Discussion
Cardiac tamponade is the most frequent lethal complication after
catheter ablation and is an independent predictor for mortality(5,6).
Standard non-surgical management after cardiac perforation includes
percutaneous pericardiocentesis. The risk of late term tamponade still
exists combined with the inherent risks of the procedure such as
pleural, liver or cardiac puncture. It gives a false sense of security
and prolongs the interval until surgical exploration, which is still
necessary in up to 50% of cases(1,7). This study analysed the
feasibility of VATS exploration after cardiac perforation. It concludes
that VATS leads to a significantly lower 30-day mortality but there are
no differences to all-round mortality, length of ICU or hospital
stay. Since this is a novel technique, there is little to no available
reference literature.
Thoracoscopy avoids the supplementary burden of a full sternotomy and
obsoletes its inherent risks such as wound infection of sternal
detachment. In contrast to other authors(8), we believe thoracoscopy is
faster than a full sternotomy in a dedicated minimally invasive
cardiothoracic centre, allowing to quickly estimate the size of the
problem and avoiding a full sternotomy for minor perforations.
Almost all possible perforation sites are thoracoscopically accessible.
As stated before, most perforations occur at the left atrium or left
atrial appendage, which is easily accessible by left sided thoracoscopy
even on the beating heart. Should the damage done exceed the limitations
of VATS, conversion to full sternotomy is still possible as happened
twice in the sternotomy cohort. One case was converted due to massive
right ventricle wall rupture after perforating the interventricular
septum. Another case was converted to full sternotomy due to the
proximity of the perforation to the right coronary artery, requiring
closer inspection and complex reconstruction.
Ischemic cerebral and cardiac damage are among the most common causes of
death after ablation(6). Most common reason for prolonged ischemic
interval are delayed transport to the operating theatre. Femoral
cannulation by percutaneous puncture and Seldinger technique can even be
done outside the operating theatre, minimizing this ischemic interval.
We experience that the longer the delay, the poorer the neurological
prognosis.
Lastly, thoracoscopy is an accessible and reproducible method with
minimal economic burden. Its main downside is a steep learning curve,
emphasizing the need for proper training in centres dedicated to
minimally invasive cardiac surgery.
There are several limitations to be adressed. Firstly, the patient group
is rather small and single centre. To our knowledge, there are no other
centres with the same approach to these cardiac emergencies. Secondly,
patients were not randomised. VATS was only performed when the surgeon
capable of it was on call for these emergencies. However, there was no
patient preselection for either group, confirmed by the absence of
differences in the baseline characteristics. For example, one could
argue that the more obese patient would be difficult to explore
thoracoscopically or that the more critique patient is preselected for
sternotomy. However, the results deny any treatment allocation. Thirdly,
the delay between perforation recognition and surgical exploration could
not be withdrawn from our database, which undeniably correlates with
(neurological) outcome.