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Ann Thorac Surg 2004;77:1134
© 2004 The Society of Thoracic Surgeons

Correspondence

Alternative energy sources for atrial fibrillation

A. Marc Gillinov, MD, Patrick M. McCarthy, MD

The Center for Atrial Fibrillation, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation/F24, 9500 Euclid Ave, Cleveland, OH 44195, USA

e-mail: gillinom{at}ccf.org

To the Editor:

The publication by Thomas and colleagues [1] and the accompanying editorial by Damiano [2] highlight critically important challenges in the development of new surgical approaches for the treatment of atrial fibrillation. In an experimental model, Thomas and co-workers observed that epicardial application of dry, unipolar radiofrequency energy to a beating heart produced transmural atrial lesions in only 13% of sheep. Lesion depth was influenced by epicardial fat, intracavitary blood cooling the endocardium, and, possibly, blood circulating within the atrial tissue. In contrast, 92% of endocardial lesions were transmural.

These findings have important implications for the development of minimally invasive epicardial approaches to the surgical ablation of atrial fibrillation. Such procedures are on the horizon. Currently, most surgical treatment of atrial fibrillation is undertaken in patients requiring concomitant cardiac surgical procedures. At The Cleveland Clinic Foundation, 291 patients had surgical treatment of atrial fibrillation in 2002; only 11% had lone atrial fibrillation as the indication for operation. To be able to offer curative surgical therapy to the millions of people afflicted by lone atrial fibrillation, surgeons must develop a minimally invasive approach that is both effective and safe. Such a procedure will be performed on the beating heart from the epicardial surface through small incisions or endoscopes. An assessment of lesion transmurality, conduction block, or both is a critical component of such a procedure. The data from Thomas and colleagues clearly demonstrate that we cannot simply assume transmurality when applying heat-based energy sources to the epicardium. Devices designed to produce transmural lines of conduction block with endocardial application may not produce such lesions when placed on the epicardium of a beating heart.

Successful minimally invasive surgical ablation of atrial fibrillation requires a focused effort to develop tools for ablation and lesion assessment designed specifically for an epicardial beating-heart approach. As Damiano emphasized, such development must be guided by sound scientific principles with meticulous experimental testing to confirm safety and efficacy. If properly performed, this work will culminate in successful and safe minimally invasive approaches to atrial fibrillation, thus offering the possibility of ablation to large numbers of patients.

References

  1. Thomas S.P., Guy D.J.R., Boyd A.C., Eipper V.E., Ross D.L., Chard R.B. Comparison of epicardial and endocardial linear ablation using handheld probes. Ann Thorac Surg 2003;75:543-548.[Abstract/Free Full Text]
  2. Damiano R.J., Jr. Alternative energy sources for atrial ablation: judging the new technology. Ann Thorac Surg 2003;75:329-330.[Free Full Text]



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