Abstract
With the development of less invasive surgical approaches and new ablation techniques, surgical treatment of atrial fibrillation has gained increasing interest over the past decade. Contrary to the complex Maze procedure, new less laborious approaches with pulmonary vein isolation as the main focus are within the reach of most cardiothoracic surgeons. However, although important new pathophysiological mechanisms have emerged in recent years due to extensive basic and clinical research, several uncertainties and hurdles concerning this treatment modality remain. This article reviews the rationale of surgical pulmonary vein isolation, based on these increased insights. Furthermore, important technical aspects including the possible advantages of an epicardial approach, the optimal left-sided lesion set and the need for transmurality are discussed in depth.
Keywords: atrial fibrillation, pulmonary vein ablation, arrhythmia surgery
Full text
PDF




Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Benussi S., Pappone C., Nascimbene S., Oreto G., Caldarola A., Stefano P. L., Casati V., Alfieri O. A simple way to treat chronic atrial fibrillation during mitral valve surgery: the epicardial radiofrequency approach. Eur J Cardiothorac Surg. 2000 May;17(5):524–529. doi: 10.1016/s1010-7940(00)00391-2. [DOI] [PubMed] [Google Scholar]
- Benussi Stefano, Nascimbene Simona, Agricola Eustachio, Calori Giliola, Calvi Simone, Caldarola Alessandro, Oppizzi Michele, Casati Valter, Pappone Carlo, Alfieri Ottavio. Surgical ablation of atrial fibrillation using the epicardial radiofrequency approach: mid-term results and risk analysis. Ann Thorac Surg. 2002 Oct;74(4):1050–1057. doi: 10.1016/s0003-4975(02)03850-x. [DOI] [PubMed] [Google Scholar]
- Blom N. A., Gittenberger-de Groot A. C., DeRuiter M. C., Poelmann R. E., Mentink M. M., Ottenkamp J. Development of the cardiac conduction tissue in human embryos using HNK-1 antigen expression: possible relevance for understanding of abnormal atrial automaticity. Circulation. 1999 Feb 16;99(6):800–806. doi: 10.1161/01.cir.99.6.800. [DOI] [PubMed] [Google Scholar]
- Chen S. A., Hsieh M. H., Tai C. T., Tsai C. F., Prakash V. S., Yu W. C., Hsu T. L., Ding Y. A., Chang M. S. Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation. 1999 Nov 2;100(18):1879–1886. doi: 10.1161/01.cir.100.18.1879. [DOI] [PubMed] [Google Scholar]
- Chiou C. W., Eble J. N., Zipes D. P. Efferent vagal innervation of the canine atria and sinus and atrioventricular nodes. The third fat pad. Circulation. 1997 Jun 3;95(11):2573–2584. doi: 10.1161/01.cir.95.11.2573. [DOI] [PubMed] [Google Scholar]
- Davis Z., Jacobs H. K., Bonilla J., Anderson R. R., Thomas C., Forst W. Retaining the aortic fat pad during cardiac surgery decreases postoperative atrial fibrillation. Heart Surg Forum. 2000;3(2):108–112. [PubMed] [Google Scholar]
- Duru F., Hindricks G., Kottkamp H. Atypical left atrial flutter after intraoperative radiofrequency ablation of chronic atrial fibrillation: successful ablation using three-dimensional electroanatomic mapping. J Cardiovasc Electrophysiol. 2001 May;12(5):602–605. doi: 10.1046/j.1540-8167.2001.00602.x. [DOI] [PubMed] [Google Scholar]
- Guden Mustafa, Akpinar Belhhan, Caynak Baris, Turkoglu Cavlan, Ozyedek Zeki, Sanisoglu Ilhan, Sagbas Ertan, Aytekin Saide, Oztekin Seher Deniz. Left versus bi-atrial intraoperative saline-irrigated radiofrequency modified maze procedure for atrial fibrillation. Card Electrophysiol Rev. 2003 Sep;7(3):252–258. doi: 10.1023/B:CEPR.0000012393.09666.26. [DOI] [PubMed] [Google Scholar]
- Haïssaguerre M., Jaïs P., Shah D. C., Arentz T., Kalusche D., Takahashi A., Garrigue S., Hocini M., Peng J. T., Clémenty J. Catheter ablation of chronic atrial fibrillation targeting the reinitiating triggers. J Cardiovasc Electrophysiol. 2000 Jan;11(1):2–10. doi: 10.1111/j.1540-8167.2000.tb00727.x. [DOI] [PubMed] [Google Scholar]
- Haïssaguerre M., Jaïs P., Shah D. C., Takahashi A., Hocini M., Quiniou G., Garrigue S., Le Mouroux A., Le Métayer P., Clémenty J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998 Sep 3;339(10):659–666. doi: 10.1056/NEJM199809033391003. [DOI] [PubMed] [Google Scholar]
- Hirose Masamichi, Leatmanoratn Zeng, Laurita Kenneth R., Carlson Mark D. Partial vagal denervation increases vulnerability to vagally induced atrial fibrillation. J Cardiovasc Electrophysiol. 2002 Dec;13(12):1272–1279. doi: 10.1046/j.1540-8167.2002.01272.x. [DOI] [PubMed] [Google Scholar]
- Jessurun E. R., van Hemel N. M., Defauw J. A., Stofmeel M. A., Kelder J. C., de la Rivière A. B., Ernst J. M. Results of maze surgery for lone paroxysmal atrial fibrillation. Circulation. 2000 Apr 4;101(13):1559–1567. doi: 10.1161/01.cir.101.13.1559. [DOI] [PubMed] [Google Scholar]
- Keane David. New catheter ablation techniques for the treatment of cardiac arrhythmias. Card Electrophysiol Rev. 2002 Dec;6(4):341–348. doi: 10.1023/a:1021115804352. [DOI] [PubMed] [Google Scholar]
- Lönnerholm S., Blomström P., Nilsson L., Oxelbark S., Jideus L., Blomström-Lundqvist C. Effects of the maze operation on health-related quality of life in patients with atrial fibrillation. Circulation. 2000 Jun 6;101(22):2607–2611. doi: 10.1161/01.cir.101.22.2607. [DOI] [PubMed] [Google Scholar]
- Melo J., Adragão P., Neves J., Ferreira M., Timóteo A., Santiago T., Ribeiras R., Canada M. Endocardial and epicardial radiofrequency ablation in the treatment of atrial fibrillation with a new intra-operative device. Eur J Cardiothorac Surg. 2000 Aug;18(2):182–186. doi: 10.1016/s1010-7940(00)00489-9. [DOI] [PubMed] [Google Scholar]
- Mohr Friedrich W., Fabricius Alexander M., Falk Volkmar, Autschbach Rüdiger, Doll Nicolas, Von Oppell Ulrich, Diegeler Anno, Kottkamp Hans, Hindricks Gerd. Curative treatment of atrial fibrillation with intraoperative radiofrequency ablation: short-term and midterm results. J Thorac Cardiovasc Surg. 2002 May;123(5):919–927. doi: 10.1067/mtc.2002.120730. [DOI] [PubMed] [Google Scholar]
- Oral Hakan, Knight Bradley P., Tada Hiroshi, Ozaydin Mehmet, Chugh Aman, Hassan Sohail, Scharf Christoph, Lai Steve W. K., Greenstein Radmira, Pelosi Frank., Jr Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation. Circulation. 2002 Mar 5;105(9):1077–1081. doi: 10.1161/hc0902.104712. [DOI] [PubMed] [Google Scholar]
- Pasic M., Bergs P., Müller P., Hofmann M., Grauhan O., Kuppe H., Hetzer R. Intraoperative radiofrequency maze ablation for atrial fibrillation: the Berlin modification. Ann Thorac Surg. 2001 Nov;72(5):1484–1491. doi: 10.1016/s0003-4975(01)03069-7. [DOI] [PubMed] [Google Scholar]
- Perez-Lugones Alejandro, McMahon James T., Ratliff Norman B., Saliba Walid I., Schweikert Robert A., Marrouche Nassir F., Saad Eduardo B., Navia José L., McCarthy Patrick M., Tchou Patrick. Evidence of specialized conduction cells in human pulmonary veins of patients with atrial fibrillation. J Cardiovasc Electrophysiol. 2003 Aug;14(8):803–809. doi: 10.1046/j.1540-8167.2003.03075.x. [DOI] [PubMed] [Google Scholar]
- Prasad Sunil M., Maniar Hersh S., Camillo Cindy J., Schuessler Richard B., Boineau John P., Sundt Thoralf M., 3rd, Cox James L., Damiano Ralph J., Jr The Cox maze III procedure for atrial fibrillation: long-term efficacy in patients undergoing lone versus concomitant procedures. J Thorac Cardiovasc Surg. 2003 Dec;126(6):1822–1828. doi: 10.1016/s0022-5223(03)01287-x. [DOI] [PubMed] [Google Scholar]
- Santiago Teresa, Melo João, Gouveia Rosa H., Neves José, Abecasis Miguel, Adragão Pedro, Martins Ana P. Epicardial radiofrequency applications: in vitro and in vivo studies on human atrial myocardium. Eur J Cardiothorac Surg. 2003 Oct;24(4):481–486. doi: 10.1016/s1010-7940(03)00344-0. [DOI] [PubMed] [Google Scholar]
- Schauerte P., Scherlag B. J., Pitha J., Scherlag M. A., Reynolds D., Lazzara R., Jackman W. M. Catheter ablation of cardiac autonomic nerves for prevention of vagal atrial fibrillation. Circulation. 2000 Nov 28;102(22):2774–2780. doi: 10.1161/01.cir.102.22.2774. [DOI] [PubMed] [Google Scholar]
- Schuetz A., Schulze C. J., Sarvanakis K. K., Mair H., Plazer H., Kilger E., Reichart B., Wildhirt S. M. Surgical treatment of permanent atrial fibrillation using microwave energy ablation: a prospective randomized clinical trial. Eur J Cardiothorac Surg. 2003 Oct;24(4):475–480. doi: 10.1016/s1010-7940(03)00377-4. [DOI] [PubMed] [Google Scholar]
- Smeets J. L., Allessie M. A., Lammers W. J., Bonke F. I., Hollen J. The wavelength of the cardiac impulse and reentrant arrhythmias in isolated rabbit atrium. The role of heart rate, autonomic transmitters, temperature, and potassium. Circ Res. 1986 Jan;58(1):96–108. doi: 10.1161/01.res.58.1.96. [DOI] [PubMed] [Google Scholar]
- Spach M. S., Barr R. C., Jewett P. H. Spread of excitation from the atrium into thoracic veins in human beings and dogs. Am J Cardiol. 1972 Dec;30(8):844–854. doi: 10.1016/0002-9149(72)90009-4. [DOI] [PubMed] [Google Scholar]
- Stabile Giuseppe, Turco Pietro, La Rocca Vincenzo, Nocerino Pasquale, Stabile Eugenio, De Simone Antonio. Is pulmonary vein isolation necessary for curing atrial fibrillation? Circulation. 2003 Aug 4;108(6):657–660. doi: 10.1161/01.CIR.0000086980.42626.34. [DOI] [PubMed] [Google Scholar]
- Todd Derick M., Skanes Allan C., Guiraudon Gerard, Guiraudon Colette, Krahn Andrew D., Yee Raymond, Klein George J. Role of the posterior left atrium and pulmonary veins in human lone atrial fibrillation: electrophysiological and pathological data from patients undergoing atrial fibrillation surgery. Circulation. 2003 Dec 1;108(25):3108–3114. doi: 10.1161/01.CIR.0000104567.72914.BF. [DOI] [PubMed] [Google Scholar]
- de Bakker Jacques M. T., Ho Siew Y., Hocini Mélèze. Basic and clinical electrophysiology of pulmonary vein ectopy. Cardiovasc Res. 2002 May;54(2):287–294. doi: 10.1016/s0008-6363(01)00532-6. [DOI] [PubMed] [Google Scholar]
- van Brakel Thomas J., Bolotin Gil, Salleng Kenneth J., Nifong L. Wiley, Allessie Maurits A., Chitwood W. Randolph, Jr, Maessen Jos G. Evaluation of epicardial microwave ablation lesions: histology versus electrophysiology. Ann Thorac Surg. 2004 Oct;78(4):1397–1402. doi: 10.1016/j.athoracsur.2004.04.030. [DOI] [PubMed] [Google Scholar]
