Gen Thorac Cardiovasc Surg (2009) 57:612–615 DOI 10.1007/s11748-009-0441-1
CASE REPORT
Minimally invasive cardiac surgery for atrial fibrillation complicated by coronary artery disease: combination of video-assisted pulmonary vein isolation and minimally invasive direct coronary artery bypass Toshinori Totsugawa, MD · Masahiko Kuinose, MD Kosaku Nishigawa, MD · Hidenori Yoshitaka, MD Yoshimasa Tsushima, MD · Atsuhisa Ishida, MD
Received: 22 November 2008 / Accepted: 19 April 2009 © The Japanese Association for Thoracic Surgery 2009
Abstract Here we report a minimally invasive cardiac surgery procedure without sternotomy combining videoassisted bilateral pulmonary vein isolation and minimally invasive direct coronary artery bypass as treatment for atrial fibrillation complicated by coronary artery disease. The patient’s chest was accessed through a left anterolateral thoracotomy over the fourth intercostal space, and the left internal thoracic artery (LITA) was harvested under direct vision. The left pulmonary veins were isolated electrically by a bipolar radiofrequency clamp. Subsequently, the harvested LITA graft was anastomosed to the left anterior descending artery. Right pulmonary vein isolation was then performed through a small thoracotomy at the right fourth intercostal region in the same manner as the left side. A linear block on the left atrial roof, connecting the lesions encircling the left and right pulmonary veins, was created from both sides by a pen-like bipolar radiofrequency.
cant morbidity and mortality.1 Recently, the number of patients suffering from both AF and coronary artery disease (CAD) has been steadily increasing; and the patients could benefit from procedures that treat their AF together with coronary revascularization.2,3 On the other hand, the technological development of ablation devices has enabled less-invasive maze procedures such as video-assisted bilateral epicardial pulmonary vein (PV) isolation reported by Wolf et al. in 2005.4 However, we do not know of a less-invasive surgical intervention that treats both AF and CAD simultaneously. To our knowledge, this is the first report of combining videoassisted bilateral PV isolation and minimally invasive direct coronary artery bypass (MIDCAB). Here we report minimally invasive cardiac surgery without sternotomy for AF in the presence of CAD.
Case Key words Atrial fibrillation · Coronary artery disease · Pulmonary vein isolation · Video-assisted · Minimally invasive direct coronary artery bypass
Introduction Atrial fibrillation (AF), the most common sustained cardiac rhythm disturbance, is associated with signifiT. Totsugawa (*) · M. Kuinose · K. Nishigawa · H. Yoshitaka · Y. Tsushima · A Ishida Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-1-10 Marunouchi, Okayama 700-0823, Japan Tel. +81-86-225-7111; Fax +81-86-223-5265 e-mail:
[email protected]
A 53-year-old man was suffering from palpitation and dyspnea on exertion. Although he had been receiving antiarrhythmia medication for paroxysmal AF for 10 years, the highly symptomatic and drug-refractory AF was interfering with his daily life. Furthermore, coronary angiography revealed chronic total occlusion in the left anterior descending (LAD) artery with good collateral vessels from the right coronary artery. He was admitted to our hospital for the treatment of both paroxysmal AF and CAD in July 2007. On admission, the patient’s heart rate was 70 beats/ min, and his blood pressure was 140/80 mmHg. Physical examination showed no significant findings. The laboratory tests were unremarkable except for mild hyperlipidemia. Electrocardiography showed normal sinus
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rhythm at the time of admission. Transthoracic echocardiography revealed normal valve architecture and mild hypokinesis of the anterior wall of the left ventricle. The institutional review board of our hospital approved minimally invasive cardiac surgery combining videoassisted bilateral PV isolation and MIDCAB based on our excellent results with port-access surgery.5 We therefore planned on minimally invasive cardiac surgery after informed consent instead of percutaneous catheter intervention and conventional coronary artery bypass grafting (CABG) with a maze procedure. The patient’s recovery was uneventful. The chest drainage tube was removed on the first postoperative day. He had almost recovered enough for discharge within a week, but he strongly wanted to prolong the hospitalization for personal reasons. He was maintained in sinus rhythm with the administration of 10 mg of carvedilol alone. A postoperative computed tomography scan revealed a patent left internal thoracic artery (LITA) graft to the LAD. The patient was discharged from our hospital 27 days after surgery. He returned to his physical work shortly after discharge. Holter recording 6 months after surgery revealed that his heart had maintained a normal sinus rhythm. He has been asymptomatic without recurrence of AF and was free from antiarrhythmia drug therapy for the18 months since surgery.
Surgical technique The patient was placed on the operating table in a supine position with both arms extended. General anesthesia was introduced with intubation using a double-lumen endotracheal tube. A transesophageal echocardiography probe was inserted for cardiac monitoring. The table was Fig. 1 a Location of incisions. A 13-cm left anterolateral thoracotomy over the fourth intercostal space (1) and a 5-cm small thoracotomy at the right fourth intercostal region with a 1.5-cm small incision in the sixth intercostal space (2) are shown. b Lesion setup of surgical ablative therapy
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turned slightly to the right side. The patient’s chest was entered through a 13-cm left anterolateral thoracotomy over the fourth intercostal space under single-lung ventilation; no ribs were detached (Fig. 1a). The LITA was harvested under direct vision through the thoracotomy. The pericardium was then opened vertically 1 cm posterior to the phrenic nerve to expose the left pulmonary veins. Blunt dissection with a lighted articulating dissector (Wolf dissector; AtriCure, Cincinnati, OH, USA) was performed to enter the oblique sinus behind the left atrium. A bipolar radiofrequency clamp (AtriCure Isolator Transpolar Clamp; AtriCure) was placed on the left atrium medial to the left PVs, which were then isolated electrically by three overlapping lesions (Figs. 1b, 2a). The conduction block was assessed by pacing the left PVs. Subsequently, another pericardial incision anterior to the phrenic nerve was created to expose the LAD. After stabilizing the LAD using an Octopus 4 Tissue Stabilizer (Medtronic, Minneapolis, MN, USA), the LITA was anastomosed to the LAD in an end-to-side fashion with a running 7-0 polypropylene suture. The left atrial appendage was not excised. The pericardium was loosely closed, and a left pleural chest tube was placed via another intercostal space. The thoracotomy was closed in the usual manner. The table was then tilted toward the left side without repositioning the patient. A 5-cm (small) thoracotomy was performed at the right fourth intercostal region along the mid-clavicular line without spreading the ribs (Fig. 1a). After blunt dissection of the right PVs with a lighted dissector (AtriCure), the bipolar radiofrequency clamp was introduced through a 1.5-cm incision in the sixth intercostal space at the mid-clavicular line (Fig. 1a). Right PV isolation was performed in the same fashion as on the left side (Figs. 1b, 2b). A linear block
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Fig. 2 a Bipolar radiofrequency clamp (AtriCure Isolator Transpolar Clamp) was placed on the left atrium medial to the left pulmonary veins (PVs), and the left PVs were electrically isolated. b Right PV isolation was carried out in the same manner as on the left side. c A linear block on the left atrial roof was created by a
bipolar radiofrequency pen (AtriCure Isolator Transpolar Pen). H, heart; LA, left atrium; LAA, left atrial appendage; LAR, left atrial roof; LL, left lung; LPVs, left pulmonary veins; PA, left pulmonary artery; RA, right atrium; RL, right lung; RPVs, right pulmonary veins
on the left atrial roof, connecting the lesions encircling the left and right PVs, was created from both sides by a pen-like bipolar radiofrequency (AtriCure Isolator Transpolar Pen; AtriCure) (Figs. 1b, 2c). The pericardium was loosely closed. The thoracotomy was then closed, leaving a chest drain placed through a separate incision, which was used as a clamp port. The patient’s hemodynamic state was stable during the surgery including clamping of the left atrium. The operating time was 283 min.
therapy has a high incidence of recurrence and is associated with significant complications, such as PV stenosis and stroke.7 Surgical interventions would be preferable for the simultaneous treatment of AF and CAD. Combining the maze procedure and conventional CABG using cardiopulmonary bypass (CPB) would be the most effective and suitable procedure for the patients with persistent AF and triple-vessel disease, and it would present the least operative risk. However, this is also the most invasive option, even with the aid of ablation devices8; therefore, less-invasive procedure are increasingly required in the near future for many high-risk patients. Akpinar et al reported combined off-pump CABG and epicardial PV isolation in 2006.3 The procedure without CPB is undoubtedly less invasive than the combination of the maze procedure and CABG; however, the exposure and clamping of the left PV on a beating heart are technically challenging even with an apical suction device. Therefore, it is expected that most cardiac surgeons will utilize cardiopulmonary support devices such as percutaneous cardiopulmonary support (PCPS) for left PV isolation. Regardless of the use of CPB, the above-mentioned surgical interventions require median sternotomy, which is associated with certain disadvantages including increased risk for infection. We think that the maze procedure and conventional CABG using CPB is suitable for the present case; however, the patient chose the combination of videoassisted bilateral epicardial PV isolation and MIDCAB because he had to return to physical work shortly following discharge. Our method is slightly complicated owing to the need for sequential bilateral single lung ventilation; nevertheless, this procedure without ster-
Discussion It is well known that AF is associated with increased mortality, increased risk of stroke, and exacerbation of heart failure. Maintaining sinus rhythm could result in alleviation of symptoms, lower stroke risk, improved quality of life, and lower mortality risk for these patients.1 Therefore, several therapeutic options for AF were developed, ranging from the most invasive cut-and-sew maze procedure to the least invasive catheter-based PV isolation. Recently, the number of patients suffering from both AF and CAD is increasing. The literature reveals a distinct, negative effect of AF on event-free survival after CABG; therefore, a procedure treating AF and CAD simultaneously would offer improved prognosis for such patients.2,3 Combining catheter-based PV isolation and percutaneous coronary intervention (PCI) is the least invasive option and would be suitable for compromised patients. However, the clinical outcome of MIDCAB is better than that of PCI despite improved results of drug-eluting stents6; catheter-based ablative
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notomy offers advantages, including a good long-term outcome of CABG; easy transmural ablation on the left atrial cuff and the left atrial roof without hemodynamic instability; avoidance of esophageal perforation and PV stenosis; lower infection rate; less risk of the need for blood transfusion; short hospital stay; and early recovery to physical activity.5 In addition, the left atrial appendage can be easily excised in this method, although it was not resected in the present case, considering secretion of atrial natriuretic peptide, its contribution to atrial transport, and the risk of bleeding.9 Furthermore, combination of additional bypass grafting or percutaneous catheter intervention would be applied to our method in the presence of triple-vessel disease.10 However, we recommend that surgeons unfamiliar with the port-access approach avoid this method as a high level of focus is needed during blunt dissection of PVs through a small thoracotomy.
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Conclusion 6.
The combination of video-assisted bilateral PV isolation and MIDCAB is a valuable procedure that treats AF and allows coronary revascularization. It may be particularly useful for patients with a low tolerance for surgical stress such as the elderly. Because heart surgery without sternotomy offers several advantages to patients, as described, the number of cases of minimally invasive cardiac surgery for AF and CAD simultaneously is expected to increase in the future.
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References 10. 1. Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. ACC/AHA/ESC 2006 Guidelines for
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