What we need to do so that the glass is more than half full in stand-alone thoracoscopic ablation

Since its first description in 2005 by Wolf et al. [1], minimally invasive stand-alone thoracoscopic ablation has become a treatment option (class IIa, level of evidence B) in patients with symptomatic paroxysmal or persistent atrial fibrillation (AF), especially after failed catheter-based ablation [2]. A recent European multicentre randomized trial, which compared thoracoscopic versus catheter-based ablation showed freedom from AF rates of 72.7% for paroxysmal, 68.9% for persistent, and 54.2% for longstanding persistent AF after a mean follow-up period of 20 ± 9 months. The thoracoscopic ablation was significantly better in restoring sinus rhythm as compared to the catheter-based ablation (87% vs 56%) [3]. Similar findings have been published before, with superior results for thoracoscopic ablation (66% compared to 37% catheter-based ablation) despite a slightly higher rate of complications (e.g. pneumothorax, pacemaker implantation) [4]. Although being more invasive than catheter-based ablation, stand-alone thoracoscopic ablation results in excellent long-term results. The study from Belluschi et al. [5] sheds some light into the long-term course after thoracoscopic ablation for AF. According to their analysis, long-term results after bilateral stand-alone thoracoscopic ablation of paroxysmal AF are promising. During a mean follow-up period of 8.4 years, thoracoscopic ablation resulted in only 20% of AF recurrence, with 75% of the patients being in EHRA class I. Sinus rhythm off antiarrhythmic drugs and without electrical cardioversion or re-catheter ablation was 53%. More importantly, no stroke occurred during follow-up, although 76% of the patients were off anticoagulation therapy. This shows how effective surgical ablation in combination with left-atrial appendage management can be. The published data from Belluschi et al. gives important long-term data, and sends an important message: stand-alone thoracoscopic ablation results in favourable short- and most importantly, long-term outcomes. The surgical community must make an effort to fill up the glass with more prospective randomized data, in order to show the electrophysiological community, how effective the thoracoscopic ablation is. Achieving a sinus rhythm rate of 85% 8 years after stand-alone ablation is an excellent outcome, and should be an important key point in the decision-making process. In addition, the ability to manage the left-atrial appendage, with electrical isolation and reduction of thromboembolic risk is an advantage of the thoracoscopic approach [6]. Also, a simultaneous or staged hybrid approach can be useful, combining the advantages of thoracoscopic and catheter-based ablation. If such a hybrid approach is realized, it can significantly improve the results of catheter-based ablation alone (49.9% freedom of AF after catheter-based ablation compared to 70.7% after hybrid approach) [7, 8].

Furthermore, an ‘AF heart-team’ (as it has been established in many other fields of cardiovascular medicine) consisting of an electrophysiologist and a dedicated AF surgeon, can be a step towards the right direction in order to treat the patients hand in hand. Electrophysiologists and surgeons should work together and combine the advantages of both techniques, in the best interest of the patients. Discussing, and treating those patients with complex atrial arrhythmias together can help to offer each patient a personalized treatment strategy, with the best possible long-term outcome in terms of freedom from arrhythmias and stroke prevention.

Nevertheless, more prospective randomized studies on stand-alone ablation are necessary to persuade the electrophysiologist that the glass is at least half full, if not even full enough to consider minimally invasive stand-alone thoracoscopic ablation as the treatment of choice in selected patients with AF, especially in those with persistent AF, significantly enlarged atria or previously failed catheter ablation.

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