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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3753_Библиотеки_им_академика_М_И_Перельмана
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164 M. Castella and J. Ruíz
AB
Fig. 1 A Lesion pattern in the left atrium, including the
Box lesion and lesions towards the mitral annulus and the
left appendage. B Lesion pattern in the right atrium
used both for isolated persistent or long-standing
persistent AF as wel l as for patients with mitral
and/or tricuspid disease with concomitant AF.
1 Technique
1.1 General Considerations
Our technique for AF ablation is based in cryothermy lines performed endocardially through an
8 cm right mini-thoracotomy with the help of
extracorporeal circulation by femoral cannulation.
The patient is placed in a supine position, with
a small bean bag underneath his/her right chest,
so the body is slightly tilted to the left. Both arms
are joined to the body, being the right arm
slightly lower to the chest, allowing full exposure
of the right side of the thorax. Surgical draping
allows access to the right thoracic wall as well as
sternotomy.
It is our suggestion not to use selective
bronchial cannulation with a specific orotracheal
tube and to use a normal oro-tracheal tube with
including lines to the tricuspid annulus, right appendage
and both venae cavae
right bronchial blocker when needed. We
strongly recommend full ventilation of both
lungs as much as possible, but mostly important
coming off bypass, to prevent right lung oedema.
1.2 Cannulation
Cannulation is performed by a 2–3 cm incision
over following the right inguinal ligament.
Femoral artery and vein are dissected only in the
anterior side where cannulae are inserted by
Seldinger technique through a previous 5/0
polypropylene purse string sutures. The most
used arterial cannulae sizes are 17 and the 19Fr.
For venous cannulation we always use the 25Fr
Medtronic multiperforated cannula that it is
advanced to the entrance of the superior vena
cavae under echocardiographic supervision. If
the right atrium is to be opened to perform the
right-side lesions of the Cox-Maze, this cannula
is advanced up to the diaphragm and anothe r
19Fr venous cannula is placed in the superior
vena cava by percutaneous jugular puncture.
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1.3 Access to the Chest
While cannulation is performed by the first and
second assistant, the surgeon places a trocar port
on the third intercostal space on the anterior
axillary line. If a 2D 30º camera technology is
going to be used, the trocar can be a 5 mm and
be the camera access to the chest. If a 3D view
system is going to be used, this trocar will be a
working port for needle-holders or pick-ups. In
either case, this port is the first one to place in
order to insufflate CO2 in the thoracic cavity and
help to collapse the right lung. The next step is to
perform a small (5 to 8 cm) right lateral thoracotomy through the fourth intercostal space over
the anterior axillary line and places a soft tissue
retractor. If a 3D camera is used, this will be a
working port as well as the camera port.
After heparinization and full extracorporeal
circulation is achieved, the pericardium is opened
with cautery 2 cm anteriorly to the phrenic nerve,
from the ascending aorta to the diaphragm. Two
to three retractor stitches are placed from the
inferior side of the pericardium and pulled
through the chest wall with the help of Endoclose™ (Covidien™).
1.4 Myocardial Preservation
A small purse string suture is placed on the right
side of the ascending aorta in order to fix the
cardioplegia line. We have changed from a 4/0
polypropylene to a 2/0 tycron suture leaned on
pledgets because at the end of the procedure it
can be closed with a Cor-knot®(ISI Solutions®).
This line will also be used for suction and
venting before coming off extracorporeal circulation. It is not so important that this is not in the
anterior side of the ascending aorta because the
thoracic cavity is so filled with CO
chances of air embolism in the right coronary or
carotids are slim. Once the cardioplegic line is in
place and coming off the chest through the
working port, the ascending aorta is crossclamped with a Chitwood clamp. This clamp is
placed through a new thoracic access, by a 5 mm
incision on the anterior or mid axillary line at the
second or third intercostal space. In order to find
the best spot, an imaginary line need to be drawn
from the proper place of the aorta to the chest.
Cardioplegia is given as a routine case by the
hospital protocol (Video 1).
that the
2
Video 1 Thoracic working port through the fourth intercostal space (▶ https://doi.org/10.1007/000-a7z)
166 M. Castella and J. Ruíz
1.5 Access to the Left Atrium
and Left-Sided Lesions
As soon as cardioplegia is administered, the left
atrium is open through the interatrial groove. An
atrial retractor is placed through a new 2 mm
incision on the fourth intercost al space one cm
lateral to the right mammary artery. In order to
visualize the coronary sinus, it is important to
dissect in between the left inferior pulmonary vein
and the inferior vena cava to reach the oblique
sinus. A vent is placed in the left pulmonary veins
through a new 1 cm port on the sixth inte rcostal
space over the anterior axillary line. This port will
be used aftermath to place the pleural drainage.
The ablation line set follows the pattern
described by Jim Cox [2]. Basically, it follows
three principles. First, to isolate the pulmonary
veins and the posterior wall of the left atrium in
what is called “the box line”. Second, to perform
a line that reaches all the different round structures of the atria to prevent macro re-entrant
circuits around them. These are lines to the mitral
annulus and to the left appendage, and in the
right side to the tricuspid annulus, right appendage and both venae cavae. Third, AF surgery
lowers the possibility of cardiogenic thromboembolism by closing the left appendage. On
the left side all ablation lines need to be performed from the endocardial side, where the
atrial muscle is, except of the mitral line. The
target of this line is not only the atrial tissue but
also the muscular fibers within the venous wall of
the coronary sinus behind. Since it is most possible that cryot hermy applied on the endocardial
side may not freeze the coronary sinus, it is
suggested to perform this line also from the
epicardial side.
Ablations lines will be of 3 min of duration to
ensure transmurality. To avoid gaps in the lines, it
is fundamental to press the tissue with the cryothermy probe in order to span the tissue and avoid
folds. It important to notice that while the probe
defrost fast, the tissue will take some minutes to
defrost. Therefore, it is best alternate the ablation
lines from inferior to superior to allow defreezing of previous lines. Once the heart is
arrested and the left atrium opened, we suggest to
start ablating the mitral line on the epicardial side,
paying attention to reach the coronary sinus.
Since we will have to repeat this line from the
endocardial side, we stain this line with metycilin
blue to make sure both epi and endocardial lines
are superposed (Video 2). To allow de-freezing of
this first line, the second line is the superior part of
the box lesion. This line runs from the superior
corner of the atrial incision to the midpart of the
ridge between the left pulmonary veins and the
left appendage (Video 3). This line is followed by
the inferior part of the box lesion, which goes
from the inferior corner of the left atrial incision
to the same ridge, overlapping with the previous
lesion and therefore encircling all pulmonary
veins and the posterior wall of the left atrium
(Video 4). Next is a short line from the box lesion
to the left atrial appendage (Video 5). Last line in
the left side is to repeat the mitral line from the left
corner of the atrial incision towards the posterior
annulus of the mitral valve, making sure we reach
the valve, and on top of the previously stained
line (Video 6). The left appendage can be closed
by a double running polypropylene suture or by
placing a clip through the transverse sinus. If this
is the case, we suggest the use of the Pro-2
Atriclip (Atricure inc, USA). To facilitate placing
the clip, the aorta must remain cross-clamped and
a 5/0 polypropylene suture can be placed in the tip
of the appendage to facilitate traction towards the
clip. The left atrium is closed with a 4/0
polypropylene suture starting at both ends.
1.6 Right-Sided Lesions
Right sided lesions add higher possibilities for
maintaining sinus rhythm in long follow-up, but
also increases the rate for pacemaker need after
ablation [3]. The reasons for this are unknown,
but probably deal more by damaging the sinus
node than for affecting the conduction system,
since none of the lines come close to the AV
node of the Purkinge system. Indeed, cryothermy
produce wide lines of frosted tissue that can get
close not only at the superior vena cava-right
atrium ridge where the sinus node is described
but other zones of the free wall of the right
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Video 2 Coronary sinus line which needs to be overlapped with the mitral line from the endocardium (Video 6)
(▶ https://doi.org/10.1007/000-a7v)
atrium which may be responsible to rapid pacing
during exercise [4].
To perform the right atrial lesions the right
atrium must be opened. A venous line must be
previously placed in the right jugular vein and
the femoral cannula must be at the level of the
diaphragm. The superior vena cava can be closed
with a metal bulldog while it is better to encircle
the inferior vena cava with a wide vessel
loop. We suggest to open the right atrium with a
small (5 cm) incision from the Cresta Termi-
nallis towards the tricuspid annulus.
Despite all the lines except the one to the tricuspid annulus can be performed on the epicardial
side, doing them from the endocardium makes it
easier. The first line is to the tricuspid annulus from
the upper corner of the a trial incision (Videos 7
and 8) making sure the probe reaches the anterior
leaflet. So far, there is no evidence of coronary
lesions by cryothermy [5]. The second line is
towards the right appendage from the upper corner
of the incision (Video 9). Attention must be taken
to do it from the upper part of the incision to avoid
freezing in the midpart of the free wall of the right
atrium, that might be responsible for tachycardization during exercise. The third line is from
the posterior corner of the atrial incision to the
posterior wall of the superior vena cava, parallel to
the Cresta Terminallis. Be careful that 3 min of
freezing will span the lesion very close to the sinus
node zone. Finally, a line is performed from the
posterior corner of the atrial incision towards the
inferior vena cava (Video 10). The right atrium is
closed in the usual manner.
168 M. Castella and J. Ruíz
Video 3 Box lesion at the superior side. Together with the inferior line (video 4) there is complete isolation of the
pulmonary veins and the posterior wall of the left atrium (▶ https://doi.org/10.1007/000-a7w)
the higher incidence of pacemaker happens when
2 Results
the right lesions are performed, but that no significant pacemaker incidence is described by left
Surgical ablation for atrial fibrillation has
demonstrated to be the most effective therapy to
maintain sinus rhythm in the long term [6].
Furthermore, a recent randomized trial showed a
decreased risk in stroke at 5 years follow-up [7].
and some non-randomized personal series have
described benefits in mortality at 10 years [8]. In
2015 a meta-analysis by the Cochrane Foundation showed significant benefits in sinus rhythm
maintenance while no difference of adding a
concomitant AF ablation in regards to mortality,
neurologic or thromboembolic events, cardiovascular events [9]. The most important complication described in most meta-analyses is the
increased need for pacemaker after a Cox-Maze
ablation [9]. A recent meta-analysis showed that
lesions only [3]. In our opinion, since none of the
left or right lesions come close to the AV node or
the Purkinge system, the higher incidence of
pacemaker may be due to damage of the sinus
node or its surrounding areas, responsible for
tachycardization.
Results of a Cox-Maze with cryothermy
through mini-thoracotomy as described in this
chapter have been published in non-randomized
series, showing a 73% of patients with maintained sinus rhythm at 5 years without the need
of antiarrhythmic drugs or further ablations, 79%
off antiarrhythmic drugs, or 90% allowing medication or a subsequent catheter ablation [10].
Results from mini-sternotomy have shown to be
as through sternotomy [11] There are important
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Video 4 Inferior line of the Box lesion (▶ https://doi.org/10.1007/000-a7x)
Video 5 Line from the box lesion to the entrance of the left atrial appendage (▶ https://doi.org/10.1007/000-a7y)
170 M. Castella and J. Ruíz
Video 6 Line to the mitral annulus on top of the coronary sinus line (Video 2) (▶ https://doi.org/10.1007/000-a7t)
Video 7 Line to the tricuspid annulus (▶ https://doi.org/10.1007/000-a80)
Minimally Invasive Endoscopic Maze Procedure for Atrial Fibrillation … 171
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Video 8 Line to the right appendage (▶ https://doi.org/10.1007/000-a81)
Video 9 Line to the superior venae cavae (▶ https://doi.org/10.1007/000-a82)
172 M. Castella and J. Ruíz
Video 10 Line to the inferior venae cavae (▶ https://doi.org/10.1007/000-a83)
factors that limit results, being the most important ones the size of the left atrium and the years
in atrial fibrillation [12].
3 Conclusion
In summary, atrial fibrillation surgery is a reasonably effective therapy and can be indicated
both in symptomatic patients with isolated AF
which are refractory to antiarrhythmic medication or percutaneous ablation and patients with
AF concomitant to other surgical disease. The
technique described is one of the most effective
due to the possibility of performing a full CoxMaze lesion set while being minim ally invasive.
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