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):
Hugues Jeanmart
Filip Casselman
Roel Beelen
Francis Wellens
Ihsan Bakir
Hugo Vanermen
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 Jeanmart, H.
Right arrow Articles by Vanermen, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Jeanmart, H.
Right arrow Articles by Vanermen, H.
Related Collections
Right arrow Electrophysiology - arrhythmias

Ann Thorac Surg 2006;82:1765-1769
© 2006 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Modified Maze During Endoscopic Mitral Valve Surgery: The OLV Clinic Experience

Hugues Jeanmart, MDa, Filip Casselman, MD, PhDa,*, Roel Beelen, MDa, Francis Wellens, MDa, Ihsan Bakir, MDa, F. Van Praet, MDa, Guy Cammu, MDb, Yvan Degriek, MDa, Yvette Vermeulen, MSa, Hugo Vanermen, MDa

a Department of Cardiovascular and Thoracic Surgery, OLV Clinic, Aalst, Belgium
b Department of Anesthesiology, OLV Clinic, Aalst, Belgium

Accepted for publication May 11, 2006.

* Address correspondence to Dr Casselman, OLV Clinic, Aalst, 9300, Belgium (Email: filip.casselman{at}olvz-aalst.be).


Dr Vanermen discloses a financial relationship with Cardiovations.

 

   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
BACKGROUND: The use of radiofrequency ablation to perform the mini-maze procedure (pulmonary veins isolation) has been reported with good results. The aim of this study was to evaluate our practice with the association of the mini-maze procedure, done with the use of the Cardioblade pen, and minimally invasive mitral valve surgery.

METHODS: From January 1999 to November 2004, 103 patients underwent a minimally invasive mitral valve surgery with a concomitant pulmonary veins isolation (modified maze procedure) done with unipolar radiofrequency. All files were reviewed retrospectively.

RESULTS: In our group of patients, 41.2% were known to have intermittent atrial fibrillation and 58.8%, continuous atrial fibrillation; 67.7% of the patients were in atrial fibrillation at the time of surgery. Precise time of duration of atrial fibrillation was known in 47.6% (mean time, 30.3 ± 28.9 months), but 47.7% were also known to have atrial fibrillation for many years. Mitral surgery included mitral valve repair in 71.8% and mitral valve replacement in 26.2%; 22 patients also received tricuspid annuloplasty. Major complications were mortality in 1%, myocardial infarction in 1%, stroke or transient ischemic attack in 1.9% and permanent pacemaker placement in 5.9%. At the time of discharge, 71.9% of patients were in sinus rhythm, 21.9% in atrial fibrillation, 1% in atrial flutter, and 5.2% in paced rhythm. Seventy-six and a half percent of the patients left the hospital with an antiarrhythmic drug (amiodarone 56.9%, sotalol 15.7%). At the time of follow-up, 99 patients were still alive with a mean follow-up time of 17.4 ± 14.1 months; 69.7% of patients were in sinus rhythm, 28.3% in atrial fibrillation, and 2% were pacemaker-dependent. Patients received antiarrhythmic medication in 81.2% of cases (amiodarone 46.4%, sotalol 17.9%, ß-blocker 39.3%, digoxine 7.1%). Eleven new pacemakers were implanted (11.1%).

CONCLUSIONS: The use of unipolar radiofrequency ablation to perform a mini-maze during minimally invasive mitral valve surgery is a safe procedure and is associated with good early results.

Atrial fibrillation (AF) affects more than 2.2 million people in the United States and has a well-known association with mitral valve disease. It has been reported that between 40% and 60% of patients admitted for mitral valve surgery will be in AF at the time of admission [1, 2]. Mitral valve repair alone has been associated with a low rate of conversion to sinus rhythm in patients in AF at the time of surgery and during long-term-follow-up, especially in patients with continuous AF and large left atrium [2, 3]. On the basis of the microwavelet theory, the search of a surgical treatment for AF introduced the Cox maze III procedure in 1995 [4–6]. But in recent years, new electrophysiologic data about the pathophysiology of AF has pointed out the major role played by the pulmonary veins ostia in the initiation of this anomaly. Because of these findings, less invasive surgical techniques have been developed to isolate the pulmonary veins from the rest of the left atrium. We report here our experience with pulmonary veins isolation with unipolar radiofrequency (Cardioblate, Medtronic Inc, Minneapolis, MN) for the treatment of intermittent and continuous AF, at the time of endoscopic mitral or tricuspid valve surgery.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
From January 1999 to November 2004, 103 patients underwent a minimally invasive mitral valve surgery with a concomitant mini-maze procedure done with unipolar radiofrequency. Patients with isolated mitral valve regurgitation underwent mitral valve repair (MVP), and patients with mitral valve stenosis or mixed lesions underwent a mitral valve replacement (MVR). This retrospective study was approved by the local ethics committee, and patient consent was waived because of the anonymous patient data collection.

Surgical Technique
The surgical technique has been extensively reported elsewhere [7]. In brief, the entire procedure is performed through a 4-cm working port, which is located in the right inframammary groove, usually in the fourth intercostal space. Long-shafted instruments are a prerequisite to perform the operation. Visualization is accomplished with an endoscope through a separate port in the fourth intercostal space at the anterior axillary line. Another port is used for suction and carbon dioxide insufflation. A left atrial retractor is introduced through a stab wound in the fourth intercostal space, just lateral to the right internal mammary artery. A femorofemoral extracorporeal circulation is used as well as an endoaortic balloon and antegrade cold crystalloid cardioplegia. The whole procedure is performed using a double-lumen endotracheal tube and transesophageal echocardiographic guidance.

When performing MVP, the annuloplasty stitches are put first, then the valve is analyzed and repaired using standard techniques. For MVR procedures, the valve is excised but the posterior subvalvular apparatus is preserved. Then, atrially placed pledgetted U-stitch sutures are inserted along the mitral valve annulus. The mitral valve prosthesis is introduced through the working port and tied in place.

The mini-maze procedure was performed after the insertion of the prosthesis or the completion of the MVP. Intraatrial ablation lines were created by using a saline irrigated tip unipolar radiofrequency probe (Cardioblate, Medtronic Inc). Lines of electric isolation were positioned around the four pulmonary veins ostia and connecting with the atriotomy line to complete the isolation. Another line was created to connect the mitral annulus, starting in the region of P3, with the line isolating the pulmonary veins (Fig 1). To reach the mitral annulus as far as possible, two sutures, on the posterior annulus side, are kept and used to lift the ring or prosthesis to gain access to the annulus in a more transverse fashion. The whole procedure was done in less than 5 minutes in most of the cases.


Figure 1
View larger version (9K):
[in this window]
[in a new window]
  		Fig 1. The box lesion set. Isolation of the four pulmonary veins is performed by making a line of ablation around the four ostia connecting the left atriotomy line. A second line of ablation is made toward the mitral annulus (region of P3, which is the zone of the posterior leaflet adjacent to the posterior commissure and going until the middle third of the posterior leaflet).

 
Removal of air at the end of the procedure is done using a venting catheter and inflation of the left lung before left atrial closure in addition to relying on the carbon dioxide for flooding of the operative field. All patients had an immediate intraoperative transesophageal echocardiography to assess MVP and valve prosthesis function; every patient also had a transthoracic echocardiogram before leaving the hospital.

Follow-up
All patients were seen 6 to 8 weeks postoperatively and then referred to their cardiologist for further follow-up. A questionnaire was sent to the referring cardiologist and family doctor at the time of follow-up to collect informations on the patient's functional class, heart rhythm and last electrocardiogram, procedure and anticoagulation-associated complications, reoperation, and medication.

Data Analysis
The design of the study was retrospective, and data are expressed as the mean ± standard deviation. Analysis of continuous variables was performed with the Student's t test and the multivariate analysis of variance test. The {chi}2 test or the Fisher's exact tests were used for comparison of discontinuous data.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Mitral valve repair was performed in 76 cases and MVR in 27. There were 6 patients who were referred for redo surgery, and all interventions were elective. Preoperative patient characteristics are depicted in Table 1. Sixty-one patients had intermittent AF, and 42 had continuous AF; 67.7% of patients were in AF at the time of surgery. The precise duration of AF was known in 47.6% (mean time, 30.3 ± 28.9 months), but 47.7% were also known to have AF for many years. Preoperative echographic findings are detailed in Table 2. Carpentier's classification was used to describe valve dysfunction in patients with mitral valve regurgitation. More than 70% of the patients presented with a mitral insufficiency greater than 3.


View this table:
[in this window]
[in a new window]
  		Table 1. Patient Preoperative Data
 

View this table:
[in this window]
[in a new window]
  		Table 2. Preoperative Echographic Data
 
Operative Data
All patients underwent the minimally invasive approach as described above. There were no conversions to sternotomy and no intraoperative complications. Mean aortic cross-clamp and cardiopulmonary bypass times were 97.3 ± 31.0 minutes and 136.4 ± 42.6 minutes, respectively. Associated procedures were tricuspid annuloplasty in 21.4%, closure of atrial septal defect or patent foramen ovale in 17.5%, and interventricular septal ablation in 1%. In MVR patients (n = 27), a bioprosthesis (Carpentier Perimount, Edwards Lifesciences, Irvine, CA) was implanted in 10 patients and a mechanical valve (ATS Inc, Minneapolis, MN, or St. Jude Medical, Minneapolis, MN) in 17. The mean blood loss for the first 24 hours was 560 ± 782 mL.

Postoperative Data
There was only 1 death associated with a failed mitral repair. This patient underwent a repeat emergency MVR with a median sternotomy but died in the following days of multiorgan failure. There was another early reoperation for a failed MVP that consisted of an MVR through the same approach. The patient had an uneventful recovery after the second surgery.

Other major postoperative complications included acute myocardial infarction (n = 1), transient ischemic attack (n = 2), and revision for bleeding (n = 7). Also, 6 patients (5.9%) underwent a pacemaker implantation for third-degree atrioventricular block (n = 3), second-degree atrioventricular block (n = 1), and sick sinus syndrome (n = 2). Electrical cardioversion for recurrent AF was performed in 12 patients and was successful in restoring sinus rhythm in 8.

At the time of discharge, echographic evaluation revealed that 96.9% of patients had a mitral insufficiency of grade 0 or 1, and left ventricular function was normal or mildly impaired in 94.4%. Heart rhythm at discharge was sinus rhythm (71.9%), AF (21.9%), atrial flutter (1%), and pacemaker rhythm (5.2%). Antiarrhythmic medication was prescribed in 76.5% (amiodarone 56.9%, sotalol 15.7%), and all patients left with a vitamin K antagonist. Vitamin K antagonists were recommended for at least 3 months; the decision to stop this treatment was left to the referring cardiologist during follow-up. Mean intensive care unit and hospital stay were 1.5 ± 0.9 days and 9.9 ± 4.1 days, respectively.

Follow-up Data
Follow-up was complete for all patients. At the time of follow-up, 99 patients were still alive with a mean follow-up time of 17.4 ± 14.1 months after surgery. There were 3 noncardiac-related deaths.

At the time of evaluation, 69.7% of the patients were in sinus rhythm, 28.3% in AF, and 2% were pacemaker-dependent. Antiarrhythmic medication was administrated in 81.2% of the patients (amiodarone 46.4%, sotalol 17.9%, ß-blocker 39.3%, digoxine 7.1%). There were 11 new pacemaker implantations (11.1%) for the following indications: third-degree atrioventricular block (n = 6), second-degree atrioventricular block (n = 3), and sick sinus syndrome (n = 2). Half of the patients were still receiving a vitamin K antagonist (56.4%); aspirin or clopidogrel were also taken by 26.5% of the patients. There were no major and only two minor bleeding events reported during the follow-up period. There were also four transient ischemic attacks, with 3 of the patients in AF at the time of the event. There was no statistically significant correlation between duration of AF, type of AF, and size of the left atrium, and failure of the procedure to restore sinus rhythm (Table 3).


View this table:
[in this window]
[in a new window]
  		Table 3. Follow-up Data a
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Atrial fibrillation is the most common cardiac rhythm disturbance in adults and is associated with a number of predisposing cardiovascular disorders including coronary artery disease, valvular heart disease, and congestive heart failure. It also contributes significantly to cardiovascular morbidity and mortality, especially by predisposing these patients to thromboembolism [8, 9]. The long-term medical treatment of AF with antiarrhythmic drug therapy has a known rate of failure reaching 50% at 1 year and up to 85% at 2 years [9, 10]; this has led to a search for a more effective surgical cure of this problem. Furthermore, MVP alone has been associated with only 20% to 50% rate of conversion to sinus rhythm in patients in AF at the time of surgery, during long-term-follow-up [2, 3]. The best results reported by Chua and colleagues [2] were obtained for patients with AF for less than 3 months and for intermittent AF in the study by Obajia and associates [11].

Evolution in the understanding of the pathophysiology of AF has modified our surgical approach of this disease. Earlier work of Cox and colleagues [4–6, 12], based on the multicircuit reentry model, has led to the introduction of the Cox maze procedure. After preliminary evaluation of this first version of the procedure, the Cox maze III provided excellent clinical and electrophysiologic results during the following years [4–6, 12]. Because this technique has not been widely accepted as a result of its complexity and invasiveness, alternative ways of treating AF were looked for. Haissaguerre and colleague [13] have shown, in patients with intermittent AF, that this arrhythmia originates from ectopic foci located in the ostium of the pulmonary veins in up to 94% of cases. Particular ionic characteristics of the pulmonary veins and left atrial myocytes may lead to shorter refractory period in left atrial tissue, favoring reentry [14]. A number of investigators have developed so-called partial maze or left-sided maze procedures to isolate the pulmonary veins from the left atrium. A variety of lesion designs have been described with the common point of creating electric isolation of the pulmonary veins from the rest of the left atrium. Interestingly, Doukas and coworkers [15] reported in a double-blind randomized study for patients with mitral disease and continuous AF present for more than 6 months a conversion rate of 44.4% to sinus rhythm when a mitral procedure was associated with pulmonary veins isolation done with radiofrequency at 1 year, in comparison to a 4.5% conversion rate when only a mitral procedure was done [15]. No single lesion pattern seemed to be superior, as data from most studies involving modified maze procedures confer a success rate around 70% to 80% at 1 year of follow-up [16–21], with a modest increase of procedural time and a low complication rate. The best result with pulmonary veins isolation have been reported to be associated with intermittent AF because the removal of the trigger focus in the pulmonary veins isolate the rest of the atrium from their influence. In the case of continuous AF, the exact role of these triggers remains elusive as electrophysiologic modifications of the atrial wall have been described to explain the self-perpetuation of the arrhythmia. One possible explanation for the success of pulmonary veins isolation in continuous AF is the partial ablation of surrounding macroreentrant circuits anchoring around the pulmonary veins ostia by extension of the line of ablation outside of the pulmonary veins ostia and with the ablation line toward the mitral annulus.

Our results showed the same efficacy with a success rate of 69.7% after a mean of 17 months of follow-up, with a low complication rate, probably also attributable to the minimal invasiveness of the procedure performed. A major limitation of our study is the type of follow-up investigation that was available to determine the conversion rate of our cohort of patients. On the basis of symptomatic presentation and standard electrocardiographic recording given by the general practitioner or cardiologist, our result may overestimate the actual rate of rhythm conversion. Recently, an interesting study by Hindricks and colleagues [20] has reported in a cohort of patients with highly symptomatic AF undergoing a catheter ablation that asymptomatic AF can occur after the ablation (based on a 7-day electrocardiographic period). Before ablation, greater than 50% of patients showed a mixture of symptomatic and asymptomatic AF, whereas only 38% of patients recognized all AF episodes accurately. After catheter ablation, the characteristics of AF change, with a decrease in the number of days with episodes of AF and their total duration but a significant increase in the incidence of asymptomatic AF episodes [20]. On the basis of these findings, a longer period of electrocardiographic recording would be needed to confirm our data.

Numerous devices have been introduced to create isolation of the pulmonary veins, using different sources of energy and with potential application on the epicardial or endocardial side of the left atrium. The exposure of the pulmonary veins ostia, through a single working port, is limited to the epicardial surface of the right pulmonary veins or the endocardial opening of the four pulmonary veins. This setting oriented our choice toward the Cardioblate to produce endocardial lines of isolation. Monopolar radiofrequency has the potential to create a thermal lesion as a result of resistance to conduction between the tip of the probe and the skin electrode. This technology may result in surface charring and potential thromboembolic complications. Moreover, heat may be conducted to surrounding tissues, such as the esophagus with possible esophageal perforation [21]. However, this complication has been reported with the use of dry monopolar radiofrequency delivered with a rigid coil that was applied firmly to the atrial wall for 2 minutes. This complication was not observed in our series, and it has not been reported so far after the use of irrigated radiofrequency delivered with a moving tip probe despite its use in more than 30,000 cases worldwide (Medtronic data reported at International Society for Minimally Invasive Cardiac Surgery [ISMICS] 2005). In our experience, we had two postoperative thromboembolic events (transient ischemic accident 1.9%). As per our standard protocol, all patients received a vitamin K antagonist for 3 months after surgery, unless contraindicated. The decision to stop this treatment was left to the referring cardiologist after this period. Other sources of energy are currently used to perform these lines of ablation, mainly bipolar radiofrequency, cryotherapy, microwave energy, and the latest, high-intensity focused ultrasound [21–25]. The overall results with theses devices are similar to our approach but are alternatives during endoscopic mitral or tricuspid surgery depending on the system available in a particular hospital setting.

Our results suggest that left-sided maze with unipolar radiofrequency done through a minimally invasive approach is feasible and safe with good clinical success, at more than 1 year of follow-up, for intermittent and continuous AF. Further follow-up is necessary to assess the long-term efficacy of this approach and whether antiarrhythmic and anticoagulant medication could be discontinued.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Brodell GK, Cosgrove D, Schiavone W, Underwood DA, Loop FD. Cardiac rhythm and conduction disturbances in patients undergoing mitral valve surgery Cleve Clin J Med 1991;58:397-399.[Medline]
  2. Chua LY, Schaff HV, Orszulak TA, Morris JJ. Outcome of mitral valve repair in patients with preoperative atrial fibrillation J Thorac Cardiovasc Surg 1994;107:408-415.[Abstract/Free Full Text]
  3. Chaput M, Bouchard D, Demers P, et al. Conversion to sinus rhythm does not improve long-term survival after valve surgery: insights from a 20-year follow-up study Eur J Cardiothorac Surg 2005;28:206-210.[Abstract/Free Full Text]
  4. Cox JL, Schuessler RB, D'Agostino HJ, et al. The surgical treatment of atrial fibrillationIII. Development of a definitive surgical procedure. [Comment] J Thorac Cardiovasc Surg 1991;101:569-583.[Abstract]
  5. Cox JL, Boineau JP, Schuessler RB, et al. Electrophysiologic basis, surgical development, and clinical results of the maze procedure for atrial flutter and atrial fibrillation Adv Card Surg 1995;6:1-67.[Medline]
  6. Cox JL, Jaquiss RD, Schuessler RB, Boineau JP. Modification of the maze procedure for atrial flutter and atrial fibrillationII. Surgical technique of the maze III procedure. J Thorac Cardiovasc Surg 1995;110:485-495.[Abstract/Free Full Text]
  7. Casselman FP, Van Slycke S, Dom H, Lambrechts DL, Vermeulen Y, Vanermen H. Endoscopic mitral valve repair: feasible, reproducible, and durable J Thorac Cardiovasc Surg 2003;125:273-282.[Abstract/Free Full Text]
  8. Falk RH. Atrial fibrillation[Comment] N Engl J Med 2001;344:1067-1078[erratum appears in N Engl J Med 2001;344:1876].[Free Full Text]
  9. Ezekowitz MD, Netrebko PI. Anticoagulation in management of atrial fibrillation Curr Opin Cardiol 2003;18:26-31.[Medline]
  10. Lundstrom T, Ryden L. Chronic atrial fibrillationLong-term results of direct current conversion. Acta Med Scand 1988;223:53-59.[Medline]
  11. Obadia JF, El Farra M, Bastien OH, et al. Outcome of atrial fibrillation after mitral valve repair J Thorac Cardiovasc Surg 1997;114:179-185.[Abstract/Free Full Text]
  12. Cox JL, Ad N, Palazzo L, et al. Current status of the maze procedure for the treatment of atrial fibrillation Semin Thorac Cardiovasc Surg 2000;12:15-19.[Medline]
  13. Haissaguerre M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins N Eng J Med 1998;339:659-666.[Abstract/Free Full Text]
  14. Li D, Zhang L, Kneller J, Nattel S. Potential ionic mechanism for repolarization differences between canine right and left atrium[Comment] Circ Res 2001;88:1097-1098.[Free Full Text]
  15. Doukas G, Samani NJ, Alexiou C, et al. Left atrial radiofrequency ablation during mitral valve surgery for continuous atrial fibrillation: a randomized controlled trial JAMA 2005;294:2323-2329.[Abstract/Free Full Text]
  16. Kondo N, Takahashi K, Minakawa M, Daitoku K. Left atrial maze procedure: a useful addition to other corrective operations Ann Thorac Surg 2003;75:1490-1494.[Abstract/Free Full Text]
  17. Kress DC, Sra J, Krum D, Goel A, Campbell J, Fox J. Radiofrequency ablation of atrial fibrillation during mitral valve surgery Semin Thorac Cardiovasc Surg 2002;14:210-218.[Medline]
  18. Wellens F, Casselman F, Geelen P, et al. Combined atrial fibrillation and mitral valve surgery using radiofrequency technology Semin Thorac Cardiovasc Surg 2002;14:219-225.[Medline]
  19. 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;74:1050-1056.[Abstract/Free Full Text]
  20. Hindricks G, Piorkowski C, Tanner H, et al. Perception of atrial fibrillation before and after radiofrequency catheter ablation: relevance of asymptomatic arrhythmia recurrence Circulation 2005;112:307-313.[Abstract/Free Full Text]
  21. Mohr FW, Fabricius AM, Falk V, et al. Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: short-term and midterm results J Thorac Cardiovasc Surg 2002;123:919-927.[Abstract/Free Full Text]
  22. Wolf RK, Schneeberger W, Osterday R, et al. Video-assisted bilateral pulmonary vein isolation and left atrial exclusion for atrial fibrillation J Thorac Cardiovasc Surg 2005;130:797-802.[Abstract/Free Full Text]
  23. Molloy TA. Midterm clinical experience with microwave surgical ablation of atrial fibrillation Ann Thorac Surg 2005;79:2115-2118.[Abstract/Free Full Text]
  24. Ninet J, Roques X, Seitelberger R, et al. Surgical ablation of atrial fibrillation with off-pump, epicardial, high-intensity focused ultrasound: results of a multicenter trial J Thorac Cardiovasc Surg 2005;130:803-809.[Abstract/Free Full Text]
  25. Curra F, Mourad P, Crum LA. High intensity focused ultrasound and tissue heating: the effect of nonlinear sound propagation and vessel presence Proc IEEE Ultrasonics Symp 1998;2:1419-1422.



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
W. Wisser, G. Seebacher, T. Fleck, C. Aigner, C. Khazen, G. Stix, D. Hutschala, and E. Wolner
Permanent Chronic Atrial Fibrillation: Is Pulmonary Vein Isolation Alone Enough?
Ann. Thorac. Surg., October 1, 2007; 84(4): 1151 - 1157.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
I. Bakir, F. P. Casselman, P. Brugada, P. Geelen, F. Wellens, I. Degrieck, F. Van Praet, Y. Vermeulen, R. De Geest, and H. Vanermen
Current Strategies in the Surgical Treatment of Atrial Fibrillation: Review of the Literature and Onze Lieve Vrouw Clinic's Strategy
Ann. Thorac. Surg., January 1, 2007; 83(1): 331 - 340.
[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):
Hugues Jeanmart
Filip Casselman
Roel Beelen
Francis Wellens
Ihsan Bakir
Hugo Vanermen
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 Jeanmart, H.
Right arrow Articles by Vanermen, H.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Jeanmart, H.
Right arrow Articles by Vanermen, H.
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