ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Leif Nilsson
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Lönnerholm, S.
Right arrow Articles by Blomström-Lundqvist, C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Lönnerholm, S.
Right arrow Articles by Blomström-Lundqvist, C.
Related Collections
Right arrow Electrophysiology - arrhythmias

Ann Thorac Surg 2002;73:107-111
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Atrial size and transport function after the Maze III procedure for paroxysmal atrial fibrillation

Stefan Lönnerholm, MD*a, Per Blomström, MDa, Leif Nilsson, MDb, Carina Blomström-Lundqvist, MDa

a Department of Cardiology, University Hospital, Uppsala, Sweden
b Department of Cardiovascular and Thoracic Surgery, University Hospital, Uppsala, Sweden

Accepted for publication September 5, 2001.

* Address reprint requests to Dr Lönnerholm, Department of Cardiology, University Hospital, 751 85 Uppsala, Sweden


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Background. The Maze procedure is a curative surgical therapy for atrial fibrillation, restoring sinus rhythm and improving quality of life. Because the procedure results in tissue scarring, the atrial transport function is most likely affected.

Methods. Seventeen patients with paroxysmal atrial fibrillation underwent the Maze III procedure without any concomitant valve operation. Atrial size and transport function were measured before and at 2, 6, and 24 months after operations with two-dimensional echocardiography and pulsed-wave Doppler.

Results. Fifteen patients (88%) had signs of left atrial contractions as shown by the presence of a transmitral atrial filling wave on Doppler echocardiography at 6 months follow-up. The transmitral early filling wave and atrial filling wave were measured to calculate the early filling/atrial filling wave ratio, which increased from 1.2 before to 1.9 at 2 months after the Maze procedure (nonsignificant), and further to 2.8 at 24 months (p = 0.02). A decrease in the right and left atrial size was seen at 2 months after an operation, but no further decrease occurred.

Conclusions. In patients with paroxysmal atrial fibrillation, there is a progressive increase in the transmitral early filling/atrial filling wave ratio after the Maze procedure, consistent with a gradual decrease in the left atrial transport function.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Atrial fibrillation (AF) is a clinical challenge, since it is one of the most common tachyarrhythmias and has a significant impact on the quality of life, morbidity, and mortality of the affected individual [1]. Drug treatment to restore and maintain sinus rhythm and prevent relapse is successful in only a small number of patients [2]. Various nonpharmacological therapies have therefore been developed to improve the treatment of AF.

The Maze procedure is a surgical intervention that was developed in 1987 by Cox and coworkers [3] to restore sinus rhythm, AV synchrony, and atrial transport function in patients with AF and thereby eliminate the risk of thromboembolism. Multiple incisions are made in both atria so that the atrial masses between the incisions are below the critical reentry circuit size responsible for initiating and maintaining AF. The initial surgical technique has been gradually modified, and the third version, the Maze III procedure, is now in use [4].

Although the Maze procedure is effective in eliminating AF [5] and increasing quality of life [6] in patients with paroxysmal AF, the effect on atrial function is still unclear. The Maze procedure has been mainly offered to patients with mitral valve disease and associated AF, and only a few centers have included patients with lone AF [7–9]. Although atrial transport function after the Maze procedure has been described previously, the majority of these patients have had concomitant surgical procedures [7–13], such as mitral valve replacement, which affect the atrial size and function. Moreover, only a few patients in these studies have had sinus rhythm before the procedure, permitting an evaluation of the effects of Maze procedures per se. Because of the rather extensive surgical procedure with multiple incisions in both atria with subsequent scarring, we hypothesized that, although sinus rhythm can be restored, the atrial transport function can be adversely affected after the Maze procedure.

The purpose of this study was to longitudinally evaluate the effects of the Maze III procedure per se on atrial size and function in patients with paroxysmal AF.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
Patients
Between February 1996 and February 2000, a total of 75 patients underwent the Maze III procedure at the University Hospital of Uppsala, Sweden. In 42 of these patients the primary indication for the procedure was symptomatic and drug-refractory paroxysmal AF. Many of these patients with paroxysmal AF were in AF at the preoperative evaluation because antiarrhythmic drugs were withdrawn. The 17 patients who did not undergo any other cardiac operation (except cardiopulmonary bypass grafting in 1 patient), and who were in sinus rhythm or AAI pacemaker rhythm at the preoperative examination, constitute the study group. There were 12 males (71%) and 5 females (29%), with a mean age of 59 years (range, 34 to 72 years). Atrial fibrillation had been symptomatic (palpitations, irregular heart rhythm, breathlessness) for a mean of 16 ± 22 years (range, 3 to 25 years).

The standard Maze III procedure, described by Cox and associates [4], was completed in all patients without any modifications. The cardiopulmonary bypass time averaged 162 ± 30 minutes, and the aortic cross-clamping time was a mean of 69 ± 15 minutes. Complications occurred in 3 patients (18%); 1 patient suffered a retinal embolism during operation, and 2 patients had reoperations because of bleeding. There were no perioperative deaths.

All 17 patients were examined by echocardiography before operation and at 6 ± 1 month after the procedure. In 12 patients, echocardiography was performed serially during follow-up at a mean time of 2 ± 1, 6 ± 1, and 24 ± 3 months after the operation.

Echocardiographic examination
Echocardiographic examinations were made according to a standard study protocol by experienced technicians, supervised by a clinical physiologist. They used a Hewlett Packard Sonos 1500, 2500, or 5500 instrument with a 2.5 MHz transducer and recorded the results on VHS videotapes. The recordings were later reviewed by one cardiologist (S.L.) who measured the right and left atrial dimensions and transmitral inflow velocities. Maximal right and left atrial cavity areas were obtained by planimetry in the apical four-chamber view at the end of systole, defined as the last frame before mitral valve opening. Minimal left and right atrial cavity areas were obtained at end diastole at the time of the R wave on the electrocardiogram. The mean values were calculated from three to five consecutive beats. The atrial fractional area change (maximum area - minimum area/maximum area x 100) of the right and left atria was then calculated.

Pulsed Doppler echocardiography was used to assess the transmitral flow velocities from an apical four-chamber view with a sample volume from the tip of the mitral leaflets during diastole. Peak velocities of the early filling wave (E) and atrial filling wave (A), as well as the deceleration time of the early filling wave, were measured and averaged over three to five beats, and the early filling/atrial filling wave (E/A) ratios were calculated.

Left ventricular systolic function was visually assessed and categorized as normal (left ventricular ejection fraction > 0.50), slightly depressed (left ventricular ejection fraction, 0.45 to 0.50), moderately depressed (left ventricular ejection fraction, 0.30 to 0.45), severely depressed (0.15 to 0.30), and very severely depressed (< 0.15).

The heart rates were derived from the three-channel echocardiography recording at each echocardiography examination.

Reproducibility
Reproducibility was evaluated in 11 randomly picked examinations as the variability between a first and a second measurement at one recorded echocardiographic examination. Comparisons for reproducibility were made of the left and right atrial area fractional changes and transmitral Doppler E/A ratio. No statistically significant differences were found with the paired t test or Wilcoxon’s matched pairs test.

Statistical analysis
Measurements of atrial areas, Doppler flow velocities and heart rate are expressed as means ± one standard deviation. The results of the preoperative measurements of atrial areas and Doppler flow velocities were compared with those obtained at 6 months after operation using the paired t test. A repeated analysis of variance test was used for longitudinal follow-up comparisons in patients with complete data at all follow-up visits. The transmitral velocities could not be evaluated in 5 of 12 patients at one of the visits, as they did not have a measurable E/A ratio (nodal rhythm in 2 patients, no detectable A wave in 2, tachycardia in 1). The atrial area fractional change could not be evaluated at one of the visits in 2 of 12 patients because of poor image quality in 1 patient and a missed recording in the other patient. A p value less than 0.05 was considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
Before the operations 16 of 17 patients were in sinus rhythm and 1 of 17 patients were in AAI pacemaker rhythm. At 2 months and 6 months postoperatively all patients were in sinus rhythm. Twenty-four months postoperatively, 10 of 12 patients were in sinus rhythm, 1 of 12 patients was in nodal rhythm, and 1 of 12 patients was in AAI pacemaker rhythm.

Doppler flow velocities
A detectable transmitral A wave was found in all patients before operation and in 15 of 17 patients (88%) 6 months postoperatively. The A-wave velocity decreased from 38 ± 15 cm per second before operation to 30 ± 12 cm per second at 6 months after operation (p = 0.03). In contrast, the E-wave velocity increased from 52 ± 16 cm per second before operation to 67 ± 16 cm per second at 6 months after operation (p = 0.00006). The E/A ratio increased from 1.6 ± 0.9 preoperatively to 2.5 ± 0.9 at 6 months follow-up (p = 0.0002). The mean transmitral E-waves, A-waves, and E/A ratios for the 12 patients serially examined postoperatively are shown in Figures 1 and 2.



View larger version (20K):
[in this window]
[in a new window]
  		Fig 1. Transmitral Doppler measurements before, at 2, at 6, and at 24 months after the Maze procedure in the 7 patients with measurable early filling and atrial filling waves at all evaluations (mean and 95% confidence interval). *p less than 0.05 versus base line. **p less than 0.05 versus 2 months follow-up. All other changes are nonsignificant. (E/A-ratio = early filling/atrial filling wave ratio.)

 


View larger version (18K):
[in this window]
[in a new window]
  		Fig 2. Transmitral Doppler measurements before, at 2, at 6, and at 24 months after the Maze procedure in the 7 patients with measurable early filling and atrial filling waves at all evaluations (mean and 95% confidence interval). *p less than 0.05 versus base line. All other changes are nonsignificant. (A = atrial filling wave; E = early filling wave.)

 
Atrial area measurements
Six months postoperatively, the maximal right atrial area had decreased from a base line value of 16.4 ± 3.4 cm2 to 14.0 ± 3.2 cm2 (p = 0.0008), and the maximal left atrial area had decreased from 17.6 ± 3.2 cm2 to 15.4 ± 3.4 cm2 (p = 0.01).

The fractional change in the right atrial area decreased from 31.1 ± 12 before to 14.5 ± 9.7 (p = 0.004) at 6 months after surgery, and the fractional change in the left atrial area change decreased from 36.3 ± 9.1 to 19.9 ± 9.1 (p = 0.00005) during the same period.

The fractional changes in the atrial areas for the 12 patients serially examined postoperatively are shown in Figure 3.



View larger version (24K):
[in this window]
[in a new window]
  		Fig 3. Echocardiographic measurement of the fractional changes in the right and left atrial areas before, at 2, at 6, and at 24 months after the Maze procedure in the 10 patients with well-defined atrial boundaries at all evaluations (mean and 95% confidence interval). *p less than 0.05 versus base line. All other changes are nonsignificant.

 
Left ventricular function and heart rate
The mean heart rate increased in the immediate postoperative period, but at 24 months after the Maze procedure there was no change in heart rate compared with base line. Left ventricular systolic function did not change between measurements before, at 2 months, at 6 months, and at 24 months after the Maze procedure (Table 1). The deceleration time of the transmitral early filling wave was 223 ± 43 at base line and 216 ± 37 at 6 months (p = 0.4).


View this table:
[in this window]
[in a new window]
  		Table 1. Left Ventricular Systolic Function and Heart Rate Before and After the Maze III Procedure in the 12 Patients Followed for 24 Months

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
Although the Maze procedure is the only curative therapy for AF that is well documented, the effects on atrial transport function are still unclear. The presence of left atrial contractions after operation has been reported in 61% to 71% of patients with chronic atrial fibrillation [7, 9, 11, 12]. Atrial transport function has been difficult to assess because the Maze procedure has mainly been combined with mitral valve repair in patients with chronic AF. In one echocardiographic Doppler study, the atrial filling wave increased and the E/A ratio decreased between measurements at 19 ± 8 and 245 ± 134 days after the Maze procedure [13], which was interpreted as a gradual improvement in the atrial function after conversion to sinus rhythm as seen after electrical conversion of AF [14, 15]. A major limitation of that study was the concomitant valve operation, which probably affected both the atrial transport function and the ventricular diastolic filling pattern. In another study [9], there were no differences in transmitral or tricuspid E/A ratios at repeated follow-up visits after the Maze procedure in a mixed population of chronic and paroxysmal AF, some of whom underwent concomitant valve repair. However, the transmitral E/A ratio increased from 1.7 ± 0.8 before operation to 4.2 ± 1.2 after operation in the 5 patients with paroxysmal AF [9].

In several studies, the right atrial transport function after the Maze procedure has been comparable to that of a control population [7–13]. In a population of patients with paroxysmal AF without structural heart disease, atrial transport function, measured as the presence of an atrial filling wave with echocardiographic Doppler, was found on the left side in only 65% of the patients and on the right side in only 76%, 12 months after the Maze procedure. This is remarkably few because 92% of the patients were in stable sinus rhythm. However, no qualitative evaluation of the atrial function was made [16].

Although several studies have reported the presence of atrial contractions after the Maze procedure, comparisons with base line measurements before the procedure and information regarding the long-term effects are lacking.

Our observation of a decrease in both right and left atrial size at 2 months after the Maze procedure compared with base line may be explained by the space taken by suture lines and myocardial scarring subsequent to the extensive incisions required by the procedure. A somewhat unexpected finding was the continuous increase in the transmitral E/A ratio throughout the 24-month follow-up. The transmitral E/A ratio can be influenced by a number of factors (atrial systolic function, loading conditions, ventricular diastolic function, heart rate, and age) [17, 18]. In this study, there were no changes in the left ventricular systolic function or mean heart rate that could explain the increasing E/A ratio during the follow-up period. In situations with impaired left ventricular diastolic function as in restrictive myocardial disease, the deceleration time is markedly shortened, but that was not seen in this study. A difference in preload is an unlikely explanation for the increasing E/A ratio. It is therefore most likely that the progressive increase in transmitral E/A ratio is related to a progressive decline in the left atrial transport function.

During the Maze procedure the posterior left atrium between the pulmonary vein orifices is electrically and thus mechanically isolated, thereby preventing approximately 29% of the left atrium from contributing to the transport function [19]. It has been further hypothesized that this isolation of the posterior atrial wall in combination with a prolonged activation time of the left atrium can cause desynchronized atrial contractions. Moreover, interruption of atrial coronary arteries can result in impaired myocardial circulation [20]. In an animal study comparing atrial function after different surgical procedures for chronic AF, the Maze procedure caused a significantly higher E/A ratio postoperatively compared with a novel surgical intervention "the radial approach" [21]. This finding strongly suggests that the elevated E/A ratio seen postoperatively is caused by decreased atrial transport function due to the surgical procedure, and that the explanations for decreased atrial transport function mentioned earlier are reasonable. However, the progressive decline in the left atrial transport function observed in our study cannot be explained by the immediate atrial changes seen in this animal model.

The progressive decline in atrial transport function seen in the present study raises concerns about the long-term effects of the Maze procedure. For patients with chronic AF, any active atrial transport function is valuable if combined with restored AV synchrony. For patients with paroxysmal AF, and especially patients with lone paroxysmal AF, the atrial myocardial function is well preserved before operation, and a decrease in the atrial transport function may have significant clinical implications such as a risk of thrombus formation. At present, the magnitude of atrial contractions required to prevent thrombus formation is not known. However, there were no late complications reported by Cox and coworkers [5] after long-term follow-up of patients who underwent the Maze procedure, but cardiac function was not well described in that report. Further studies regarding the long-term effects of atrial transport function and the risk of thrombus formation are warranted. With the advent of pulmonary vein ablations, patients with paroxysmal AF should be carefully evaluated for focal origin before they are referred for the Maze procedure [22].

Study limitations
Peak atrial filling wave, early filling wave, and the E/A ratio represent an indirect method of measuring the atrial transport function. Measurements of pulmonary vein inflow velocities could perhaps have added additional data. Invasive cardiac catheterization would have been superior for determining atrial pressures and flow volumes, but it was not considered feasible for repeated measurements. Although the size of the population studied is small, it is homogeneous and without concomitant valvular disease. It was therefore possible to evaluate the effects of the surgical procedure per se on the atrial transport function. Despite these limitations, we believe that our data are important, since they are novel findings concerning an already fairly widespread surgical procedure.

Conclusions
This study evaluating patients undergoing the Maze procedure for paroxysmal atrial fibrillation shows that the left atrial transport function is reduced after operation compared with before, and continues to decrease throughout the 24-month follow-up period after the procedure. The reason for this decline is unclear.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
Grants have been provided by The Swedish Medical Society and "Kungliga Vetenskapssamhället."


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Kannel W.B., Abbott R.D., Savage D.D., McNamarra P.M. Epidemiological features of atrial fibrillation in the Framingham study. N Engl J Med 1982;306:1018-1022.[Abstract]
  2. Crijns H., Van Gelder I.C., Van Gilst W.H., Hillege H., Gosselink A.M., Lie K.I. Serial antiarrhythmic drug treatment to maintain sinus rhythm after electrical cardioversion for chronic atrial fibrillation of atrial flutter. Am J Cardiol 1991;69:335-341.
  3. Cox J.L., Schuessler R.B., D’Agostino H.J., et al. The surgical treatment of atrial fibrillation III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg 1991;101:569-583.[Abstract]
  4. Cox J.L., Boineau J.P., Schuessler R.B., Jaquiss R.D., Lappas D.G. Modification of the Maze procedure for atrial flutter and atrial fibrillation. Rational and surgical results. J Thorac Cardiovasc Surg 1995;110:473-484.[Abstract/Free Full Text]
  5. Cox J.L., Schuessler R.B., Lappas D.G., Boineau J.P. An 8-year clinical experience with surgery for atrial fibrillation. Ann Surg 1996;224:267-273.[Medline]
  6. Lonnerholm S., Blomstrom P., Nilsson L., Oxelbark S., Jideus L., Blomstrom-Lundqvist C. Effects of the Maze operation on health-related quality of life in patients with atrial fibrillation. Circulation 2000;101:2607-2611.[Abstract/Free Full Text]
  7. Feinberg M.S., Waggoner A.D., Kater K.M., Cox J.L., Lindsay B.D., Perez J.E. Restoration of atrial function after the Maze procedure for patients with atrial fibrillation. Circulation 1994;90(Part 2):II285-II292.
  8. Feinberg M.S., Waggoner A.D., Kater K.M., Cox J.L., Perez J.E. Echocardiographic automatic boundary detection to measure left atrial function after the Maze procedure. J Am Soc Echocardiogr 1995:139-148.
  9. Albrini A., Scalia G.M., Murray D., et al. Left and right atrial transport function after the Maze procedure for atrial fibrillation: an echocardiographic Doppler follow-up study. J Am Soc Echocardiogr 1997;10:937-945.[Medline]
  10. Kawaguchi A., Kosakai Y., Sasako Y., Eishi K., Nakano K., Kawashima Y. Risks and benefits of combined Maze procedure for atrial fibrillation associated with organic heart disease. J Am Coll Cardiol 1996;28:985-990.[Abstract]
  11. Isobe F., Kawashima Y. The outcome and indication of the Cox Maze III procedure for chronic atrial fibrillation with mitral valve disease. J Thorac Cardiovasc Surg 1998;116:220-227.[Abstract/Free Full Text]
  12. Kim K.-B., Cho K.R., Sohn D.-W., Ahn H., Rho J.R. The Cox Maze III procedure for atrial fibrillation associated with rheumatic mitral valve disease. Ann Thorac Surg 1999;68:799-804.[Abstract/Free Full Text]
  13. Yashima N., Nasu M., Kawazoe Hiramori K. Serial evaluation of atrial function by Doppler echocardiography after the Maze procedure for chronic atrial fibrillation. Eur Heart J 1997;18:496-502.[Abstract/Free Full Text]
  14. Scott M.E., Patterson G.C. Cardiac output after direct current conversion of atrial fibrillation. Br Heart J 1969;31:87-90.[Free Full Text]
  15. Manning W.J., Leeman D.E., Gotch P.J., Come P.C. Pulsed Doppler evaluation of atrial mechanical function after electrical cardioversion of atrial fibrillation. J Am Coll Cardiol 1989;13:617-623.[Abstract]
  16. Jessurun E.R., Van Hemel N.M., Defuaw J., Stofmeel M.A., Kelder K.C., de la Riviere A.B., Ernst J.M. Results of Maze surgery for lone paroxysmal atrial fibrillation. Circulation 2000;101:1559-1567.[Abstract/Free Full Text]
  17. Grodecki P.V., Klein A.L. Pitfalls in the echo-Doppler assessment of diastolic dysfunction. Echocardiography 1993;10:213-234.[Medline]
  18. Schirmer H., Lunde P., Rasmussen K. Mitral flow derived Doppler indices of left ventricular diastolic function in a general population. Eur Heart J 2000;21:1376-1386.[Abstract/Free Full Text]
  19. Tsui S., Grace A.A., Ludman P.F., et al. Maze 3 for atrial fibrillation: two cuts too few?. PACE 1994;17(Pt II):2163-2166.
  20. Nitta T., Lee R., Schuessler R.B., Boineau J.P., Cox J.L. Radial approach: A new concept in surgical treatment for atrial fibrillation I. Concept, anatomic and physiologic bases and development of a procedure. Ann Thorac Surg 1999;67:27-35.[Abstract/Free Full Text]
  21. Ishii Y., Nitta T., Fujii M., et al. Serial changes in the atrial transport function after the Radial incision approach. Ann Thorac Surg 2001;71:572-576.[Abstract/Free Full Text]
  22. Jais P., Haissaguerre M., Shah D.C., et al. A focal source of atrial fibrillation treated by discrete radiofrequency ablation. Circulation 1997;95:572-576.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
R. K. Voeller, A. Zierer, S. C. Lall, S.-i. Sakamoto, N.-L. Chang, R. B. Schuessler, M. R. Moon, and R. J. Damiano Jr.
The effects of the Cox maze procedure on atrial function.
J. Thorac. Cardiovasc. Surg., November 1, 2008; 136(5): 1257 - 1264.e3.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
S. Lonnerholm, P. Blomstrom, L. Nilsson, and C. Blomstrom-Lundqvist
Long-Term Effects of the Maze Procedure on Atrial Size and Mechanical Function
Ann. Thorac. Surg., March 1, 2008; 85(3): 916 - 920.
[Abstract] [Full Text] [PDF]

Home page
 J Am Coll CardiolHome page
G. Casaclang-Verzosa, B. J. Gersh, and T. S.M. Tsang
Structural and functional remodeling of the left atrium: clinical and therapeutic implications for atrial fibrillation.
J. Am. Coll. Cardiol., January 1, 2008; 51(1): 1 - 11.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
G. Bonanomi, D. Schwartzman, D. Francischelli, K. Hebsgaard, and M. A. Zenati
A new device for beating heart bipolar radiofrequency atrial ablation
J. Thorac. Cardiovasc. Surg., December 1, 2003; 126(6): 1859 - 1866.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
J. Raman, S. Ishikawa, M. M. Storer, and J. M. Power
Surgical radiofrequency ablation of both atria for atrial fibrillation: results of a multicenter trial
J. Thorac. Cardiovasc. Surg., November 1, 2003; 126(5): 1357 - 1365.
[Abstract] [Full Text] [PDF]

Home page
 Cardiovasc ResHome page
H. T Sie, W. P Beukema, A. Elvan, and A. R Ramdat Misier
New strategies in the surgical treatment of atrial fibrillation
Cardiovasc Res, June 1, 2003; 58(3): 501 - 509.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Leif Nilsson
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Lönnerholm, S.
Right arrow Articles by Blomström-Lundqvist, C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Lönnerholm, S.
Right arrow Articles by Blomström-Lundqvist, C.
Related Collections
Right arrow Electrophysiology - arrhythmias

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS