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Ann Thorac Surg 2003;75:329-330
© 2003 The Society of Thoracic Surgeons
a Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, Missouri, USA
* Address reprint requests to Dr Damiano, Washington University School of Medicine, Division of Cardiothoracic Surgery, One Barnes-Jewish Hospital Plaza, Queeny Tower, Suite 3308, St. Louis, MO, USA
e-mail: damianor{at}msnotes.wustl.edu
In 1987 Dr James Cox introduced a new operation for treating atrial fibrillation. The Maze procedure created several incisions throughout both the left and right atria. These incisions were designed to block the multiple macroreentrant circuits felt to be responsible for atrial fibrillation. Over the years Dr Cox and his group had developed a successful paradigm for introducing operations for cardiac arrhythmias. This paradigm was based on first developing a sound understanding of the fundamental substrates and interactive mechanisms. Successful surgical interventions were only introduced clinically after a thorough understanding of the basic electrophysiology and anatomy was developed in the laboratory in animal models [1].
After the clinical introduction of the Maze procedure it went through several iterations before settling on what has become the gold standard for treating atrial fibrillation, the Cox-Maze III procedure. Our long-term results at Washington University have revealed a cure rate of more than 96% at 10 years [2]. Despite its remarkable success the operation has not been widely adopted by surgeons, in part owing to its technical difficulty and complexity. There also is still significant morbidity associated with this operation including the need for pacemaker implantation in as many as 10% of patients. These problems have led numerous investigators around the world to develop potentially less invasive or simpler approaches to treating this extremely common arrhythmia. A common strategy has been to replace the surgical incisions with linear lines of ablation. Various energy sources have been used to perform this ablation including radiofrequency energy, microwave, laser, cryoablation, and ultrasound [3].
The objective of these new technologies is to replace the surgical incisions with lines of transmural ablation to create conduction block. Doing so would fulfill the goal of the Cox-Maze procedure to block reentrant circuits. Theoretically this would be less invasive and easier to perform as it would replace the traditional cut-and-sew technique. However because these new ablation devices are replacing a well-developed and extensively studied operation, it is imperative that they be safe and effective and at the same time provide a truly less invasive alternative treatment option.
In the last several years many of these new technologies have been introduced clinically. The Food and Drug Administration has approved most of these devices only for soft-tissue coagulation. Unfortunately they have been used widely in an off-label manner for treating atrial fibrillation without adequate experimental or clinical investigation of their efficacy for arrhythmia ablation. The absence of peer-reviewed evaluation has led to many predictable problems. Because of the lack of established dose-response curves, surgeons have had to estimate appropriate ablation times to account for the varying thicknesses of pathologic atria encountered in the operating room. Moreover most of these technologies give no indication of when the lesion becomes transmural. These shortcomings have led to prolonged ablation times to ensure lesion transmurality. Not only can this lead to unintended collateral tissue injury [4] but also the lack of any verification of lesion transmurality and clinically relevant dose-response curves may explain the higher failure rate compared with the Cox-Maze III procedure that has been seen in some series [5, 6].
Doctor Thomas and his colleagues are to be congratulated on the careful experimental investigation of perhaps the most frequently used energy source for atrial fibrillation, unipolar radiofrequency energy [7]. The authors used a multielectrode ablation device to create lesions in 10 animals. They found that lesions were unlikely to be transmural with either epicardial or endocardial ablation when the wall thickness was greater than 4 mm. Moreover only 3 of 24 atrial epicardial lesions were transmural and that was thought to be due to endocardial cooling by circulating blood. Epicardial fat had an important negative effect on lesion formation. Prolonging the duration of ablation from 1 to 2 minutes did not significantly increase lesion depth. These are important findings with significant clinical implications. This technology does not appear to be effective in thick atrial tissue, which is often encountered at the time of valvular surgery. It also does not appear to be suited to epicardial use. Our laboratory also has reported on the inefficiency of unipolar radiofrequency energy for epicardial ablation on the beating heart [8].
These experimental results suggest that surgeons should proceed with caution when applying this new technology to patients with atrial fibrillation. Despite the lack of careful experimental studies hundreds of cases have been performed with this ablation device and others throughout the United States. It must be emphasized that FDA approval for soft-tissue coagulation does not mean that these devices are either safe or efficacious for myocardial ablation. When we already have a proven operation with relatively low rates of morbidity and mortality, it is imperative that any alternative approach be carefully investigated in the laboratory before its clinical introduction. We already have a curative procedure for treating atrial fibrillation. Patients should not be denied this operation unless the alternative approach offers substantial clinical benefits without significantly increasing the failure rate. This study and, it is hoped, many future experimental reports represent the necessary first steps in the rational introduction of these exciting new devices. In the final analysis it is our duty as surgeons, not that of industry, to insure the safety and efficacy of new technology.
References
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F. Onorati, A. Curcio, G. Santarpino, D. Torella, P. Mastroroberto, L. Tucci, C. Indolfi, and A. Renzulli Routine ganglionic plexi ablation during Maze procedure improves hospital and early follow-up results of mitral surgery. J. Thorac. Cardiovasc. Surg., August 1, 2008; 136(2): 408 - 418. [Abstract] [Full Text] [PDF]
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 S. Benussi, S. Nascimbene, A. Galanti, A. Fumero, E. Dorigo, V. Zerbi, M. Cioni, and O. Alfieri Complete left atrial ablation with bipolar radiofrequency Eur J Cardiothorac Surg, April 1, 2008; 33(4): 590 - 595. [Abstract] [Full Text] [PDF]
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F. Onorati, A. Esposito, G. Messina, A. di Virgilio, and A. Renzulli Right Isthmus Ablation Reduces Supraventricular Arrhythmias After Surgery for Chronic Atrial Fibrillation Ann. Thorac. Surg., January 1, 2008; 85(1): 39 - 48. [Abstract] [Full Text] [PDF]
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A. M. Gillinov Choice of Surgical Lesion Set: Answers From the Data Ann. Thorac. Surg., November 1, 2007; 84(5): 1786 - 1792. [Abstract] [Full Text] [PDF]
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N. Ad The multi purse string maze procedure: A new surgical technique to perform the full maze procedure without atriotomies J. Thorac. Cardiovasc. Surg., September 1, 2007; 134(3): 717 - 722. [Abstract] [Full Text] [PDF]
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E. Sagbas, B. Akpinar, I. Sanisoglu, B. Caynak, B. Tamtekin, K. Oral, and B. Onan Video-Assisted Bilateral Epicardial Pulmonary Vein Isolation for the Treatment of Lone Atrial Fibrillation Ann. Thorac. Surg., May 1, 2007; 83(5): 1724 - 1730. [Abstract] [Full Text] [PDF]
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J. R. Doty, D. B. Doty, K. W. Jones, J. H. Flores, M. Mensah, B. B. Reid, S. E. Clayson, G. Snow, E. Righter, and R. C. Millar Comparison of standard Maze III and radiofrequency Maze operations for treatment of atrial fibrillation J. Thorac. Cardiovasc. Surg., April 1, 2007; 133(4): 1037 - 1044. [Abstract] [Full Text] [PDF]
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F. Onorati, M. Bilotta, F. Borrello, M. Vatrano, A. di Virgilio, M. C. Comi, F. Perticone, and A. Renzulli Successful radiofrequency ablation determines atrio-ventricular remodelling and improves systo-diastolic function at tissue Doppler-imaging Eur J Cardiothorac Surg, March 1, 2007; 31(3): 414 - 422. [Abstract] [Full Text] [PDF]
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S. J. Melby, A. Zierer, S. P. Kaiser, R. B. Schuessler, and R. J. Damiano Jr Epicardial microwave ablation on the beating heart for atrial fibrillation: The dependency of lesion depth on cardiac output. J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 355 - 360. [Abstract] [Full Text] [PDF]
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T. Miyairi, M. Nakao, I. Kigawa, T. Kitamura, Y. Miura, M. Wakasugi, S. Fukuda, D. Sonehara, and H. Nishimura A closed biatrial procedure using bipolar radiofrequency ablation J. Thorac. Cardiovasc. Surg., July 1, 2006; 132(1): 168 - 169. [Full Text] [PDF]
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B. Akpinar, I. Sanisoglu, M. Guden, E. Sagbas, B. Caynak, and Z. Bayramoglu Combined Off-Pump Coronary Artery Bypass Grafting Surgery and Ablative Therapy for Atrial Fibrillation: Early and Mid-Term Results Ann. Thorac. Surg., April 1, 2006; 81(4): 1332 - 1337. [Abstract] [Full Text] [PDF]
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A. M. Gillinov, F. Bakaeen, P. M. McCarthy, E. H. Blackstone, J. Rajeswaran, G. Pettersson, J. F. Sabik III, F. Najam, K. M. Hill, L. G. Svensson, et al. Surgery for Paroxysmal Atrial Fibrillation in the Setting of Mitral Valve Disease: A Role for Pulmonary Vein Isolation? Ann. Thorac. Surg., January 1, 2006; 81(1): 19 - 28. [Abstract] [Full Text] [PDF]
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S. L. Gaynor, G. D. Byrd, M. D. Diodato, Y. Ishii, A. M. Lee, S. M. Prasad, J. Gopal, R. B. Schuessler, and R. J. Damiano Jr Microwave Ablation for Atrial Fibrillation: Dose-Response Curves in the Cardioplegia-Arrested and Beating Heart Ann. Thorac. Surg., January 1, 2006; 81(1): 72 - 76. [Abstract] [Full Text] [PDF]
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A. M. Gillinov, J. Sirak, E. H. Blackstone, P. M. McCarthy, J. Rajeswaran, G. Pettersson, F. J. Sabik III, L. G. Svensson, J. L. Navia, D. M. Cosgrove, et al. The Cox maze procedure in mitral valve disease: Predictors of recurrent atrial fibrillation J. Thorac. Cardiovasc. Surg., December 1, 2005; 130(6): 1653 - 1660. [Abstract] [Full Text] [PDF]
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R. E. Accord, R.-J. van Suylen, T. J. van Brakel, and J. G. Maessen Post-Mortem Histologic Evaluation of Microwave Lesions After Epicardial Pulmonary Vein Isolation for Atrial Fibrillation Ann. Thorac. Surg., September 1, 2005; 80(3): 881 - 887. [Abstract] [Full Text] [PDF]
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R. K. Wolf, E. W. Schneeberger, R. Osterday, D. Miller, W. Merrill, J. B. Flege Jr, and A. M. Gillinov Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation J. Thorac. Cardiovasc. Surg., September 1, 2005; 130(3): 797 - 802. [Abstract] [Full Text] [PDF]
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A. M. Gillinov, P. M. McCarthy, E. H. Blackstone, J. Rajeswaran, G. Pettersson, J. F. Sabik III, L. G. Svensson, D. M. Cosgrove, K. M. Hill, G. V. Gonzalez-Stawinski, et al. Surgical ablation of atrial fibrillation with bipolar radiofrequency as the primary modality J. Thorac. Cardiovasc. Surg., June 1, 2005; 129(6): 1322 - 1329. [Abstract] [Full Text] [PDF]
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S. L. Gaynor, Y. Ishii, M. D. Diodato, S. M. Prasad, K. M. Barnett, N. R. Damiano, G. D. Byrd, S. A. Wickline, R. B. Schuessler, and R. J. Damiano Jr Successful Performance of Cox-Maze Procedure on Beating Heart Using Bipolar Radiofrequency Ablation: A Feasibility Study in Animals Ann. Thorac. Surg., November 1, 2004; 78(5): 1671 - 1677. [Abstract] [Full Text] [PDF]
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S. L. Gaynor, M. D. Diodato, S. M. Prasad, Y. Ishii, R. B. Schuessler, M. S. Bailey, N. R. Damiano, J. B. Bloch, M. R. Moon, and R. J. Damiano Jr A prospective, single-center clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation J. Thorac. Cardiovasc. Surg., October 1, 2004; 128(4): 535 - 542. [Abstract] [Full Text] [PDF]
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A. M. Gillinov and P. M. McCarthy Alternative energy sources for atrial fibrillation Ann. Thorac. Surg., March 1, 2004; 77(3): 1134 - 1134. [Full Text] [PDF]
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T. B. Ferguson Jr Invited commentary Ann. Thorac. Surg., November 1, 2003; 76(5): 1715 - 1715. [Full Text] [PDF]
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