TOTALLY THORACOSCOPICABLATIONGan H Dunnington MDDirector of Arrhythmia ProgramSt Helena Hospital2017

DISCLOSURE

• Atricure• Boon VR

Have done over 400 VATS afib AblationsSkills needed: Thoracic>> Cardiac

Laparoscopic>>VATSVery effective in hybrid setting

90% NSR at 1 year, 75% at 3 yearsNo known embolic events, or strokes

in post op period

ST HELENA AFIB SURGICAL CASE VOLUME

2012 2013 2014 2015 2016 2017(annualized)

OpenMaze

0 16 29 37 39 35

TT/Hybrid Maze

0 43 68 84 128 90

BASIC DEMOGRAPHICSPatients (n = 402)

Age 67.2 ± 8.9

Female 86 (21.4%)

Non-Paroxysmal Afib 383 (95.3%)

AF Duration 5.8 yrs

Previous Cardiac Surgery 34 (8.5%)

BMI 30.1 ± 6.0

LA Diameter (cm) 4.93 ± 0.88

COMPLICATIONS Patients (n = 402)

Death (within 30 days) 6 (1.5%)

Stroke 5 (1.2%)

Conversion to Sternotomy 3 (0.7%)

Excessive Bleeding (requiring transfusion)

3 (0.7%)

Pacemaker Insertion 8 (1.9%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 (n=255) 2 (n=121) 3 (n=49)

Perc

ent F

ree

From

ATA

Time (Years)

Freedom From Atrial Tachyarrhythmia

Taking AADs Off AADs

8888%83%

73%76% 74%80%

PATIENT SELECTION

•Symptomatic NonParoxysmal Afib•Bleeding or embolic events•Failed medical management•Failed catheter ablations•Patient choice

PATIENT SELECTION

• Different criteria for different levels of experience• Beware:

• Obese (BMI >40)• Elderly (age>80)• COPD• Renal insufficiency• Undiagnosed Valvular disease (10%)• Previous procedures/adhesions/pericarditis

PRE-OP TESTING

• Rhythm monitor or EKG to confirm• Stress Test• TTE• Chest CT (non-contrast)• Carotid dopplers

TOTALLY THORACOSCOPIC TIPS

• No Direct vision• CO2 Insufflation –so need Laparoscopic ports!• Laparoscopic Instruments (lap chole)

• Much more like a lap chole than a VATS lobe!!

POSITIONING

• Supine with arms on arm boards (opens axilla)• Dbl lumen ETT, triple lumen, radial A-line• Bladder bags behind scapulae• TEE to r/o thrombus or unexpected valvular findings• Defib pads anterior/posterior• Groins prepped• CPB standby, Bailout plan in place

PORT PLACEMENT/INSTRUMENTS/PERICARDIAL RETRACTION

• 4 ports (5mmx3, 12mmx1)• Caution to not put lowest

port under diaphragm• Generous local analgesia

• Open anterior to phrenic• Long hook cautery (hand

held!)• Endo-kittners• Laparoscopic grasper• Endostitch

CARDIAC DISSECTION

• Combo of blunt and cautery dissection

• Develop inter-atrial groove

• ”Active” Assistant - drives camera AND retracts

• Lighted Tip Dissector to encircle veins

• Possible to connect transverse and oblique sinuses

MANEUVERING BIPOLAR CLAMP

• Getting into chest• Getting heal into

pericardium• Clamp 6-10x – adjusting

between• Removal of heal first

• Must use all degrees of freedom

• Can be MOST difficult part

MAPPING AND TESTING/ABLATING GP’S

• Entry/Exit Block• Good for

communication with EP’s

• Immediate confirmation of your work

FUSION• Magnets will find each other with

minimal effort• Make sure going posterior to LAA• Heparinize to ACT 300• Establish suction

• Sometimes have to hold to maintain sxn

• Leave magnet in place for retrieval from left side

• Reinforce connection points• Close right side over drain• +/- pericardial closure

FUSION PITFALL!• Magnets will find each other with

minimal effort• Make sure going posterior to LAA• Heparinize to ACT 300• Establish suction

• Sometimes have to hold to maintain sxn

• Leave magnet in place for retrieval from left side

• Reinforce connection points• Close right side over drain• +/- pericardial closure

LEFT SIDE• Ports, pericardial opening POSTERIOR to phrenic

• Hang anterior edge• Retrieve Fusion Magnets and

re-route in opposite way• Two handed procedure

• Divide ligament of marshall• Encircle left veins and guide

Bipolar clamp into place for 6-10 clamps

• Mapping• LAA line• +/- Mitra line (LIPV to CS)

• With marking with hemoclips

POSTOP

• Intercostal nerve block• Extubate to PACU• Tele floor with PCA• CT’s/foley removed POD 1• DC home POD2 on amio, bb, lasix, colchicine, pain

meds

BEWARE!

• CPB standby – Always• Backup plan• Thoracoscopic suture

skills

BEWARE!

• CPB standby – Always• Backup plan• Thoracoscopic suture

skills

BRADYCARDIA

• Be Ready!• Have Pacing device

LUNG ADHESIONS

• Not always able to predict

• Air leaks!

SUMMARY

•Excellent procedure that can be safe and effective

• Not easy cases – STEEP LEARNING CURVE• Scope skills are essential• Backup/Bailout plan must ALWAYS be in place