Long-term follow-up of thoracoscopic ablation in long-standing persistent atrial fibrillation.

OBJECTIVES: Catheter ablation of long-standing persistent atrial fibrillation (LSPAF) remains challenging, with suboptimal success rates obtained following multiple procedures. Thoracoscopic ablation has shown effective at creating transmural lesions around the pulmonary veins and box; however, long-term rhythm follow-up data are lacking. This study aims, for the first time, to assess the long-term outcomes of thoracoscopic pulmonary vein and box ablation in LSPAF. METHODS: Rhythm follow-up consisted of continuous rhythm monitoring using implanted loop recorders or 24-h Holter recordings. Rhythm status and touch-up interventions were assessed up to 5 years. RESULTS: Seventy-seven patients with symptomatic LSPAF underwent thoracoscopic ablation in 2 centres. Freedom from atrial arrhythmias at 5 years was 50% following a single thoracoscopic procedure and 68% allowing endocardial touch-up procedures (performed in 21% of patients). The mean atrial fibrillation burden in patients with continuous monitoring was reduced from 100% preoperatively to 0.1% at the end of the blanking period and 8.0% during the second year. Antiarrhythmic drug use decreased from 49.4% preoperative to 12.1% and 14.3% at 2 and 5 years, respectively (P < 0.001). Continuous rhythm monitoring resulted in higher recurrence detection rates compared to 24-h Holter monitoring at 2-year follow-up (hazard ratio: 6.5, P = 0.003), with comparable recurrence rates at 5-year follow-up. CONCLUSIONS: Thoracoscopic pulmonary vein and box isolation are effective in long-term restoration of sinus rhythm in LSPAF, especially when complemented by endocardial touch-up procedures, as demonstrated by the 68% freedom rate at 5 years. Continuous rhythm monitoring revealed earlier, but not more numerous documentation of recurrences at 5-year follow-up.

A new approach to determine the results of minimally invasive pulmonary vein isolation using a continuous loop monitor: preliminary results.

OBJECTIVES: Surgical ablation is a well-known treatment for atrial fibrillation (AF); however, little is known about the absolute success rate. The aim of this study is to compare the absolute pre- and postoperative incidence of AF after minimally invasive surgical ablation for paroxysmal AF. METHODS: Twenty consecutive patients (mean age 55 ± 8; 55% male) received a continuous loop monitor (CLM) 4 weeks prior to a minimally invasive pulmonary vein isolation (MIPVI). The mean preoperative AF burden was compared with the mean AF burden during follow-up. Follow-up was achieved for a period of 12 months. RESULTS: Seventeen patients underwent an MIPVI successfully. Two patients did not reach the threshold for surgery. In 1 patient, surgery was discontinued because of a perioperative bleeding due to adhesions after a previous percutaneous AF ablation. Mean AF burden preoperatively was 66%. After 12 months, there was an absolute reduction in AF burden of 65% (95% CI 42-88, P < 0.001) and 12 of 15 patients in follow-up (80%) were free of AF without antiarrhythmic drugs (AADs). CONCLUSIONS: The use of a CLM in the follow-up of surgical ablation is a very accurate way to confirm absolute surgical results. Furthermore, with the use of a CLM, preoperative evaluation can be done more accurately, and the surgical procedure can be adjusted to the patients' needs.

[Surgery in patients with centrally-situated non-small cell lung carcinoma: lung-parenchymal sparing procedure versus pneumonectomy]. / Chirurgie bij patiënten met centraal gelegen niet-kleincellig longcarcinoom: longparenchymsparende ingreep versus pneumonectomie.

OBJECTIVE: To examine if lung-parenchymal sparing resection ('sleeve' resection) is a safe and oncologically responsible alternative to pneumonectomy in patients with central tumours. Further, to evaluate in how far this technique is being used in the Netherlands. DESIGN: Retrospective cohort study. METHOD: Patients undergoing either lung-parenchymal sparing procedure or pneumonectomy for centrally situated non-small cell lung carcinoma (NSCLC) between January 1995 and January 2010 were included. Early mortality, perioperative complications, survival and disease-free survival in both groups were compared. Survival was calculated using the Kaplan-Meier method. RESULTS: A total 78 patients underwent sleeve resection and 89 pneumonectomy. Early mortality (during admission or within 30 days of operation) in the sleeve-resection group was 1.3% (1 patient), and 9.0% (8) (p = 0.038) in the pneumonectomy group. In the sleeve-resection group 6.4% (5) developed a bronchopleural fistula; in the pneumonectomy group this was 4.5% (4) (p=0.735). Median survival in the sleeve-resection group was 90 months, and 1- and 5-year-survival were 88 (SD: 4) and 61% (SD: 6), respectively. Median survival in the pneumonectomy group was 17 months, with a 1- and 5-year survival of 63 (SD: 5) and 24% (SD: 5), respectively. The difference in survival was significant (p <0.001; hazard ratio: 3.27; 95% CI: 2.11-5.08). The effect of TNM stage was not statistically significant in addition to operation (p = 0.079) and TNM stage was not a clear confounder: even after analysis the hazard ratio was 2.74. In the sleeve-resection group, after 5 years disease-free survival was 62% (SD: 7). In the pneumonectomy group, this was 34% (SD: 7) (p = 0.05). CONCLUSION: Patients with centrally-situated NSCLC who undergo a lung-parenchymal sparing procedure have lower mortality and better survival than patients who undergo pneumonectomy.