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Ann Thorac Surg 1998;66:1401-1403
© 1998 The Society of Thoracic Surgeons

Case Reports

Intraoperative map-guided operation for chronic atrial fibrillation

Atsushi Harada, MDa, Tadahiko Sugimoto, MDa, Tetsuo Asano, MDa, Kenichi Yamada, MDa

a Department of Thoracic and Cardiovascular Surgery, Nippon Medical School, Chiba Hokuso Hospital, Chiba City, Japan

Accepted for publication April 19, 1998.

Address reprint requests to Dr Harada, Department of Cardiovascular Surgery, Ebina General Hospital, 1519 Kawaraguchi Ebina-city, Kanagawa, Japan


   Abstract
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 Abstract
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Intraoperative map-guided cryoablation for chronic atrial fibrillation and coronary artery bypass grafting were simultaneously performed in a 55-year-old man. Computerized atrial mapping revealed that regular and repetitive electrical discharges originated in the left atrial appendage. Without opening the left atrium, we successfully ablated atrial fibrillation with cryoablation on the epicardium of the left atrial appendage. Thus, intraoperative mapping should facilitate operations for atrial fibrillation.


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During the past decade, surgery has emerged as an increasingly important modality in the treatment of atrial fibrillation (AF). The selection of the appropriate type of surgical procedure to ablate AF should be based on the mechanism of AF, verified by electrophysiologic mapping. However, current surgical procedures for AF are complex and performed without intraoperative mapping. In this report, we present a simple procedure guided by intraoperative mapping.

A 55-year-old man was diagnosed with chronic AF and ischemic cardiomyopathy with a low left ventricular ejection fraction (0.24). The patient had maintained AF for at least 18 months. Preoperative coronary angiography demonstrated that there were chronic total occlusion in segment 1 of the right coronary artery and 90% stenosis in segment 7 of the anterior descending artery. Coronary artery grafting and ablation of AF were proposed.

Before the institution of cardiopulmonary bypass, intraoperative mapping was performed. The card-type electrode was attached to the right atrial epicardial surface to record 30 unipolar local electrograms simultaneously. Then the electrode was switched and similarly attached to the left atrial epicardial electrograms. All unipolar electrograms were recorded at a frequency response of 100 to 1,000 Hz. A computer stored the digitalized unipolar data and displayed the wave forms. A computer program determined the local activation times from the unipolar tracings. The peak negative derivative of the major deflection of the unipolar complex was defined as the time of local activation. Within 30 seconds after acquisition of the atrial epicardial electrograms, atrial activation maps for a 100-millisecond window were automatically produced from the computer analysis and displayed sequentially.

Intraoperative atrial mapping revealed that regular and repetitive electrical discharges at a cycle length of 136 milliseconds originated in the left atrial appendage (Fig 1). In contrast to the regular and repetitive activation sequences in the left atrial appendage, complex and chaotic activation sequences perpetuated in the other part of the left and right atria.



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  		Fig 1. Twelve consecutive activation maps in the posterior aspect of the left atrium for a 100-millisecond window. The same pattern of activation sequences emerged from the left atrial appendage (LAA), indicated by a closed circle, and propagated to the body of the left atrium. The repetition of the same activation sequences was demonstrated in maps A, C, D, E, F, H, I, J, and K. Isochronous lines are drawn at intervals of 5 milliseconds, and the black arrows indicate the direction of spread of the activation. (PV = pulmonary vein.)

 
After the institution of cardiopulmonary bypass, the ascending aorta was cross-clamped and the heart was arrested by cold cardioplegic solution. Cryoablation (-60°C for 3 minutes) was applied at four sites on the epicardial surface of the left atrial appendage where regular and repetitive activation originated. Other procedures, such as cryoablation on the endocardium, exclusion of the atrial appendage, and surgical incision, were not performed in either the right or left atrium. Then, in routine fashion, uneventful coronary artery bypass grafting of the left internal thoracic artery to the left descending artery and the right gastroepiploic artery to the posterior descending artery was performed. After the aortic clamp was released, the patient maintained sinus rhythm and was weaned from cardiopulmonary bypass without the use of artificial pacing. The patient has maintained normal sinus rhythm without any antiarrhythmic agents for 22 months after the operation.


   Comment
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The advent of technology for cardiac mapping has led to the elucidation of the mechanism of AF. However, it requires a sophisticated mapping system and an investigator with considerable experience. To overcome the problem of intraoperative mapping, we developed a special mapping system for analysis of AF. Then we reported the characteristics of the atrial activation during chronic AF associated with mitral valve disease. In our previous study of chronic AF [1], rapid repetitive activation originated in the left atrium and complex activation dominated in the left atrium in the majority of patients with mitral valve disease. As in our previous study of chronic AF with mitral valve disease, regular and repetitive activation originated in the left atrial appendage in the patient with ischemic cardiomyopathy. Although this repetitive activation was not determined to be reentrant or automatic in mechanism, we eradicated the electrical discharge in the left atrial appendage by cryoablation and succeeded in returning the patient to regular sinus rhythm after the operation.

Several surgical procedures to treat AF have been developed and reported [2–5]. The maze operation, a representative surgical method to ablate AF, requires considerable experience of surgeons and additional time for aortic cross-clamping. One of the advantages of the intraoperative map-guided operation is that it simplifies the complex procedure to ablate AF [6, 7]. Indeed, we applied cryoablation only on the epicardium of the left atrial appendage, without excluding the left atrial appendage or opening the left atrium. This simple procedure required an additional 15 minutes for the aortic cross-clamp time and was acceptable as a concomitant procedure to coronary artery bypass grafting.

We conclude that intraoperative mapping can guide surgeons in determining the appropriate surgical procedure and can facilitate operations to treat AF.


   References
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  1. Harada A., Sasaki K., Fukushima T., et al. Atrial activation during atrial fibrillation in patients with isolated mitral valve disease. Ann Thorac Surg 1996;61:104-112.[Abstract/Free Full Text]
  2. Cox J.L., Schuessler R.B., D’Agostino H.J., Jr, et al. The surgical treatment of atrial fibrillation: III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg 1991;101:569-583.[Abstract]
  3. Guiraudon G.M., Campbell C.S., Jones D.L., McLellan D.G., MacDonald J.L. Combined sino-atrial node atrio-ventricular isolation: a surgical alternative to His bundle ablation in patients with atrial fibrillation. Circulation 1985;72(Suppl 3):220.
  4. Graffigna A., Pagnai F., Minizioni G., Salerno J., Vigano M. Left atrial isolation associated with mitral valve operations. Ann Thorac Surg 1992;54:1093-1098.[Abstract/Free Full Text]
  5. McCarthy P.M., Castle L.W., Maloney J.D., et al. Initial experience with the maze procedure for atrial fibrillation. J Thorac Cardiovasc Surg 1993;105:1077-1078.[Abstract]
  6. Harada A., Sasaki K., Fukushima T. Combined operation for mitral valve stenosis and chronic atrial fibrillation. Ther Res 1994;14:163-166.
  7. Yamauchi S., Imura H., Bessho R., Yamada K., Tanaka S. Simultaneous surgical correction of a common atrium and impure flutter. Ann Thorac Surg 1997;64:548-552.[Abstract/Free Full Text]



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