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J Thorac Cardiovasc Surg. 2012 Dec;144(6):1460-5; discussion 1465. doi: 10.1016/j.jtcvs.2012.08.069. Epub 2012 Oct 11.

Durable staged hybrid ablation with thoracoscopic and percutaneous approach for treatment of long-standing atrial fibrillation: a 30-month assessment with continuous monitoring.

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Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy.



Electrophysiologic and surgical procedures to treat stand-alone atrial fibrillation (AF) have recently evolved, but disappointing results in patients with long-standing persistent (LSP) AF have challenged the durability of these procedures.


Lone AF patients (n = 36) with either LSP-AF (n = 28) or persistent AF (n = 8) were prospectively enrolled in the study and consecutively treated by thoracoscopic ablation followed by electrophysiologic evaluation 30 days afterward. Mean left atrial dimension was 50.3 ± 5.5 mm, and average AF duration was 72.8 months (range, 7-240 months). The thoracoscopic procedure was a right monolateral approach to create a box lesion using a temperature-controlled radiofrequency device with suction adherence. A continuous rhythm monitoring device was implanted at the end of the operation.


Thoracoscopic ablation was successfully completed without morbidity or mortality and without any intensive care unit stay. Intraoperative exit and entrance block was achieved in 100% and 88.8% (32/36) of patients, respectively. At 33 ± 2 days after the operation, an electrophysiologic study confirmed entry-exit block in 83.3% (30/36) whereas pulmonary vein reconnections were observed in 16.7% (6/36) of patients. Additional transcatheter lesions were performed in 61.1% (22/36) of patients. At a mean follow-up of 30 months (range, 1-58 months), 91.6% (33/36) of patients are in sinus rhythm with 77.7% (28/36) of these patients off antiarrhythmic drugs and 88.8% (32/36) free of warfarin. Long-term incidence of left atrial flutter was 0%.


The combination of a surgical box lesion and transcatheter ablation in a hybrid approach provided excellent durable clinical outcomes in patients with LSP-AF.

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