Surgical Ablation for Atrial Fibrillation

Surgical ablation for Atrial Fibrillation

With this procedure atrial fibrillation can be treated very effectively, even in complex situation after failed catheter ablations or persistent atrial fibrillation. Medications can thus be reduced, and the risk of heart failure and stroke sink drastically. It is a surgical procedure under general anaesthesia. Catheter ablation is usually the first in the line of treatment – but not always.

Highly effective in regard to freedom of Atrial Fibrillation

What is surgical ablation

For stubborn cases, we apply a unique method. Surgical ablation, also called thoracoscopic ablation, is a minimally invasive operation. It is performed by cardiac surgeons (Prof. Salzberg & Dr. van Boven) under general anaesthesia. Small incisions on the chest wall allow us to insert camera and instruments in order to gently perform the ablation procedure on the surface of the heart. We perform a pulmonary vein isolation and a complete box with bipolar radio-frequency, and close the left atrial appendage with a clip. The procedure usually takes less than 90 minutes.

For whom is surgical ablation

If you are planning to undergo a cardiac surgery – and you have symptoms of atrial fibrillation – you should be treated by a surgeon (Class I Indication). This includes surgical ablation and closure of the left atrial appendage.

If you only suffer from stand-alone or isolated atrial fibrillation, then the symptoms determine whether a minimally invasive procedure should be done. We make this decision within the HeartTeam. The operation is done to free patients from medication and to improve their quality of life. Patients who have already had a catheter ablation or are not eligible for a catheter ablation can be evaluated by our team for the procedure. But the desire or the need to stop taking blood thinners can also qualify patients.

Pulmonary vein isolation

Where the pulmonary veins flow into the heart, “misfires” (lat. Foci) arise, which can then cause the entire atrium to atrial fibrillation. At this point, it is important to make a scar and through that create an electrical barrier. This barrier prevents the "misfire" from spreading to the heart. The ablation performed with energy leads to tissue denaturation, which then over time (days-weeks) develops into a scar. This scar is the electrical insulation. That is why we speak of pulmonary vein isolation. The pulmonary vein isolation is the cornerstone of all atrial fibrillation ablation therapies.

Here a short animation depicting the procedure (without LAA closure).

Minimally Invasive technqiue

Keyhole access is used to get to the heart. We use "state of the art" bipolar radio frequency instruments. Our ablations are done on the hearts surface under direct vision in a controlled, effective and safe manner. In addition to the pulmonary veins we create a complete box lesion of the back of the left atrium. At the end of the procedure, the left atrial appendage is clipped off so that it no longer poses a danger through formations of clots. Before the ablation and after the ablation we carry out an epicardial 3D mapping to document the effects of the electrical isolation. The intervention usually lasts less than 90 minutes. The patients leave the clinic after 3-5 days to go back home.

On this picture you can see the 1cm small incision that are necessary to get to the heart. Pain is rather rare after such a procedure. Complications can occur. The doctor will educate you about all of this.

Pros and cons of the surgical ablation

Con

Epicardial targets only
Anaesthesia is necessary
3-5 days in the clinic
Not all patients qualify

Pro

No opening of the chest
Very effective and safe
Excellent long-term results
Low complication rate
Stopping anticoagulation
Less medications
Higher freedom of arrhythmias
Less symptoms
Higher quality of life (QOL)

There are many studies that provide results for surgical ablation. This method has already found its way into the most recent guidelines of the European Society for Cardiology. This technique has advantages, particularly for patients with more complex diseases. Many studies are currently underway, and the results that are presented to us are indeed promising. We would be happy to inform you.

Impressions from the operating theater

Well-rehearsed team during the approx. 90-minute intervention. All our procedures are performed in modern operating theatres for cardiac surgery. We have been doing these procedures together for over 10 years. The procedure is done under general anaesthesia without opening the chest. With our instruments, we can apply radio frequency specifically to the heart surface and thus ensure a sustainable result. By closing the left atrial appendage with a clip, discontinuation of the blood thinner can be discussed after the procedure.

Illustrations surgical ablation

The healthy heart (from behind)

The heart can be seen from behind. The four pulmonary veins come from the lungs and lead to the left atrium. At the transition from the pulmonary veins to the left atrium, within the muscle sleeves atrial fibrillation occurs like electrical misfires. These misfires are initiated by so-called triggers. These lead to an electrical chaos in the heart. The left atrial appendage is where blood clots can form - a dead end.

Pulmonary vein isolation

The ablation lines, i.e. the denaturized tissue on the surface of the heart lead to the development of scars that isolate the heart from the misfires. These scars are the result of radio frequency energy applied on the surface of the heart with our instruments. Pulmonary vein isolation is the most important therapy for atrial fibrillation. This must be permanent to ensure a good result.

Left atrial appendage closure with a Clip

DThe left atrial appendage is a small bulge in the left atrium. When atrial fibrillation occurs, blood clots can form there. That is why it is so important, to take a blood thinner to prevent stroke. If the left atrial appendage is closed, blood thinning is no longer necessary. The left atrial appendage will always be closed after a surgical ablation, but this procedure can also be done by itself. It’s called a stand-alone left atrial appendage closure.

Video

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FAQs

What are the advantages of surgical ablation?

Few complications, minimally invasive and therefore no opening of the chest, less medication, very good long-term results. Discontinuation of blood thinners, due to the removal of the left atrial appendage performed in the same procedure.

When is surgical ablation usefull?

If you are scheduled for cardiac surgery, your atrial fibrillation should be treated. Patients who have already had catheter ablation or are not candidates for catheter ablation may be evaluated for the procedure.

What are the most common symptoms of atrial fibrillation?

There are patients who experience no symptoms and only get the diagnosis through a complication, such as a stroke. Others clearly perceive atrial fibrillation: unadjusted pulse, lack of cardiac output, severe shortness of breath or panic attacks.