totally thoracoscopic ablationtotally thoracoscopic ablation gan h dunnington md director of...
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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