Simultaneous hybrid maze procedure for long-standing persistent atrial fibrillation with dilated atrium

Figures

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  Results of the simultaneous hybrid maze procedure for long-standing persistent atrial fibrillation and dilated atrium.

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  Figure 1. A schematic drawing of biatrial lesion sets in simultaneous hybrid ablation. A, Posterior view of the left atrium, with linear lesions including bilateral pulmonary vein isolation, the roof line, the inferior line, left fibrous trigone lesion, the linear lesion connecting the left upper pulmonary vein to the left atrial appendage (LAA), the linear lesion connecting the left inferior pulmonary vein to the great cardiac vein (GCV), and GCV linear ablation. B, Lateral view of the right atrium, with linear lesions including the superior vena cava–inferior vena cava (SVC-IVC) line, the linear lesion connecting the right atrial appendage (RAA) to the SVC-IVC line, and the linear lesion connecting the tip to the base of the RAA on the inner wall of the RAA and cavotricuspid isthmus line. The solid red lines represent epicardial ablation sites with a bipolar radiofrequency clamp, and the dotted red lines represent epicardial ablation sites with a bipolar radiofrequency pen during thoracoscopic ablation. The yellow line with crosses represents ablation sites other than touch-up or reinforced sites during catheter ablation. PA, Pulmonary artery; LPV, left pulmonary vein; RPV, right…

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  Figure 2. Endocardial 3-dimensional voltage mapping and catheter ablation after initial thoracoscopic epicardial ablation. A, Right atrial mapping (right atrial free wall view) showing a persistent normal potentials area and a low-voltage area located at the superior vena cava–inferior vena cava (SVC-IVC) linear lesion and almost entire linear lesion connecting the right atrial appendage (RAA) to the SVC-IVC lesion was composed of a persisting normal potentials area. B, Bi-atrial mapping (anteroposterior view) showing the roof line and the left fibrous trigone line. C, Biatrial mapping (posteroanterior view) showing gray areas located in bilateral pulmonary veins, implying complete bilateral pulmonary vein isolation and persistent normal potentials at the posterior wall of the left atrium and without an obvious inferior line. D, Based on the electrophysiological mapping in A, touch-up endocardial catheter ablation (blue spots) was performed at the SVC-IVC line, and a cavotricuspid isthmus line was also created. E, Based on the electrophysiological mapping in B, reinforced endocardial catheter ablation (yellow spots) was performed at the roof line and left fibrous trigone line. F, Based on…

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  Figure 3. Flow diagram of the simultaneous hybrid maze procedure and the results at latest follow-up. LSPAF, Long-standing persistent atrial fibrillation; SR, sinus rhythm; AFL, atrial flutter; AF, atrial fibrillation; CA, catheter ablation; AADs, antiarrhythmic drugs.

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  Figure 4. Freedom from atrial tachyarrhythmia without antiarrhythmic drugs (AADs) after the single hybrid procedure was 70.4% at 6 months and 60% at 12 months. Freedom from atrial tachyarrhythmia without AADs in all patients was 74.1% at 6 months and 73.1% at 12 months after the hybrid ablation and redo catheter ablation.

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  Figure 5. Twenty-seven patients with long-standing persistent atrial fibrillation (LSPAF) with markedly dilated atrium underwent simultaneous hybrid ablation with a biatrial lesion set consistent with the principle of the Cox maze procedure. The upper part of the middle portion in the picture shows epicardial left-sided box lesion ablation by a bipolar clamp through the transverse and oblique sinus, epicardial ablation with a bipolar pen at the free wall of the right atrium, and endocardial ablation at the right atrium (blue spots) and the posterior wall of the left atrium (blue spots and yellow spots). The inferior part of the middle portion in the picture show the complete lesion set during the simultaneous hybrid ablation. At 12 months after the single simultaneous hybrid ablation, without antiarrhythmic drugs, 60% patients restored sinus rhythm (SR), 28% patients had new-onset atrial flutter (AFL), and 12% patients had recurrent atrial fibrillation (AF). At last follow-up after the simultaneous hybrid procedure and redo catheter ablation (CA) (4 of 5 patients who underwent redo CA were followed for 12 months, and 1 patient was followed for 6 months), 74.1% restored SR, 14.8% had…