Ann Thorac Surg 2008;86:1663. doi:10.1016/j.athoracsur.2008.07.014
© 2008 The Society of Thoracic Surgeons
New Technology
Invited Commentary
Randall K. Wolf, MD
Capital University, Beijing, China, Deaconess Hospital, 311 Straight St, Cincinnati, OH 45219
(Email: randallwolf{at}dataquesthealthcare.com).
Four years ago, while visiting The University of Oklahoma and performing and demonstrating minimally invasive pulmonary vein isolation to Dr Jackman and the Oklahoma arrhythmia team, I toured the Oklahoma arrhythmia center. Purely by chance, we observed Dr Ben Scherlag performing ganglionic plexi (GP) ablation in the canine model using alcohol injections into the canine fat pads. Ben was then kind enough to accept an invitation to visit us in Cincinnati with his equipment, where we performed the first ever GP testing and isolation in a human during a minimally invasive pulmonary vein isolation procedure (MiniMaze). We did not inject alcohol into the fat pads as Ben had done in the laboratory, but instead we used neurosurgical bipolar forceps to cauterize the fat pads around the pulmonary veins. After that case, we routinely added GP testing and isolation to the MiniMaze procedure, evolving from bipolar forceps application of cautery to the fat pads to a bipolar pen application. We reported our GP technique in this journal [1].
The article by Doll and colleagues [2] is significant as it lays the foundation for a randomized study of concomitant surgical AF treatment with and without GP fat pad isolation. Bipolar clamp treatment alone (without specific fat pad lesions with a pen) creates epicardial lesions that block some of the autonomic activity. The questions yet to be answered are as follows: (1) How much autonomic activity is blocked by pulmonary vein isolation alone? (2) How much does fat pad isolation add to pulmonary vein isolation? To date, we have not shown that the addition of the specific fat pad lesions improves the cure of AF. In fact, in our own series of minimally invasive stand-alone procedures (MiniMaze), the initial 20 cases were performed before we started the specific GP testing and isolation. This included the very first patient in the series who was longstanding, persistent, and who is now 5 years out from the MiniMaze and is AF free. He had only clamp isolation of the pulmonary veins. It may well be true that bipolar clamp isolation of the pulmonary veins results in enough GP isolation. We really may be comparing only the extent of GP isolation when we compare isolation of the pulmonary veins alone versus isolation of the pulmonary veins with "additional" fat pad isolation. How much is enough? We do not know. We also do not know if fat pad isolation alone, without pulmonary vein isolation will be enough to cure AF in some subsets of patients.
It seems, at least in humans, in the case of the importance of specific fat pad GP ablation during PV isolation, we have a mountain of theory based on a molehill of evidence. Doll and colleagues' [2] article based on the follow-up of 8 of 12 patients at 1 year will not shed light on this conundrum. However, their planned randomized study is a great idea.
 |
References
|
|---|
- Mehall JR, Kohut Jr RM, Schneeberger EW, Taketani T, Merrill WH, Wolf RK. Intraoperative epicardial electrophysiologic mapping and isolation of autonomic ganglionic plexi Ann Thorac Surg 2007;83:538-541.[Abstract/Free Full Text]
- Doll N, Pritzwald-Stegmann P, Czesla M, et al. Ablation of ganglionic plexi during combined surgery for atrial fibrillation Ann Thorac Surg 2008;86:1659-1663.[Abstract/Free Full Text]
Related Article
-
Ablation of Ganglionic Plexi During Combined Surgery for Atrial Fibrillation
- Nicolas Doll, Patrick Pritzwald-Stegmann, Markus Czesla, Joerg Kempfert, Monika Anna Stenzel, Michael A. Borger, and Friedrich-Wilhelm Mohr
Ann. Thorac. Surg. 2008 86: 1659-1663.
[Abstract]
[Full Text]
[PDF]
Top
References