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Ann Thorac Surg 2009;87:1573-1576. doi:10.1016/j.athoracsur.2008.12.019
© 2009 The Society of Thoracic Surgeons
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New Technology

Complete Right Atrial Ablation With Bipolar Radiofrequency

Stefano Benussi, MD, PhD*, Andrea Galanti, MD, Simona Nascimbene, MD, Andrea Fumero, MD, Enrica Dorigo, MD, Valerio Zerbi, Ottavio Alfieri, MD

Division of Cardiac Surgery, S. Raffaele University Hospital, Milan, Italy

Accepted for publication December 5, 2008.

* Address correspondence to Dr Benussi, Division of Cardiac Surgery, S. Raffaele University Hospital, via Olgettina 60, Milan, 20132, Italy (Email: stefano.benussi{at}hsr.it).


Dr Benussi discloses that he has a financial relationship with Estech Inc, St. Jude Medical Inc, Atricure Inc, Medtronic Inc, Cryocath Inc, and Edwards Lifesciences Inc; Dr Zerbi with Medtronic Inc; Dr Alfieri with Edwards Lifesciences Inc.

 

   Abstract
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Purpose: Although it is deemed important, right atrial ablation is not considered feasible with bipolar radiofrequency alone. Normally, unipolar devices are used to complete the tricuspid connecting lines. We describe a simple technique to achieve a complete maze-like set of right ablations using a standard bipolar radiofrequency device.

Description: Thirty-four patients underwent concomitant ablation with a right set of lines performed using bipolar radiofrequency only. The epicardium adjacent to the right atriotomy was entered and after separating the sulcus fat from the atrial wall, the deepest portion of the atrioventricular groove was developed bluntly with the scissors down to the tricuspid annulus. The tricuspid connecting lines were then performed with bipolar radiofrequency in an endo-epicardial fashion.

Evaluation: No ablation-related complications occurred. No patient died. Three patients required pacemaker implantation. At a mean follow-up of 8 ± 5, 85% of the patients were free from arrhythmias. At 6 months 20 of 24 patients (83%) were in stable sinus rhythm.

Conclusions: All the maze III right atrial ablations can be performed using a bipolar radiofrequency device alone. The procedure is safe and easily reproducible on a regular basis.


   Technology
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Bipolar radiofrequency is the most reliable means to create transmural atrial scars [1]. Nevertheless, due to its clamping nature, bipolar devices are typically not used to perform the mitral and tricuspid connecting lines. In fact, surgeons using bipolar radiofrequency describe completing the lesion sets on the mitral and tricuspid annulus with a second unipolar device [2, 3]. This makes the procedure more expensive, time-consuming, and possibly less effective [4]. We have recently reported performing the left isthmus line with bipolar radiofrequency to complete a left atrial set of lines [4]. Here we describe an easy and reproducible technique to ablate up to the tricuspid annulus with a bipolar device.


   Technique
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Patients and Methods
From February 2007, 34 consecutive patients undergoing open heart surgery had concomitant ablation with right lines performed using bipolar radiofrequency in addition to a complete left lesion set. The indication to adjunctive right ablation was the presence of permanent atrial fibrillation in 27 patients and persistent atrial fibrillation in 7 patients. Preoperative data are depicted in Table 1.


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  		Table 1 Preoperative Data
 
Surgical Technique
After cross clamping, usually during cardioplegia administration, a right atriotomy was performed perpendicular to the atrioventricular (AV) groove. The epicardium was entered through a 1-cm incision parallel to the groove proper, and the outer part of the AV groove was dissected following the plane between the sulcus fat and the atrial myocardium (Fig 1). The deepest portion of the AV groove was then developed with the scissors by blunt dissection, sliding on the outer surface of the right atrial wall, down until crossing the plane of the tricuspid annulus corresponding to the anterior portion of the posterior leaflet (around 2 o'clock). Optionally, the ventricular portion of the AV groove was inspected for the exact location of the right coronary artery. A small right angle was bluntly passed in the fat tissue largely around the vessel and the pedicle was looped with a silastic string and gently tractioned. The bipolar radiofrequency device was then set in place in an endo-epicardial fashion. The tip of the epicardial jaw was sled in the dissected portion of the AV groove up to the level of the tricuspid annulus (Fig 2), and the ablation was performed. When clamping the device and during energy deployment, using traction of the edge of the atriotomy upward while forcing the clamp down in the groove helped preventing possible backsliding of the device.


Figure 1
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  		Fig 1. The epicardium is entered adjacent to the atrial wall. The level of the tricuspid annulus is reached (at around 2 o'clock) through blunt dissection.

 

Figure 2
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  		Fig 2. After suspending the right coronary artery (optional) the bipolar device is positioned endo-epicardially with the external jaw following the dissected pathway until crossing the tricuspid annulus.

 
Although clear biting of the tricuspid annulus is key to preventing arrhythmia recurrence, liberal clamping of the tricuspid leaflets must be avoided to prevent valve impairment.

The same atriotomy was then connected with the inferior vena cava and (when a complete right set of lines was desired) with the postero-superior aspect of the superior vena cava in an endo-epicardial fashion during a brief period of release of the caval snare and partial occlusion of the venous cannula.

After amputation of the tip of the right appendage, the same type of dissection was carried out on the medial aspect of the right atrium, facing the ascending aorta. As previously described, the blunt dissection was carried out with the scissors following the atrial wall down to the level of the tricuspid annulus. The bipolar device was positioned with the external jaw following the dissected pathway down until the internal jaw intersected the tricuspid annulus at the level of the medial portion of the anterior leaflet (around 10 o'clock). Because the appendage incision was kept minimal, visual feedback was better obtained through the main right atriotomy (Fig 3). As previously described, upward traction of the atrial wall helped keep the clamp in place during ablation.


Figure 3
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  		Fig 3. The same dissection is carried out medial to the right appendage and the clamp is positioned endo-epicardially through the appendage incision to ablate up to the anterior leaflet of the tricuspid valve (at around 10 o'clock).

 
In patients receiving a complete maze III set of lines, an additional endo-epicardial ablation was performed from the appendage incision towards the main atriotomy. Figure 4 shows the final set of right atrial ablations totally performed with bipolar radiofrequency.


Figure 4
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  		Fig 4. Complete set of right atrial lines totally performed with bipolar radiofrequency.

 
Occasional venular bleeding from the epicardial dissection could be easily controlled by epicardial reapproximation of the AV groove dissection with a pledgetted fine polypropylene "U" stitch and protamine administration.

Postoperative Management and Follow-Up
Perioperative anti-arrhythmic prophylaxis with amiodarone was administered for 3 to 6 months in the absence of contraindications [5].

A twelve-lead electrocardiogram, 24-hour Holter monitoring, and transthoracic echocardiography were performed at 3, 6, and 12 months after surgery.


   Clinical Experience
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Results
The main operation consisted in mitral surgery in 32 of 34 patients (replacement in 18 and repair in 14), atrial septal defect closure in 1, and lone atrial fibrillation ablation in 1. Thirty of 34 patients had two or more open heart procedures, 28 of which consisted in tricuspid repair.

Of the 34 study patients, 18 had a right isthmus ablation, 4 had a right isthmus plus anteromedial tricuspid ablation, and 12 had a complete maze III set of lines (Fig 4).

All the available bipolar radiofrequency devices were used: the Cobra Bipolar (Estech Inc, Camino Ramon, CA) was used in 18 patients, the BP2 (Medtronic Inc, Minneapolis, MN) in 11, and the Isolator (Atricure Inc, Cincinnati, OH) in 5.

The whole ablation procedure was carried out with bipolar radiofrequency in all but one patient with a left dominant coronary system who had the mitral line performed with unipolar radiofrequency to prevent coronary injury [6].

All patients survived. No ablation-related complication was recorded. No patient needed re-exploration for bleeding (mean, 270 ± 103 cc).

Three patients (one for each different set of right lines) had a pacemaker implanted after surgery: 1 for AV block, 1 for sick sinus syndrome, and 1 for low-rate atrial fibrillation.

At discharge, 24 of 34 patients (71%) were free from atrial fibrillation.

Follow-up was 100% complete. At a mean follow-up of 8 ± 5 months sinus rhythm recovery rate was 85% (29 of 34 patients), with 21 of 34 free from class I/III antiarrhythmic drugs. Of the 24 patients reaching 6 months follow-up, 20 (83%) were in stable sinus rhythm, with 3 of 24 still assuming class I/III antiarrhythmic drugs. No patients experienced flutter. No patient had repeat percutaneous ablation. No patient required pacemaker implantation after discharge. No patient died.


   Comment
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There is evidence supporting the beneficial role of right ablations in improving atrial fibrillation cure rate [7].

Bipolar radiofrequency is the most popular energy source today, and it has been shown to effectively ablate up to the tricuspid annulus in the animal model without preparatory dissection of the AV groove [1]. Nevertheless, in the clinical setting, blind ablation across the AV groove does not allow reaching the tricuspid annulus easily, and it carries a potential risk of coronary injury. Therefore, right ablations are usually either omitted or complemented by cryoablations on the tricuspid annulus [2, 3].

Of note, use of unipolar devices to complete right atrial ablation at the tricuspid level does not predictably prevent coronary injury [8]. In addition, the use of two devices adds consistently to the costs and increases the potential for incomplete lines [4].

By developing the plane between the sulcus fat and the right atrial myocardium, and mainly using blunt dissection with scissors, the outer aspect of the tricuspid annulus is readily reachable [9], and can be routinely ablated across with bipolar radiofrequency. Coronary risk is predictably avoided since thermal spread outside a bipolar clamp is negligible.

Epicardial blunt dissection of the AV groove is so straightforward that bipolar radiofrequency is a reasonable first choice for tricuspid ablation, even when a second unipolar device would be available (eg, in patients with a left dominance).

By adopting the previously described technique, the use of bipolar radiofrequency will not negatively influence the attitude of the surgeon to perform adjunctive right ablations, because the whole maze III procedure becomes easily feasible in a few minutes.

The extent of right ablations should however be based on the likelihood and clinical importance of sinus rhythm recovery in the single patient, considering they can potentially increase the need of postoperative pacemaker implantation.


   Disclosures and Freedom of Investigation
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All the material used to perform the procedures was regularly purchased by S. Raffaele University Hospital, Milan, Italy. The innovative technical aspects of the procedure were conceived and developed independently by the authors. The study was not in any way funded, and the authors had full control of the design, methods, data analysis, and production of the written report.


   Acknowledgments
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We are grateful to Professor Bruno Pellegrini for his contributing all the artwork in this article.


   Footnotes
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Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.


   References
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  1. Melby SJ, Gaynor SL, Lubahn JG, et al. Efficacy and safety of right and left atrial ablations on the beating heart with irrigated bipolar radiofrequency energy: a long-term animal study J Thorac Cardiovasc Surg 2006;132:853-860.[Abstract/Free Full Text]
  2. Cox JL. Atrial fibrillation II: rationale for surgical treatment J Thorac Cardiovasc Surg 2003;126:1693-1699.[Free Full Text]
  3. Gaynor SL, Diodato, 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]
  4. Benussi S, Nascimbene S, Galanti A, et al. Complete left atrial ablation with bipolar radiofrequency Eur J Cardio-thorac Surg 2008;33:590-595.[Abstract/Free Full Text]
  5. 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]
  6. Benussi S, Nascimbene S, Calvi S, Alfieri O. A tailored anatomical approach to prevent complications during left atrial ablation Ann Thorac Surg 2003;75:1979-1981.[Abstract/Free Full Text]
  7. Barnett 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]
  8. 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]
  9. Sealy WC. The evolution of the surgical methods for interruption of right free wall Kent bundles Ann Thorac Surg 1983;36:29-36.[Abstract/Free Full Text]



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Ottavio Alfieri
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