Isolating the entire posterior left atrium improves surgical outcomes after the Cox maze procedure.
ABSTRACT The importance of each ablation line in the Cox maze procedure for treatment of atrial fibrillation remains poorly defined. This study evaluated differences in surgical outcomes of the procedure performed either with a single connecting lesion between the right and left pulmonary vein isolations versus 2 connecting lesions (the box lesion), which isolated the entire posterior left atrium.
Data were collected prospectively on 137 patients who underwent the Cox maze procedure from April 2002 through September 2006. Before May 2004, the pulmonary veins were connected with a single bipolar radiofrequency ablation lesion (n = 56), whereas after this time, a box lesion was routinely performed (n = 81). The mean follow-up was 11.8 +/- 9.6 months.
The incidence of early atrial tachyarrhythmia was significantly higher in the single connecting lesion group compared with that in the box lesion group (71% vs 37%, P < .001). The overall freedom from atrial fibrillation recurrence was significantly higher in the box lesion group at 1 (87% vs 69%, P = .015) and 3 (96% vs 85%, P = .028) months. The use of antiarrhythmic drugs was significantly lower in the box lesion group at 3 (35% vs 58%, P = .018) and 6 (15% vs 44%, P = .002) months.
Isolating the entire posterior left atrium by creating a box lesion instead of a single connecting lesion between the pulmonary veins showed a significantly lower incidence of early atrial tachyarrhythmias, higher freedom from atrial fibrillation recurrence at 1 and 3 months, and lower use of antiarrhythmic drugs at 3 and 6 months. A complete box lesion should be included in all patients undergoing the Cox maze procedure.
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ABSTRACT: Atrial fibrillation, the most common sustained disturbance of heart rhythm, is associated with a 5-fold increase in the incidence of ischemic stroke. The National Hospital Discharge Survey was used to estimate the annual number and prevalence of hospitalizations with atrial fibrillation among men and women 35 years of age or older. From 1985 through 1999, hospitalizations increased from 154 086 to 376 487 for a first-listed diagnosis and from 787 750 to 2 283 673 for any diagnosis. Prevalence was higher among successive age groups. Age-standardized prevalence was consistently higher among men than women. In 1999, essential hypertension, ischemic heart disease, congestive heart failure, and diabetes were prominent coexisting conditions. The number of male patients discharged home decreased from 77% to 63%, whereas the number of discharges to long-term care increased from 9% to 15%; the corresponding values for women were 72% to 56% and 15% to 23%. A slight increase in discharges to short-term care was indicated, whereas no trends were noted for in-hospital mortality. Hospitalizations for atrial fibrillation have increased dramatically (2- to 3-fold) in recent years. The public health burden of atrial fibrillation is enormous and expected to continue to increase over the next decades. Primary prevention of atrial fibrillation must be recognized and pursued as a complementary management strategy for reducing cardiovascular morbidity and mortality.Circulation 09/2003; 108(6):711-6. · 15.20 Impact Factor
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ABSTRACT: Pulmonary veins are considered to be the most common origin of the focal activity that triggers the onset of atrial fibrillation (AF). However, little is known about the importance of ectopic activity located outside the pulmonary veins. This study included 45 patients (8 women and 37 men, mean age 55 +/- 12 years) with paroxysmal (n = 25) and persistent (n = 20) AF in whom multisite mapping of the right and left atria was performed using a 64-electrode basket catheter (n = 21) or a noncontact mapping system (n = 24). Spontaneous or orciprenaline-induced atrial premature complexes (APCs) were mapped. In all, 94 AF onsets from 38 distinct foci in 30 patients were observed and analyzed. Of these foci, 20 (53%) were located in pulmonary veins and 18 (47%) were located outside the pulmonary veins in other parts of the atria. In 22 patients (73%), AF was reproducibly induced by APCs from a single focus (59 episodes). In 8 patients (27%), AF originated from 2 distinct foci (35 episodes). Additionally, 20 of 30 patients (67%) who developed AF had APCs in different locations not inducing AF. APCs inducing AF had shorter coupling intervals than APCs not inducing AF (307 +/- 54 vs 409 +/- 76 ms, p <0.001). This study showed that 47% of ectopic foci triggering the onset of AF were located outside the pulmonary veins in extravenous parts of the left atrium and the right atrium, and 27% of patients had AF onsets of bifocal origin. These data challenge the current opinion that extrapulmonary foci play a minor role in inducing AF.The American Journal of Cardiology 06/2002; 89(12):1381-7. · 3.21 Impact Factor
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ABSTRACT: : Bipolar radiofrequency ablation recently has been used to replace many of the incisions of the Cox-Maze procedure in the surgical treatment of atrial fibrillation. The unique aspect of this technology is that it uses an algorithm based on changes in tissue conductance to determine the energy required to achieve a transmural lesion instead of relying on predetermined time and/or temperature criteria to determine ablation duration, as with most other ablation technologies. The purpose of this study was to determine variations in the different parameters of ablation needed to create transmural lesions in human atria. : Initial impedance, total energy, temperature, and ablation time were measured in 38 patients undergoing surgery, using an impedance-controlled bipolar radiofrequency device (AtriCure Isolator, Cincinnati, OH). Lesions were categorized into the following groups: right atrial free wall, left atrial free wall, atrium up to mitral valve annulus, atrium up to tricuspid valve annulus, and right or left pulmonary veins. : There was a wide range of initial impedance (32.3 to 760.7 Ohms), and this correlated with total energy delivered (r = -0.31, P = 0.002). Ablation times varied widely (2.0 to 29.9 seconds) and were longer on left atrial structures than right (P < 0.005) and shortest near the tricuspid annulus (P < 0.001). Mean tissue temperature 1 mm from the electrode was only 45.7 ± 7.8°C (range, 23.7°C to 69.3°C). : Bipolar ablation of different atrial structures required widely different amounts of energy and ablation times, probably as the result of the inhomogeneity of atrial geometry and tissue impedance. These data cast doubt on the efficacy of any fixed-time or temperature ablations in the clinical setting.Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery 03/2007; 2(2):67-72.