We explained all about TTA to AF patients who were interested in this new technique before surgery because TTA can be performed in patients with both persistent and paroxysmal AF. For the first time in our institution, 2 patients with persistent AF were treated with TTA. Both patients wanted to quit warfarin in spite of symptom improvement using antiarrhythmic drugs and wanted to undergo TTA on a voluntary basis. The first patient was a 66-year-old man with a 12-month history of persistent AF. His chief complaints were palpitations and dizziness. His medications included warfarin and sotalol. One attempt of cardioversion did not work. Coronary angiography and echocardiography showed that he had normal coronary arteries, normal heart valve function, left atrial diameter was 38 mm, left atrial volume index was 54.9 mL/m², left ventricular ejection fraction was 60%, and no intracardiac thrombi or vegetations were seen by transesophageal echocardiography. The second patient was 50-year-old man with a 5-year history of persistent AF. His chief complaints were dyspnea on exertion and palpitations; in addition, this patient had on-going problems with hypertension, diabetes, and alcoholism. His medications included warfarin and bisoprolol. Two attempts at cardioversion failed. Echocardiography showed that his left ventricular and heart valve function were normal and there were no intracardiac thombi, but the left atrial diameter was increased to 60 mm and left atrial volume index was 66 mL/m².

Both patients were admitted 3 days prior to their respective surgery. Oral anticoagulation was transitioned to IV heparin, transesophageal echocardiography was performed to exclude left atrial thrombi, and antiarrhythmic drugs were continued during the hospital stay. Other preoperative evaluations included a 12-lead electrocardiography, chest radiography, pulmonary function testing, coronary computed tomography, and laboratory tests.

Both TTAs were performed through 3 ports at both sides under general anesthesia with double-lumen endotracheal intubation for selective pulmonary ventilation. Starting on the right side, a 5 mm port was introduced in the fourth intercostal space at the mid-axillary line. Carbon dioxide insufflation was used to expand the operative field and depress the diaphragm. Using a 0-degree scope, good visualization was obtained. The remaining 2 ports were placed in the third intercostal space at the anterior axillary line and the sixth intercostal intercostal space at the mid-axillary line. After pericardial tenting and blunt dissection of the Waterstone groove, a lighted dissector (AtriCure Lumitip Dissector, Atricure, Inc., Cincinnati, OH, USA) was used to pass a rubber band under the PV antrum. Then, an AtriCure Isolator Transpolar Clamp (Atricure, Inc., Cincinnati, OH, USA) (Fig. 1A) was connected to the rubber band and positioned around the PV antrum. PV antrum isolation was performed via the application of bipolar RF energy 6 times to the clamps around the PV antrum. To prevent macro-reentry, we made an additional inferior ablation line connecting both PV isolation lines. GPs were subsequently ablated with bipolar RF energy. GPs around PV antrum were ablated with AtriCure Cooltip pen (Atricure, Inc., Cincinnati, OH, USA) three times. Confirmation of ablation lines was performed via pacing testing using the AtriCure Cooltip pen. The procedure was then repeated on the left side. A 5 mm port was introduced in the left fourth intercostal space at the mid-axillary line for the thoracoscope. The locations of the remaining 2 ports were symmetrical bilaterally. After PV and GP ablation, the ligament of Marshall was dissected and ablated. After all ablations were completed and conduction block was confirmed, the LAA was removed with an endoscopic stapling device (Fig. 1B). Single chest tubes were inserted bilaterally. The patients were monitored for the first 24 hours in the intensive care unit. Postoperatively, both patients received warfarin and amiodarone for 6 months. During follow-up, we had each patient undergo 24 hours of Holter monitoring at 6 months postoperative; at one-year postoperative, both patients will undergo 2-weeks long-term monitoring.

The right and left groin areas and left subclavian area were infiltrated with lidocaine. Sheaths were placed: one 7.5 Fr sheath and one 6 Fr sheath in the right femoral vein. A quadripolar catheter was placed from the right femoral vein into the apex of the right ventricle. After positioning the catheter, one SL1 sheath was introduced into the left atrium through transseptal puncture using fluoroscopy and blood pressure monitoring. Systemic anticoagulation with intravenous bolus injection of 3000 U heparin was initiated just after the trans-septal insertion of the sheath. Under fluoroscopic exam, the SL1 sheath position was confirmed. We inserted lasso catheters of 15-25 mm diameter into the PVs and their potentials were checked. We measured the conduction intervals of posteroanterior, AH, and. We determined antegrade and retrograde refractory periods. After the procedures were completed, we pulled out all catheters and a complete hemostasis was performed on each patient.