Ann Thorac Surg 2007;84:1041-1042
© 2007 The Society of Thoracic Surgeons
How To Do It
Ablation of Atrial Fibrillation With Minimally Invasive Mitral Surgery
A. Marc Gillinov, MD*,
Lars G. Svensson, MD, PhD
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio
Accepted for publication January 3, 2007.
* Address correspondence to Dr Gillinov, Department of Thoracic and Cardiovascular Surgery/F24, 9500 Euclid Ave, Cleveland, OH 44195 (Email: gillinom{at}ccf.org).
| Doctor Gillinov discloses that he has a financial relationship with Edwards Lifesciences, LLC, AtriCure, Inc, Medtronic, Inc, Guidant, Inc, and St. Jude Medical, Inc; Doctor Svensson with Edwards Lifesciences, LLC, Medtronic, Inc, and Cardiosolutions.
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Abstract
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With the advent of minimally invasive mitral valve surgery, transeptal exposure of the mitral valve has become increasingly popular. While this approach provides excellent exposure of the mitral valve, it necessitates development of novel strategies for concomitant ablation in patients with atrial fibrillation. We describe a technique for creation of a biatrial lesion set for atrial fibrillation ablation that is easily employed using the transeptal approach to the mitral valve.
The transseptal approach to the mitral valve described by Guiraudon and associates [1] has become increasingly popular for both minimally invasive and complex mitral valve operations. Indeed, this is now our preferred approach for most mitral valve procedures; it is particularly useful in reoperations and in patients with ischemic mitral regurgitation and small left atria [2]. However, this technique presents special challenges in the patient who requires concomitant ablation for atrial fibrillation (AF). Using a combination of bipolar radiofrequency and cryothermy, we have developed an approach for creation of a biatrial lesion set for AF ablation that is easily applied through transeptal exposure.
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Technique
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With either a standard full sternotomy or minimally invasive partial upper sternotomy, patients are bicavally cannulated with arterial inflow into the aorta. Cardiopulmonary bypass is initiated, and the aorta is cross clamped. The cavae are occluded, and the right atrium opened. Using a modification of the classic Guiraudon incision, a right atrial incision is made just anterior to the posterior fat pad on the lateral wall above the interatrial groove; this incision is carried 2 cm above the junction of the superior vena cava and the right auricle and then angled posteroinferiorly (Fig 1). A knife is then used to incise the crista terminalis, and the two incisions are connected. This incision is then continued along the superior aspect of the dome of the left atrium toward the left atrial appendage. A bipolar radiofrequency device is then used to make the lesions depicted in Figure 1. Each set of pulmonary veins is isolated with 3 applications of the bipolar radiofrequency clamp, taking care to position the clamp on the left atrial cuff adjacent to the pulmonary veins (Fig 1, inset). Connecting lesions are created from the incised dome of the left atrium to the lesions around the right and left pulmonary veins, respectively. Bipolar radiofrequency is used to begin a connecting lesion to the mitral annulus; this lesion is completed with a reusable cryoprobe applied at –60°C for 2 minutes. A similar cryolesion is created on the right atrial isthmus. The left atrial appendage is excised, and its orifice is oversewn with a double layer of running 4-0 polypropylene suture. The mitral valve procedure is then performed.
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Fig 1. View of right atrium (RA) and left atrium (LA) after extended transseptal incision. Each set of pulmonary veins is isolated separately with bipolar radiofrequency (inset, dashed lines). Connecting lesions are made to the right and left pulmonary veins with bipolar radiofrequency (dashed lines). Cryolesions are created on the left and right atrial isthmus (ovals). (IVC = inferior vena cava; SVC = superior vena cava.)
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Comment
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While long-term results of new AF ablation strategies are limited, there is growing agreement that AF ablation is indicated at the time of mitral valve surgery in patients with preexisting AF. The choice of lesion set is controversial, but we believe that the left atrial lesion set should resemble that of the Cox-Maze III and that a right atrial isthmus lesion should be included to reduce the potential for typical right atrial flutter [3]. The transseptal approach to the mitral valve renders traditional approaches to AF ablation problematic. We describe our technique for creation of a biatrial lesion set at the time of transeptal mitral valve exposure. With a combination of bipolar radiofrequency and cryothermy, the lesion set is created in 10 to 20 minutes.
Continued follow-up and analysis will be necessary to confirm the effectiveness of this approach to AF ablation; however, the left atrial lesion set employed resembles that used by Damiano and coworkers [4] with excellent early results. With the technique described, a minimally invasive approach incorporating an 8-cm skin incision and partial upper sternotomy can be used to perform both a mitral valve procedure and AF ablation.
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Acknowledgments
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This work is supported by the Atrial Fibrillation Innovation Center, which is a Wright Center of Innovation funded by the State of Ohio.
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References
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- Guiraudon GM, Ofiesh JG, Kaushik R. Extended vertical transatrial septal approach to the mitral valve Ann Thorac Surg 1991;51:293-295.[Abstract]
- Gillinov AM, Cosgrove DM. Minimally invasive mitral valve surgery: mini-sternotomy with extended transseptal approach Sem Thorac Cardiovasc Surg 1999;11:206-211.[Medline]
- Bartnett SD, Ad N. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis J Thorac Cardiovasc Surg 2006;131:1029-1035.[Abstract/Free Full Text]
- Gaynor Sl, Diodata, MD, Prasad SM, et al. A prospective, single-center clinical trial of a modified Cox maze procedure with bipolar radiofrequency ablation J Thorac Cardiovasc Surg 2004;128:535-542.[Abstract/Free Full Text]
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