Epicardial Box Lesion Using Bipolar Biparietal Radiofrequency and Multimodality Scar Evaluation - a case series

Background Surgical epicardial AF ablation can be performed as a stand-alone (thoracoscopic) procedure or concomitant to other cardiac surgery. In hybrid AF ablation thoracoscopic surgical epicardial ablation is combined with a percutaneous endocardial ablation. The Medtronic Gemini-S clamp is a surgical tool that uses irrigated bipolar biparietal RF energy applied with two clamp lesions that overlap to create one epicardial box lesion including the posterior LA wall and the pulmonary veins. Case summary We describe three patients with therapy-refractory persistent AF and different stages of atrial remodelling in whom the Medtronic Cardioblate Gemini-S Irrigated RF Surgical Ablation System was used for hybrid AF ablation. Acute endocardial validation at the end of the hybrid ablation revealed a complete box lesion in all three cases. At 2-year follow-up, two out of three patients had recurrence of atrial arrhythmias. Invasive electro-anatomical mapping confirmed persistence of the box lesion, and the mechanism of arrhythmia recurrence in both patients was unrelated to posterior left atrium or the pulmonary veins. The third patient has been without arrhythmia symptoms since the ablation procedure. A 3D late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) illustrates the ablation scar non-invasively in two cases. Discussion Thoracoscopic biparietal RF AF ablation with the Medtronic Cardioblate Gemini-S Irrigated RF Surgical Ablation System results in permanent transmural scar formation, irrespective of the stage of atrial remodelling, as shown in this small population by means of multimodality scar evaluation.

Outcomes of left atrial appendage occlusion using the AtriClip device: a systematic review

Atrial fibrillation increases lifetime stroke risk. The left atrial appendage (LAA) is thought to be the source of embolic strokes in up to 90% of cases, and occlusion of the LAA may be safer than the alternative of oral anticoagulation. Occlusion devices, such as the AtriClipTM (AtriCure, Mason, OH, USA) enable safe and reproducible epicardial clipping of the LAA. A systematic review was performed in May 2018, based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, using the keyword ‘AtriClip’. A total of 68 papers were identified and reviewed; 11 studies were included. Data including demographics, medical history intervention(s) performed, periprocedural outcomes and follow-up were assessed and analysed. A total of 922 patients were identified. LAA occlusion was achieved in 902 out of 922 patients (97.8%). No device-related adverse events were reported across the studies. The reported incidence of stroke or transient ischaemic attack post-clip placement ranged from 0.2 to 1.5/100 patient-years. Four hundred and seventy-seven of 798 patients (59.7%) had ceased anticoagulation on follow-up. The AtriClip device is safe and effective in the management of patients with atrial fibrillation, either as an adjunct in patients undergoing cardiac surgery or as a stand-alone thoracoscopic procedure.

THORACOSCOPIC POSTERIOR TRACHEOPEXIE IN A NEWBORN WITH TRACHEOMALACIA AND ESOPHAGEAL ATRESIA

Introduction. Esophageal atresia is often accompanied by some form of tracheomalacia. Soon after birth, tracheal collapse can result in respiratory disturbances of various degrees – from mild to severe – requiring artifcial pulmonary ventilation. In this study, we describe the use of a new treatment method of tracheomalacia with posterior tracheopexie.Material and methods. A patient with tracheomalacia that developed against the background of esophageal atresia was presented in the study. A newborn boy of 2,720 g had a prenatally established diagnosis of esophageal atresia. The infant was born with the signs of respiratory disturbances. Following tracheoscopy, severe tracheomalacia was established with complete collapse of tracheal lumen. During the next thoracoscopic procedure, the trachea was fxed to the anterior longitudinal spinal ligament with several sutures.Results. Thoracoscopic posterior tracheopexie was performed prior to esophageal anastomosis. Overall duration of surgery was 85 minutes. Spontaneous breathing was restored at day 3 after the surgery. Tracheoscopy performed at day 10 after the surgery demonstrated a complete opening of the tracheal lumen.Conclusion. Promising results of the surgery prove that the procedure is effective for the treatment of tracheomalacia. Moreover, more complex (aortopexy) recurrent surgeries can be prevented using this approach as posterior tracheopexie can be performed during the primary thoracoscopic correction of esophageal atresia.

PS02.005: THORACOSCOPIC ESOPHAGECTOMY IN PRONE POSITION USING A PRECEDING ANTERIOR APPROACH FOR ESOPHAGEAL CANCER: LONG-TERM AND SHORT-TERM OUTCOMES

Background The purpose of this study was to clarify the long-term and short-term outcomes of consecutive patients who underwent thoracoscopic esophagectomy in prone position using a preceding anterior approach for the resection of esophageal cancer at a single institution. Methods We retrospectively reviewed a database of 690 patients with thoracic esophageal cancer who had undergone a thoracoscopic esophagectomy (TE, 351 patients) or an esophagectomy through thoracotomy (OE, 343 patients) between 2003 and 2017. To compare the long-term outcomes of TE and OE, we used a propensity score matching analysis and a Kaplan-Meier survival analysis. To analyze the short-term outcomes of TE, patients were chronologically divided into three groups (117 patients per group). As for thoracoscopic procedure, the esophagus was mobilized from the anterior structure during the first step and from the posterior structure during the second step. The lymph nodes around the esophagus were also dissected anteriorly and posteriorly. The intraoperative factors, the number of dissected lymph nodes, and the incidence of adverse events were compared among the three period groups. Results As for long term outcome, 203 patients from each group, for a total of 406 patients, were completely selected and paired. The 5-year survival of the TE patients (66.8%) was better than that of the OE patients (56.4%) (P = 0.044). The thoracoscopic times were 226 min, 241 min, and 214 min (P < 0.001), and the blood losses during the thoracoscopic procedure were 36.1 mL, 43.3 mL, and 18.0 mL (P < 0.001), respectively, according to the period groups. The mean numbers of harvested lymph nodes in the chest were 22.2, 25.1, and 28.9 (P < 0.001). The rates of recurrent laryngeal nerve palsy were 23.9%, 29.9%, and 8.6% (P < 0.001). Conclusion The long-term outcome of TE patients might be better than that of OE patients. As for the short-term outcomes, intraoperative factors, quality of lymph node dissection, and reduction of adverse events were best in the third period group. Establishment of standard procedure and accumulation of surgical cases seemed to make TE a safe and effective procedure for esophageal cancer. Disclosure All authors have declared no conflicts of interest.

Robot-assisted thoracoscopic repair of a late-onset Bochdalek hernia: a case report

Bochdalek hernia (BH) is a major malformation that consists of a postero-lateral diaphragmatic defect through which abdominal contents can migrate into the thorax. It is most commonly a neonatal pathology associated with significant morbidity and mortality. Rarely, this type of congenital diaphragmatic hernia (CDH) presents later in life, some even in adulthood. Indications for surgery are not clear even though the majority of authors, being aware of the possible severe complications, recommend surgical correction in all cases. Many surgical approaches have been tried for this pathology, both open (laparotomic or thoracotomic) and minimally invasive (laparoscopic or thoracoscopic). We report a case of a late-onset BH corrected with a robot-assisted thoracoscopic procedure. The use of robotic technology for CDH has never been described to date.

SINGLE-PORT VIDEO-ASSISTED THORACOSCOPIC LOBECTOMIES IN SURGICAL TREATMENT FOR LUNG CANCER

This paper summarizes recent Russian and international literature describing endoscopic surgical methods in lung cancer management, particularly, video-assisted lung anatomic resection with different approaches. Own experience of 72 video-assisted single-port lobectomies of stage I-II lung cancer patients is presented. The mean operating time in the second part of the learning curve (40 last procedures) was 90.3, statistically not different from the time of open procedure. Mean blood loss was 98,3 ml. Mean number of lymph nodes was similar in video-assisted single port and open group (14,2 vs 14,8). The conversion rate was 2,8% (2 cases). Only 5 (6,9%) non-lethal complication were associated with thoracoscopic procedure -pneumonia and 4 cases of arrhythmias. The duration of air leak was 2,3 days. The duration of chest drain use was 4,6 days. Postoperative pain was minimal, pain-killers were used not more than 2-3 days after surgery. Patients were ready to be discharges in 5, 8 days.