Management of focal atrial tachycardias originating from the atrial appendage with the combination of radiofrequency catheter ablation and minimally invasive atrial appendectomy

Abstract

Background: Focal atrial tachycardias (ATs) originating from the left and the right atrial appendage (AA) were the most difficult to eliminate.

Objective: To evaluate the safety and long-term efficacy of minimally invasive surgical atrial appendectomy in combination with radiofrequency catheter ablation (RFCA) in the management of focal atrial appendage tachycardias (AATs).

Methods: We included 42 consecutive patients with 42 AATs confirmed by activation mapping and contrast venography. Thirty of them were successfully managed with RFCA (RFCA-successful group), while the remaining 12 (28.6%) finally resorted to video-assisted thoracoscopic atrial appendectomy owing to RFCA failure (resort-to-surgery group). We searched for predictors of RFCA failure, and the need for surgery by using a binomial logistic regression model.

Results: In the RFCA-successful group, 6 (20.0%) patients experienced recurrence and re-do ablation and 11 (36.7%) AATs originated from distal AAs. In the resort-to-surgery group, the tachycardias involved exclusively distal AAs and required more RFCA attempts compared with those of the RFCA-successful group (1.58 ± 0.51 vs 1.20 ± 0.41; P = .0165). During atrial appendectomy, incessant ATs were terminated immediately after resection of the AA at the base. Long-term success was achieved in all 42 patients with a follow-up of 29.1 ± 17.5 months. No complications occurred. Fourteen patients with tachycardia-induced cardiomyopathy recovered fully. We identified origin at distal AATs and longer time to tachycardia termination by ablation as predictors of RFCA failure and the need for surgical intervention.

Conclusion: ATs originating from the distal portion of AA were more refractory to RFCA. The combination of catheter ablation and video-assisted thoracoscopic atrial appendectomy was an effective strategy to manage AATs.

Keywords: AA; AAT; AT; Atrial appendage; Focal atrial tachycardia; LAA; Long-term success; RAA; RFCA; Radiofrequency catheter ablation; TCM; VAT; Video-assisted thoracoscopic atrial appendectomy; atrial appendage; atrial appendage tachycardia; atrial tachycardia; left atrial appendage; radiofrequency catheter ablation; right atrial appendage; tachycardia-induced cardiomyopathy; video-assisted thoracoscopy.