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European Heart Journal Advance Access published online on January 6, 2005
European Heart Journal, doi:10.1093/eurheartj/ehi097
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European Heart Journal © The European Society of Cardiology 2005; all rights reserved

Preclinical paper

Robot-assisted epicardial ablation of the pulmonary veins: is a completed isolation necessary?

Thomas J. van Brakel 1*, Gil Bolotin 2, L. Wiley Nifong 2, André L.A.J. Dekker 1, Maurits A. Allessie 3, W. Randolph Chitwood Jr2, and Jos G. Maessen 1

1 Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, University Hospital Maastricht, P. Debyelaan 25, Postbus 5800, 6202 AZ Maastricht, The Netherlands
2 Department of Surgery and the Center for Minimally Invasive and Robotic Surgery, Brody School of Medicine, East Carolina University, Greenville, USA
3 Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands

* To whom correspondence should be addressed.
Thomas J. van Brakel, E-mail: t.vanbrakel{at}ctc.unimaas.nl


  Abstract

Aims To study the feasibility and electrophysiological efficacy of minimally invasive beating heart ablation of the pulmonary veins (PVs) via a robot-assisted single-sided approach.

Background PV isolation by minimally invasive epicardial ablation may offer a new treatment for patients with lone atrial fibrillation (AF). However, complete PV isolation has been shown to be difficult to obtain.

Methods and results In 14 mongrel dogs, robot-assisted epicardial microwave ablation was performed on the beating heart by a single-sided right chest approach. Isolation of all PVs was performed in two steps to study the effect of an incomplete and a complete isolation on AF. AF was studied by random and burst pacing. Incremental pacing was performed to study conduction characteristics across the lesions. Opening of the pericardial reflections, introduction of the catheter and ablation were robotically feasible by a single-sided approach in 11 dogs. The AF duration decreased from 6.6 ± 4.1 to 1.3 ± 0.8 s (P = 0.03) and 1.6 ± 1.6 s (P = 0.04 compared with control) after incomplete and completed isolation of the PVs. The AF cycle length increased from 134 ± 5 to 141 ± 5 and 145 ± 8 ms (P = 0.03) after incomplete and complete isolation, respectively. Several incomplete lesions showed 2 : 1 exit and/or entrance block during incremental pacing. After complete isolation, AF was no longer inducible from the PVs.

Conclusion Epicardial PV isolation can be successfully performed by a single-sided robot-assisted approach. The effect of PV ablation on AF is not an all or none phenomenon. Incomplete isolation already decreases AF duration and lengthens the AF cycle length. However, complete isolation is necessary to prevent AF induction by triggering from the isolated area.

Keywords: Ablation; Epicardial; Robot; Pulmonary veins; Atrial fibrillation.
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