• Vol. 44 No. 1
  • 15 January 2015

A Novel “Box Lesion” Minimally Invasive Totally Thoracoscopic Surgical Ablation for Atrial Fibrillation



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Introduction: Minimally invasive surgical ablation is an emerging alternative method to catheter ablation and the full surgical maze procedure for nonpharmacologic treatment of atrial fibrillation (AF). We present a totally thoracoscopic “box lesion” radiofrequency ablation procedure in patients with paroxysmal or persistent AF.

Materials and Methods: From June 2011 to October 2012, 14 patients with lone paroxysmal (n = 7) or persistent AF (n = 7) were enrolled in this study. Procedures were performed through 3 5-12 mm holes on each side of the chest wall. A bipolar ablation device was used to create a box lesion in the posterior wall of the left atrium that encircled the 4 pulmonary veins (achieving bilateral pulmonary vein/posterior left atrial wall isolation). Perioperative complications were recorded for all patients. Freedom from AF was assessed by 24-hour Holter monitoring every 3 months or during symptoms of arrhythmia.

Results: The ablation was successfully performed in all patients, with median operation time of 128 minutes (range, 45 to 180 minutes). No operative mortality or morbidity were noted during the study period. Freedom from AF was achieved in 12 patients (85.7%) during follow-up (median follow-up 9 months). One patient with persistent AF was shifted to paroxysmal AF. No atrial flutter or atrial tachycardia was noted during the follow-up.

Conclusion: These early results show that totally thoracoscopic surgical ablation using a unique “box lesion” procedure for persistent or paroxysmal AF is a feasible and effective method with good short-term results. Further study is necessary to validate this result.


Atrial fibrillation (AF) is the most common and severe cardiac arrhythmia. It affects 0.4% to 1% of the general population, and the prevalence of AF,1 which increases with age, is 8% in people aged over 80. About three-quarters of the cases are non-valvular AF. The risk for stroke in AF patients is 5 times higher than that of the non-AF population. Maintaining sinus rhythm has been shown to be superior to heart rate control in this arrhythmia in reducing the incidence of stroke and other cardiovascular events. But the success rate of drug-only therapy or catheter ablation in maintaining sinus rhythm in AF patients does not exceed 60%.2 The traditional surgical “cut-and-sew” Cox maze III procedure is the most successful treatment for the management of AF, and has a cure rate of 95%.3 But this procedure requires sternotomy, cardiopulmonary bypass (CPB), and a complex series of incisions into the myocardium. The complexity of this technique and the risks involved in its use have prevented wide application of the procedure.

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