Minimally Invasive Surgical Treatment of Concomitant Coronary Artery Disease and Atrial Fibrillation: the First Russian Experience

Background: Atrial fibrillation (AF) is the most common type of treated heart arrhythmia. AF occurs in 5-10% of patients with coronary artery disease undergoing coronary artery bypass grafting. Only a few of them undergo concomitant AF treatment. Off-pump CABG and minimally invasive access are considered the key reasons why surgeons refuse to perform concomitant AF surgery.

Case Report 1: A 64-year-old patient presented with AF paroxysms lasting from 2016 and persistent AF lasting from 2019. Coronary angiography reported LAD stenosis of 95%. The patient had LVEF of 64%, LA anterior-posterior size of 50 mm, and no signs of valvular heart disease by ECHO-CG. AF was confirmed by ECG with giant F waves in the leads V1-V2. The patient underwent thoracoscopic radiofrequency ablation of the left atrium with the resection of the left atrial appendage and minimally invasive coronary artery bypass grafting of the anterior descending artery (MIDCAB). The patient was extubated after 6 hours. Postoperative blood loss was 100 mL. There were no recurrent angina pectoris and AF paroxysms. The patient was successfully discharged after 8 days. There were no symptoms of heart failure after 12 months. The patient was in sinus rhythm confirmed by 72-hour Holter monitoring.

Case Report 2: A 56-year-old patient was presented with AF paroxysms lasting from 2020. Coronary angiography reported LAD stenosis of 85%. The patient had LVEF of 61%, LA anterior-posterior size of 45 mm, and no signs of valvular heart disease pathology by ECHO-CG. The patient was in sinus rhythm by ECG. The patient underwent thoracoscopic radiofrequency ablation of the left atrium with the resection of the left atrial appendage and MIDCAB of the anterior descending artery. The patient was extubated after extubated after 4 hours. Postoperative blood loss was 100 mL. There were no recurrent angina pectoris and AF paroxysms. The patient was discharged after 7 days. There were no signs of recurrent angina and heart failure after 1 month of the surgery. The patient was in sinus rhythm confirmed by 24-hour Holter monitoring.

Conclusion: Both care reports have demonstrated that the minimally invasive approach to treat AF and left anterior descending artery is an effective and safe procedure.

1. Badhwar V, Rankin JS, Ad N, et al. Surgical Ablation of Atrial Fibrillation in the United States: Trends and Propensity Matched Outcomes. Ann Thorac Surg. 2017;104(2):493-500.

2. Heijden C., Segers P., Masud А., et al. Unilateral left-sided thoracoscopic ablation of atrial fibrillation concomitant to minimally invasive bypass grafting of the left anterior descending artery. J European Journal of Cardio-Thoracic Surg. 2022; Volume 62, Issue 5, ezac409, https://doi.org/10.1093/ejcts/ezac409

3. Iribarne A, DiScipio AW, McCullough JN, et al. Surgical Atrial Fibrillation Ablation Improves Long-Term Survival: A Multicenter Analysis. Ann Thorac Surg. 2019;107 (1):135-142.

4. January CT, Wann LS, Calkins H, et al. 2019 AHA/ ACC/HRS Focused Update of the 2014 AHA/ACC/ HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019;74 (1):104-132.

5. Lee R, McCarthy PM, Wang EC, et al. Midterm survival in patients treated for atrial fibrillation: a propensitymatched comparison to patients without a history of atrial fibrillation. J Thorac Cardiovasc Surg. 2012;143 (6):1341- 1351; discussion 1350-1341.

6. Musharbash FN, Schill MR, Sinn LA, et al. Performance of the Cox-maze IV procedure is associated with improved long-term survival in patients with atrial fibrillation undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2018;155 (1):159-170.