Minimally Invasive Surgery for Atrial Fibrillation

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CHAPTER 30 Minimally Invasive Surgery for Atrial Fibrillation

Randall Kevin Wolf, Eric W. Schneeberger

Introduction

During the past decade, surgeons’ experience with video-assisted thoracic surgical (VATS) approaches has increased, and technologic advances in minimally invasive instrumentation have been made. One result of these improvements is that surgical ablation for atrial fibrillation can be successfully performed using minimally invasive techniques.

Approach to Video-Assisted Thoracic Surgery for Atrial Fibrillation

Order of Operative Steps

The order of the steps of the operation is as follows: establish working ports, open the pericardium, perform baseline electrophysiologic testing (including ganglion plexus stimulation), encircle pulmonary veins, isolate pulmonary veins, perform directed partial denervation of the heart, and remove the left atrial appendage (LAA).

Key Points

♦ Patients who choose a minimally invasive surgical approach to correcting atrial fibrillation usually are otherwise in good health. There is no room for error, and the mortality rate must be zero.
♦ Our bilateral VATS technique is designed to allow cardiac surgeons to achieve atrial fibrillation cures safely but without mastering totally thoracoscopic skills.
♦ The bilateral working ports are deliberately positioned directly over the pulmonary veins and on the left side over the LAA to allow direct (three-dimensional) visualization of these important structures. This increases the safety margin, especially for less experienced surgeons.

Video-Assisted Surgery for Atrial Fibrillation

Step 1. Setup

♦ Use a double-lumen endotracheal tube for selective lung ventilation, and place the central line, arterial line, and external defibrillator pads in the appropriate vector.
♦ Use sequential compression stockings on the lower extremities and a warmer to control body temperature.

Step 2. Patient Positioning and Port Placement

♦ Place the patient in the left lateral decubitus position at 45 to 60 degrees, with the right arm on an LPS Arm Support (Allen Medical, Acton, Maine).
♦ Document the external anatomy after reviewing the internal anatomy using the chest radiograph. Outline the scapula, mid-axillary line, and a line from the xyphoid posteriorly (Figure 30-1).
♦ Make the incisions as shown in Figure 30-2.
♦ First port placement

image Place the first port in the sixth or seventh intercostal space in the mid-axillary line where the xyphoid line and mid-axillary lines cross.
image Place the thoracoscope with a 30-degree lens in this port.

♦ Large working port placement

image Through the thoracoscope, identify the third (or fourth) intercostal space.
image Make a 4- to 6-cm working incision from the auscultatory triangle in the third or fourth intercostal space, and carry it anteriorly.
image For the muscle-sparing technique, if the third intercostal space is used, only the intercostal muscles need to be divided. If the fourth intercostal space is used, divide the serratus anterior in the direction of the muscle fibers. Avoid cutting the pectoralis muscle by retracting it anteriorly (Figure 30-3).
image Use caution posteriorly to retract the fat pad containing any neurovascular bundle with a finger when carrying the incision over the axillary contents.
image Insert a medium CardioVations soft tissue retractor (Edwards Lifesciences, Irvine, Calif) through the large working port.

image

Figure 30-1 Anatomic landmarks used to position the incisions properly.

image

Figure 30-2 Incisions used for video-assisted thoracic surgery for atrial fibrillation.

image

Figure 30-3 The skin retractor is positioned in the working incision.

Step 3. Pericardial Opening

♦ Exposure: Retract the lung directly posteriorly.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteromedially.
♦ Turn the electrocautery down to 15 or 20 watts.
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