Optimized Technical and Electrophysiological Approach for Treatment of Atrial Fibrillation

The maze procedure initially proposed by Cox for primary atrial fibrillation treatment somehow, in its complexity, increases the morbidity risk associated with mitral valve surgery. Objective. We sought to describe a surgical technique that considers the concepts of electrophysiology and to describe the initial results of a new surgical and electrophysiological approach that blocks the main atrial circuits as defined by Frame, and to optimize the surgical tactic for treatment of atrial fibrillation. Material and Methods. Eight patients with chronic atrial fibrillation and mitral valve dysfunction, with tricuspid valve regurgitation in 1 case, were operated on. The following modifications of the classic Cox procedure were employed: (1) exclusion of the left atrium appendage with an inner suture that closed the left atrial ostium, (2) exclusion of the right atrium appendage by 1 purse-string suture used for fixation of the superior vena cava draining cannula, (3) a single atrial incision, (4) transendocardium electrocauterization in the left atrium wall around all pulmonary vein ostia, and (5) substitution of the incisions and sutures in the left atrium with transendocardium electrocauterization. Results. The extracorporeal circulation time varied from 64 min to 133 min (mean, 107.5 min), and the cardioplegia time varied from 40 min to 105 min. (mean, 76.7 min). All patients were in regular atrial rhythm at the end of surgery. The postoperative period was uneventful, and all patients were discharged from the hospital showing regular atrial rhythm, without definitive pacemaker implantation. In the postoperative period 6 months after surgery, 6 patients (75%) were in regular atrial rhythm with preserved atrial contractions, and 2 (25%) with atrial fibrillation, clinically controlled (New York Heart Association class II). There were no embolic complications or evidence of thrombosis in the echodopplercardiography control. Conclusion. It is concluded from this initial series of cases that the electrophysiolgical approach and the surgical technique employed improved the surgical treatment of atrial fibrillation, making possible the correction of mitral and tricuspid valve lesions without additional morbidity.