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Tex Heart Inst J. Kogan, Raanani, and Sternik; and Mss. First and Malachy and Heart Institute Drs. We have created this lesion with a bipolar radiofrequency ablator, abandoning the usual use of this device to achieve bilateral epicardial isolation of the pulmonary veins. From March through the end of May , we performed surgical ablation of atrial fibrillation in patients. Of this number, underwent operation by a hybrid maze technique and the remaining 35 our study cohort underwent the creation of a box lesion around the pulmonary veins by means of a bipolar radiofrequency device.

Ablation lines were created by connecting the left atriotomy to the amputated left atrial appendage, with 2 ablation lines made with a bipolar radiofrequency device above and below the pulmonary veins. Lesions were made along the transverse and oblique sinuses by epicardial and endocardial application of a bipolar device. The left atrial isthmus was ablated by bipolar radiofrequency and cryoprobe. By creating a box lesion around the pulmonary veins, we expect to improve transmurality by means of epicardial and endocardial ablation of 1 rather than 2 layers of atrial wall, as in epicardial pulmonary vein isolation.

Isolation of the entire posterior wall of the left atrium is better electrophysiologically and renders dissection around the pulmonary veins unnecessary. Bipolar radiofrequency RF ablation with bilateral pulmonary vein PV isolation is one of the most important elements of these new techniques. Patients and Methods From March through May , we performed surgical ablation of atrial fibrillation in patients. Of this number, underwent operation by a hybrid maze technique. All patients signed an informed-consent form before surgery, and all details of the ablation procedure were explained to the patient.

Table I shows data regarding the preoperative characteristics of the 35 patients in the study cohort. Preoperative Patient Characteristics Open in a separate window Operative Technique We chose to perform the entire box-lesion ablation on the arrested heart, because this method facilitated exposure of the atria and the ablation line and reduced atrial wall tension between the jaws of the bipolar clamp.

Following the accepted approach for mitral valve surgery, we opened the left atrium along the interatrial groove. The left atrial appendage was amputated, after which we dissected around the superior and inferior venae cavae to reach the transverse and the oblique pericardial sinuses. Subsequently, we inserted 1 jaw of a bipolar RF ablator, applying it epicardially to the transverse sinus below the superior vena cava and connecting the upper end of the atriotomy incision to the stump of the left atrial appendage.

Another jaw of the clamp was applied endocardially into the left atrium. In this way, we created a bipolar RF lesion in the left atrial roof, connecting the left atriotomy incision to the stump of the left atrial appendage. This lesion was also epicardial and endocardial.

In the event of an enlarged left atrium that rendered the bipolar clamp too short to reach the appendage stump, we added a bipolar RF lesion from the open stump of the left atrial appendage to complete the oblique sinus line the lower line of the box. The upper and lower lines of the box lesion therefore included the bipolar RF epicardial and endocardial lesions in the left atrial roof, along the transverse sinus and along the oblique sinus.

The right and left sides of the box lesion included the left atriotomy incision along the interatrial septum and an incision left by the amputated left atrial appendage Fig. Open in a separate window Fig. B Cut-and-sew maze procedure. Left atrial ablation was performed in all patients except one, while an additional right atrial ablation was performed in 1 patient who had long-standing permanent AF and a history of tricuspid valve annuloplasty.

All patients except one underwent ablation procedures as part of either valvular or other open-heart surgery. The main operative procedures were mitral valve surgery in 23 patients, 15 of whom underwent valve repair. Other concomitant operative procedures included aortic valve surgery and coronary artery bypass grafting.

One patient underwent isolated left atrial ablation for lone AF, and 2 patients had undergone cardiac surgery in the past. The average ablation time was 25 minutes range, 17—31 min. Table II shows additional operative data.

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