Anatomic aspects of the atrioventricular junction influencing radiofrequency Cox maze IV procedures

Abstract

Bipolar radiofrequency clamps are not sufficient to complete a Cox maze IV procedure. Moreover, they may compromise coronary arteries in patients with left coronary dominance. Lines to the atrioventricular annuli need to be completed with the cut-and-sew technique or with alternative monopolar energy devices.

Assessment of concomitant paroxysmal atrial fibrillation ablation in mitral valve surgery patients based on continuous monitoring: does a different lesion set matter?

“…Surgical technique and the efficacy of electrophysiology in performing mitral line with bipolar clamp alone has been described by Benussi et al [19]. However, the work of Castellá et al [20] noted the anatomical impossibility of forming the line with a bipolar clamp. In our study, we strictly followed Benussi's technique.…”

Comparison of two radiofrequency ablation devices for atrial fibrillation concomitant with a rheumatic valve procedure

“…Regarding ablation of the isthmus, Castella et al demonstrated that bipolar clamps were not sufficient to achieve complete ablation of the atrioventricular junction in an anatomical study. [21] They concluded that an additional monopolar ablation device or the cut-and-sew technique was required to complete the isthmus ablation. In our center, we only use bipolar RF without monopolar RF for the sake of economic costs.…”

Treatment Complications of Atrial Fibrillation and Their Management

“…An example is the lesion extending to the mitral annulus, that although technically challenging, successful creation is associated with a significant decrease in left sided atrial flutter. 73 As energy technology-cryoablation and RF-ablation-has allowed for quicker therapy and more minimally invasive approaches, various groups have advocated for intentional utilization of incomplete lesion sets to decrease CPB and cross-clamp times. As previously mentioned, pulmonary vein isolation (PVI) is essential as most of the AF foci are from PV origin; however, performing only the PVI lesion set has a lower incidence of SR at 2-year follow-up when compared with a more complete linear lesion set and omission of the mitral annular lesion is associated with increased rates of left side atrial flutter.…”

“…As previously mentioned, pulmonary vein isolation (PVI) is essential as most of the AF foci are from PV origin; however, performing only the PVI lesion set has a lower incidence of SR at 2-year follow-up when compared with a more complete linear lesion set and omission of the mitral annular lesion is associated with increased rates of left side atrial flutter. [73][74][75] Although omitting the right atrial lesion set has a reduced incidence of postoperative pacemaker dependence, there remains question as to the longevity of SR maintenance when compared with a complete biatrial lesion set as demonstrated. Barnett and Ad demonstrated this in a meta-analysis confirming biatrial lesion sets result in better control of late AF (87 vs. 73%, p ¼ 0.05) than those constrained to the LA.…”

“…61 For patients undergoing only left atrial lesion sets, there is approximately a 15% rate of transient postoperative atrial flutter, with successful completion of the mitral annular lesion connecting the PVI box lesion to the mitral annulus decreasing this rate. 73,75 Early postoperative atrial flutter (30 days of procedure) is frequently transient and responds well to antiarrhythmic therapy, as recommended above. If pharmacologic therapy fails, cardioversion is frequently successful.…”