Atrial Fibrillation Video Series: Day Ten
Keyhole Surgery for AF: What Is Surgical (VATS) Ablation?
We just covered catheter ablation, which is done by cardiologists using wires from the groin. Now let’s discuss another powerful treatment option: surgical atrial fibrillation ablation, specifically done via a minimally invasive (keyhole) approach. As a cardiac surgeon, this is an area I’m deeply involved in, and I want to explain it in a patient-friendly way. You might wonder, “Why would someone need surgery for AF if catheter ablation exists?” It’s a great question.
Surgical ablation for AF often comes into play for patients who either did not get a successful result from catheter ablation, or who have more advanced AF that might benefit from a comprehensive solution. It’s also considered if someone is already having heart surgery for another reason (we’ll talk more about that in a later email about valve surgery and AF).
The keyhole surgical approach, often done via VATS (Video-Assisted Thoracoscopic Surgery), means the surgeon doesn’t open the breastbone or stop the heart. Instead, we make a few small incisions (cuts about 5-10 mm long) between the ribs on the sides of the chest. Through these ports, a tiny camera and instruments are inserted to reach the heart’s surface. The goal, like catheter ablation, is to create scars that block the abnormal electrical circuits causing AF. In surgical ablation, we often use a device that clamps around the areas where the pulmonary veins connect to the left atrium, delivering energy to create a continuous line of scar. This achieves a very thorough isolation of those pulmonary veins. Because it’s done under direct vision (the surgeon can see the heart’s surface with the camera), we can ensure lesions (scar lines) are placed accurately and completely.
One big advantage of surgical ablation is that we can address the left atrial appendage (LAA) at the same time. The LAA is the small pouch where clots often form in AF (remember the stroke discussion?). In a keyhole surgical ablation, we can place a clip on that appendage from the outside of the heart, effectively sealing it off so it can’t create clots. This is a major plus for stroke prevention, potentially reducing reliance on long-term blood thinners if successful (though that decision is made on a case-by-case basis).
Surgical ablation tends to have high success rates, especially for persistent or long-standing AF where catheter ablation alone might struggle. Some studies show that a standalone surgical ablation (without any other heart surgery) can restore normal rhythm in a large percentage of patients who had stubborn AF. However, it is more invasive than catheter ablation. It typically requires general anesthesia, and a short hospital stay (a few days) to recover from the incisions and chest tube (a temporary tube to drain fluid that’s often placed for a day or two). The risks are low but include things like bleeding, infection, or fluid around the lungs (because we’re working in the chest).
For many patients, the idea of “surgery” can be intimidating, but keyhole techniques have made it much less daunting than traditional open-heart surgery. There’s no big scar down the middle of the chest and recovery is quicker (weeks rather than months). It’s an option to discuss if you’ve had unsuccessful catheter ablations or if your doctor thinks you’re a good candidate due to the nature of your AF. In my practice, I’ve seen patients who struggled for years with AF finally get back to a normal rhythm after a keyhole ablation – it can be life-changing.
Next email: Sometimes, the best approach is combining both catheter and surgical ablation in what’s called a convergent or hybrid procedure. I’ll explain how that works when cardiologists and surgeons team up to battle AF together.
