrid treatment of patients with persistent AF. 6 patients aged 53-64 years (1 female, 5 males) were included in the study. At the first stage, thoracoscopic epicardial bipolar ablation was performed (modified “GALAXY” protocol); the second stage (in 3 to 6 months after the thoracoscopic stage) included an intracardiac electrophysiological study with three-dimensional endocardial mapping followed by endocardial ablation.

Results: The thoracoscopic stage of the hybrid treatment included ablation according to the “box lesion” scheme using a bipolar irrigation equipment. No lethal outcomes and severe, life-threatening complications were registered. The duration of the inpatient period was 5–10 hospital-days. The 2nd stage of the hybrid treatment was limited to intracardiac electrophysiological examination only in 2 patients. In 4 patients, epicardial radiofrequency ablation was complemented by endocardial radiofrequency exposure. In 3 of the 4 patients who underwent endocardial radiofrequency ablation, catheter ablation of the mitral and cavotricuspid isthmus was required because of the induction of perimitral and typical flutter, respectively. After the 2nd stage of the hybrid treatment, at the time of discharge all the patients maintained a stable sinus rhythm. There were no severe complications or lethal outcomes.

Conclusion: a hybrid approach in the AF management is a safe and effective method of treatment, which combines the advantages of minimally invasive surgery and endocardial intervention in patients with persistent AF. The technique is safe and has acceptable short-term results.

About the authors

Aleksandr S. Zotov

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Author for correspondence.
Email: zotov.alex.az@gmail.com
ORCID iD: 0000-0003-0494-0211
SPIN-code: 9315-6570

MD, PhD

Russian Federation, 28, Orekhovy blvd, Moscow, 115682

Igor A. Khamnagadaev

Endocrinology Research Centre

Email: i@khamnagadaev.ru
ORCID iD: 0000-0002-9247-4523
SPIN-code: 6338-4990

MD, PhD

Russian Federation, Moscow

Emil R. Sakharov

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Email: sakharoom@gmail.com
ORCID iD: 0000-0003-1057-2777
SPIN-code: 6744-9462

MD

Russian Federation, 28, Orekhovy blvd, Moscow, 115682

Oleg O. Shelest

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Email: toshelest@gmail.com
ORCID iD: 0000-0002-0087-9049
SPIN-code: 1195-2022

MD

Russian Federation, 28, Orekhovy blvd, Moscow, 115682

Leonid A. Belousov

Endocrinology Research Centre

Email: 3127325@gmail.com
ORCID iD: 0000-0003-4917-1743
SPIN-code: 6468-2750
Russian Federation, Moscow

Mikhail L. Kokov

Russian State Agrarian University — Moscow Timiryazev Agricultural Academy

Email: mikhailkokov@gmail.com
ORCID iD: 0000-0003-4766-5213

MD

Russian Federation, Moscow

Marina S. Michurova

Endocrinology Research Centre

Email: michurovams@gmail.com
ORCID iD: 0000-0003-1495-5847
SPIN-code: 5655-2328
Russian Federation, Moscow

Irina A. Bulavina

Buyanov City Clinical Hospital

Email: doctoroirb@yandex.ru
ORCID iD: 0000-0002-6267-3724

MD

Russian Federation, Moscow

Robert I. Khabazov

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Email: khabazov119@gmail.com
ORCID iD: 0000-0001-6801-6568
SPIN-code: 8264-7791

MD, PhD

Russian Federation, 28, Orekhovy blvd, Moscow, 115682

Natalya G. Mokrysheva

Endocrinology Research Centre

Email: mokrisheva.natalia@endocrincentr.ru
ORCID iD: 0000-0002-9717-9742
SPIN-code: 5624-3875

MD, PhD, Professor, Correspondent member of the RAS

Russian Federation, Moscow

Aleksandr V. Troitskiy

Federal Scientific and Clinical Center for Specialized Medical Assistance and Medical Technologies of the Federal Medical Biological Agency

Email: dr.troitskiy@gmail.com
ORCID iD: 0000-0003-2143-8696
SPIN-code: 2670-6662

MD, PhD

Russian Federation, 28, Orekhovy blvd, Moscow, 115682

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Supplementary files

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2. Fig. 1. Step-by-step sequence of the procedures performed in the hybrid approach.

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3. Fig. 2. Scheme for the isolation of the antrum of the pulmonary veins and the posterior wall of the left atrium (blue lines) using a Medtronic device.

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4. Fig. 3. Stages of thoracoscopic, epicardial ablation of the left atrium: а — conductors of the ablation device are installed in the transverse and oblique sinuses of the pericardium; б — ablation of the left pulmonary veins and the posterior wall of the left atrium; в — ablation of the right pulmonary veins and the posterior wall of the left atrium; г — resection of the left atrial appendage; д — formation of a cava-caval ablation line; е — formation of an ablation line from the caval-caval line to the apex of the right atrium.

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5. Fig. 4. The final view of the ablation patterns of the biatrial scheme.

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6. Fig. 5. Three-dimensional bipolar mapping of the left atrium: а — right oblique projection 30°; б — posterior view. Note: Red areas — no electrical activity (electrical signal amplitude less than 0.1 mV). Violet color — normal electrical activity (amplitude of the electrical signal is more than 0.5 mV). Yellow, green and blue colors are intermediate values of the electrical signal amplitude from 0.1 to 0.5 mV. The dotted line marks the area with the restoration of electrical activity after the thoracoscopic fragmentation of the left atrium (LA) (after endocardial ablation of this segment, electrical activity in the antrum of the pulmonary veins is not recorded). 1 — right inferior pulmonary vein (PV); 2 — right superior PV; 3 — roof of LA; 4 — left superior PV; 5 — stump of appendage of LA; 6 — mitral valve ring.

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7. Fig. 6. Three-dimensional bipolar mapping of the left atrium (posterior view). Note: Red areas — no electrical activity (electrical signal amplitude less than 0.1 mV). Violet color — normal electrical activity (amplitude of the electrical signal is more than 0.5 mV). Yellow, green and blue colors are intermediate values of the electrical signal amplitude from 0.1 to 0.5 mV. 1 — left inferior pulmonary vein (PV); 2 — left superior PV; 3 — posterior wall of the left atrium (LA); 4 — right superior PV; 5 — right inferior PV; 6 — mitral valve ring.

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8. Fig. 7. Scheme of ablation of the left and right atria (LAO 45° Cranial 25°). Note: 1 — right superior and inferior pulmonary veins (PV); 2 — left superior PV; 3 — left inferior PV; 4 — roof of left atrium (LA); 5 — mitral valve ring; 6 — ablation line in the area of the anterior and inferior segments of the right PVs; 7 — ablation line in the area of the mitral isthmus; 8 — ring of the tricuspid valve; 9 — the ostium of the inferior vena cava; 10 — ablation line in the region of the cavotricuspid isthmus; 11 — bundle of His; 12 — the ostium of the coronary sinus.

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