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Ann Thorac Surg 2003;75:1979-1981
© 2003 The Society of Thoracic Surgeons

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How to do it

A tailored anatomical approach to prevent complications during left atrial ablation

^a Division of Cardiac Surgery, S Raffaele University Hospital, Milan, Italy

Accepted for publication November 25, 2002.

^* Address reprint requests to Dr Benussi, Division of Cardiac Surgery, S Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy
e-mail: stefano.benussi{at}hsr.it

	Abstract

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Atrial fibrillation ablation surgery has grown very popular in recent years. Modern techniques involve creation of linear scars on the left atrial wall using different ablation devices. That raises the concern about new major surgical complications that can be caused by the ablation procedure. Postablation coronary obstruction and esophageal injury have been described. We report our present strategy for left atrial ablation in which the lesion set is tailored to the specific coronary anatomy. Safeguards to prevent esophageal and bronchial injury are also outlined.

	Introduction

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Owing to the increasing popularity of atrial fibrillation (AF) surgery, prevention of the potential ablation-related complications is becoming a major issue. Ablating close to the esophagus or across a major coronary branch can cause irreversible damage leading to dramatic clinical complications. Two cases of esophageal injury after left atrial radiofrequency ablation have been recently reported [1,2]. Similarly, coronary obstruction has been described as complicating both radiofrequency and cryoablation [1, 3, 4]. We describe our present strategy to prevent the risk of coronary injury while ablating across the atrioventricular (AV) groove to reach the mitral anulus. Some tips on how to predictably avoid esophageal and bronchial complications are also outlined.

	Technique

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As with most left atrial approaches, our original lesion set involves a connecting line to the posterior mitral anulus [5, 6]. To avoid ablating across a major coronary branch in the atrioventricular (AV) groove the route of the mitral line (Fig 1 , dotted line) is tailored on the specific coronary anatomy. In the case of a strongly dominant right coronary artery when the circumflex ends with a ramus medianus or an early marginal branch, the mitral line is performed following the shortest route to the mitral valve and reaches the posterior anulus between its mid portion and the anterolateral commissure (Fig 1A). When the right coronary artery is mildly dominant, the circumflex artery usually gives rise to one or two marginal branches and dwells in the lateral portion of the posterior AV groove. In this case the ablation connecting the mitral valve with the appendage is conducted to the medial portion of the posterior anulus with a curved shape in order to cross the AV groove perpendicularly (Fig 1B). In a minority of patients (about 10%) with a dominant circumflex artery, the lesion set is modified as follows: the mitral ablation line is performed from the right encircling and reaches the anulus close to the medial commissure, parallel and close to the interatrial septum (Fig 1C).

View larger version (54K): [in this window] [in a new window]   Fig 1. Tailoring of the ablation set based on coronary anatomy. Three different coronary anatomical situations (left coronary angiogram in the right anterior oblique projection) are outlined together with the corresponding suggested routes of the mitral line (arrow): (A) From the appendage to the lateral half of the posterior anulus in patients with a strongly dominant right coronary artery. (B) From the appendage to the medial portion of the posterior anulus, crossing the AV groove perpendicularly, in patients with a mildly dominant right coronary artery. (C) From the right encircling to the medial commissure, close to the interatrial septum in patients with a left dominant coronary circulation. Dotted line = ablations; solid line = surgical incision; arrow = mitral line. (LA = sutured left appendage; LPVs = left pulmonary veins; MV = mitral valve; RPVs = right pulmonary veins.)

To prevent injury, care is taken not to intersect the esophagus with the ablation lines. This is accomplished by keeping the medial portion of the left encircling ablation (when this is performed endocardially) far from the midline and by performing the transverse connecting lesion high in the atrium, opposite to the transverse pericardial sinus. In patients with a giant left atrium, the atrial imprint of left main bronchus is identified and care is taken not to cross it with the ablations.

	Results

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We have used the described technique to ablate 49 patients undergoing concomitant mitral valve surgery since December 2001. The ablation procedure was performed utilizing a linear radiofrequency system (Cobra; Boston Scientific, Natick, MA) in 47 patients, a cooled tip radiofrequency pen (Cardioblate; Medtronic, Minneapolis, MN), and a linear argon cryoablator (Surgifrost; Cryocath, Kirkland, Quebec, Canada) in 1 patient each.

Forty-one patients (87%) had the mitral ablation line carried out from the left appendage, connected to the medial portion of the posterior anulus in 34 cases (72%; Fig 1B) and to the lateral portion of the posterior anulus in 7 cases (15%; Fig 1A). An ablation line from the right pulmonary veins to the posteromedial commissure was needed in 6 of 47 patients (13%; Fig 1C) to avoid ablating across a major coronary branch. All patients survived. No major or minor operative complication was recorded. All patients but 1 recovered sinus rhythm after surgery.

	Comment

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While the prognostic benefits of atrial fibrillation surgery are being debated it is generally agreed that the crucial feature of a successful ablation procedure is a negligible rate of complications. The complex pattern of surgical incisions and the substantial rate of procedure-related complications have limited the widespread use of the maze operation. After the recent demonstration of the leading role played by the left atrium both in initiating and in perpetuating AF, reports of simplified left atrial ablation approaches have been dramatically increasing. The introduction of alternative physical means such as radiofrequency, microwave, laser, and more powerful cryoablators has allowed to perform a complete left lesion set in less than 15 minutes, thus magnifying the popularity of AF surgery.

Nevertheless this newly developed, rapidly growing type of surgery is prone to new, serious complications that the surgeon should be aware of and should possibly prevent. Coronary trauma due to blind unprotected ablation across the AV groove with radiofrequency [1] and with cryoablation [3, 4] and esophageal injury after radiofrequency ablation of the posterior left atrium [1, 2] have been reported. We strongly believe that a proper placement of the lesions far from the midline in the lower portion of the posterior left atrium is the best way to prevent esophageal complications [5, 6]. Similarly a systematic endocardial inspection should allow identifying and avoiding the atrial print of the left main bronchus (when present) thus preventing bronchial damage.

Conversely when the lesion set involves a mitral connecting line, the hazards of ablating across a major coronary branch running in the AV groove are not predictably preventable. Although its electrophysiologic role has been debated the mitral line is a common feature of nearly all the modern ablation approaches. Nevertheless the issue of adapting the site of the lesion to coronary anatomy has never been raised. We proposed low-flow retrograde blood cardioplegia delivery during radiofrequency ablation to protect the coronary artery from heat trauma through internal cooling [5, 6]. But cardioplegia alone is not likely to be completely safe during ablation on a major coronary branch when the atrial wall is thin as mild pressure on the ablation catheter can obstruct the coronary flow. Moreover during cryoablation blood within the AV groove arteries is likely to freeze thereby neutralizing any protective effect of cardioplegia. In addition in rare cases positioning of the retrograde cannula in the coronary sinus cannot be easily accomplished. Therefore tailoring the proper place of the mitral lesion based on coronary anatomy seems the most sensible strategy to prevent injury of a major coronary branch. Such an approach can increase safety whatever physical means is used for the ablations (ie, cryoablation) and should be considered both for endocardial and for epicardial ablation.

Although a similar clinical outcome can be expected with varying routes of the mitral line, confirmation by long-term studies is of course needed. As for the esophagus we believe that the best way to avoid the risk of injuring the main coronary branches is not to ablate on them. We therefore suggest tailoring the lesion set based on coronary anatomy as a routine precaution against coronary ablation–related complications in all patients undergoing AF surgery with whatever means of ablation.

	References

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1. Kottkamp H., Hindricks G., Autschbach R., et al. Specific linear left atrial lesions in atrial fibrillation: intraoperative radiofrequency ablation using minimally invasive surgical techniques. J Am Coll Cardiol 2002;40:475-480.[Abstract/Free Full Text]
2. Gillinov A.M., Pettersson G., Rice T.W. Esophageal injury during radiofrequency ablation for atrial fibrillation. J Thorac Cardiovasc Surg 2001;122:1239-1240.[Free Full Text]
3. Sueda T., Shikata H., Mitsui N., Nagata H., Matsuura Y. Myocardial infarction after a maze procedure for idiopathic atrial fibrillation. J Thorac Cardiovasc Surg 1996;112:549-550.[Free Full Text]
4. Berreklouw E., Bracke F., Meijer A., Peels K.H., Relik D. Cardiogenic shock due to coronary narrowings one day after a Maze III procedure. Ann Thorac Surg 1999;68:1065-1066.[Abstract/Free Full Text]
5. Benussi S., Nascimbene S., Agricola E., et al. Surgical ablation of atrial fibrillation using the epicardial radiofrequency approach: mid-term results and risk analysis. Ann Thorac Surg 2002;74:1050-1057.[Abstract/Free Full Text]
6. Benussi S., Pappone C., Nascimbene S., et al. A simple way to treat atrial fibrillation during mitral valve surgery: the epicardial radiofrequency approach. Eur J Cardio-Thorac Surg 2000;17:524-529.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stefano Benussi Ottavio Alfieri Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Benussi, S. Articles by Alfieri, O. Search for Related Content PubMed PubMed Citation Articles by Benussi, S. Articles by Alfieri, O.