Staged hybrid totally thoracoscopic maze and catheter ablation for atrial fibrillation

Figures

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  Figure 1. Lesion sets of (A) Cox‐Maze III and (B) Cox‐Maze IV procedures. The Cox‐Maze lesion set has historically provided the highest success rate for treatment of atrial fibrillation. Modifications of the original procedure need to replicate these original lesions regardless of the approach or energy source used.

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  Figure 2. Cobra Fusion device and Muneretto hybrid lesions set. The Cobra Fusion device (A) delivers radiofrequency energy to create a box lesion around the pulmonary veins and perform additional lesions to the right atrium (B) (fusion image used with permission from Atricure Inc.).

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  Figure 3. Final lesion set of our hybrid modified totally thoracoscopic maze approach with second stage catheter ablation. The lesions performed thoracoscopically in the first stage are shown in blue ((A) Left‐sided and (B) Right‐sided). The right‐sided lesions are placed first to isolate the pulmonary veins and create superior and inferior portions of a box lesion. Inferior and superior vena cave lesions are placed with a connecting lesion to the right atrial appendage. The left sided‐lesions are then placed to isolate the pulmonary lesions and connect box lesions to the right sided‐box lesions. A lesion is placed from the left portion of the superior box lesion to the left atrial appendage. The appendage is then occluded with a clip device. After 3 months, a catheter ablation is performed to add the endocardial lesions shown in red. Mapping is also performed and any additional ablation lesions are performed to close identified gaps in the surgically placed lesions.