Subxyphoid approach for closed-chest atrial fibrillation surgery: the one hand operation
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《血管的通路杂志》
Univ. Hospital de la Vall d'Hebron, Avenida de la Vall d'Hebron 119-129, 08035 Barcelona, Spain
Abstract
Although the classical Cox maze operation has been shown to be effective for curing atrial fibrillation, it is not popular due to its complexity and associated morbidity. This has led to the development of alternative methods for the creation of the Cox maze pattern. These methods are based on the creation of lines of tissue necrosis on the atrial tissue. These new methods have been shown to be equally as effective as the Cox maze operation. We describe a new technique for epicardial microwave atrial ablation for pulmonary vein isolation. This technique is performed on patients without sternotomy, through the subxyphoid process to reduce pulmonary complications.
Key Words: Atrial fibrillation; Cardiac surgery; Minimally invasive
1. Technique
After anaesthetic induction, transoesophageal echocardiography is carried out in order to discard the presence of thrombi in the left atrial appendage. The use of a Swan-Ganz catheter is also useful in order to monitor the right ventricular function.
As for a classical pericardial approach, a vertical subxyphoid incision (approximately 10 cm long) is performed. The linea alba is carefully incised, taking care not to damage the peritoneum. An inverted ‘T’ vertical incision is then made in the inferior aspect of the pericardium.
The surgeon's right hand is then carefully introduced into the pericardial cavity anterior to the heart. After a brief recognition of the heart's anatomy, the dissection is started.
The posterior aspect of the inferior vena cava is dissected using the thumb and the index finger allowing the passage of the index itself. This manoeuver can be done without difficulty, as those adherences are usually relatively weak (Fig. 1a).
The second part of the dissection includes a deeper introduction of the right hand into the pericardial cavity, laterally to the right atrium, in order to reach the space between the superior vena cava and the right superior pulmonary vein. The thumb is first placed in the beginning of the right aspect of the superior vena cava. The index finger is then carefully inserted within the space limited laterally by the superior vena cava and the aorta, and between the right superior pulmonary vein and the right pulmonary artery. The dissection of the posterior aspect of the superior vena cava begins while continuously feeling the vena cava itself. In case of bradycardia or hypotension it is strongly recommended to discontinue the procedure and to withdraw the hand. After restoration of normal haemodynamics, the operation can be resumed (Fig. 1b).
After completing the superior vena cava dissection, the first phase of the operation is completed.
The hand is withdrawn and the Flex 10 device (Guidant, Santa Clara, CA) is prepared. A little perforated ball (1 cm diameter) is knotted to the proximal part of the Flex 10. Another two large knots are made with a 0 silk suture at the beginning (segment 1) and the end (segment 10) of the ablating section of the sheath, in order to be able to sense them inside the pericardial cavity.
While having the ball-tip between the index finger and the thumb, the hand is introduced into the pericardial cavity behind the inferior vena cava. After pushing the ball-tip with the index finger, the distal part of the Flex 10 sheath can be pulled through the lateral aspect of the right atrium. When reaching the second dissected space, the ball is pushed with the thumb, in order to be placed in the transverse sinus, above the roof of the left atrium. As this is the most demanding manoeuver, it is strongly recommended to do it gently and to withdraw the hand in case of bradycardia or hypotension, mainly due to a right ventricular disturbance.
Once in the transverse sinus, the ball is pushed through, in order to reach the posterior aspect of the left atrial appendage. Then, the device can be cautiously pulled out until the tip of the Flex 10 is extracted out of the pericardial cavity.
It is important to sense the two knots made at the beginning and at the end of the active section of the ablation sheath (segments 1 and 10), in order to cross them over (Fig. 2). To insure the correct orientation of the Flex 10 relative to the left atrium, it is easy to recognise the round part (not active) which has to be completely sensed all around the left atria, to avoid any possible twisting of the device. The hand has to sense the left main coronary trunk, which is usually located far away from the roof of the left atrium. Since the Flex 10 is positioned posterior to the left appendage, there is no risk of injuring the circumflex artery. It is also important to feel some distance to the coronary sinus in order to avoid any damage.
The ablation is then carried out by setting the power at 65 watts and performing segmental ablation of 90 s each, according to the guidelines from the manufacturer.
Once the 10 lesions are created, an additional eleventh overlapping lesion is performed in order to ensure lesion continuity between the first and the last ablation of the ablation line, therefore, closing the box lesion.
We have performed this technique in at least 10 patients, with a single rubber, before the sternotomy, without any haemodynamic problem. With the Flex 10, the procedure has been done in a 45-year-old woman, 155 cm tall who presented with a severe mitral regurgitation, right ventricular hypertrophy, and permanent atrial fibrillation. The subxyphoid ablation procedure was performed before the mitral procedure, which allowed the verification of the correct location of the device, the continuity of the ablation line and to assess any damage to the surrounding tissue, or to the heart. After the mitral procedure, the patient was in sinus rhythm, as well as during her hospital stay. A coronary CT scan was also performed and no lesion was seen.
2. Discussion
The Cox-Maze III procedure considered as the gold standard for treating atrial fibrillation, has shown a high morbi-mortality [1,2] resulting in the development of lesser invasive techniques [2–5]. The work of Haissaguerre [6] and more surgical practice has resulted in the development of pulmonary vein isolation based techniques, including some minimally invasive thoracotomy: left, right or bilateral. Nevertheless this last technique, always requiring lung deflation [7,8], can lead to lung complications such as atelectasia, pleural effusion, empyema and other pulmonary problems in the peri-operative period. Furthermore, these minimally invasive techniques require dissection of the pericardial reflections using endoscopic instruments which may lead to bleeding.
This review of a classical approach can avoid such complications, and could be an alternative to percutaneous pulmonary ablation, not always complete, in the case of patients with lone atrial fibrillation.
The only concern in this approach could be the right ventricular impairment. Before doing the procedure, we performed the process at least 10 times in previous patients with a simple cotton rubber. In all cases, patients with mitral, coronary or aortic disease, the right ventricular function was sometimes impaired, but in all cases it was immediately restored after the withdrawal of the surgeon's hand.
The technique that we have described does not require lung deflation and the dissection of the pericardial reflection is performed with the surgeon's finger, thus allowing continuous direct tactile feedback, therefore reducing the risk of bleeding.
Further attempts will include a broncoscope camera vision in order to have a direct vision of the possible lesion points.
3. Conclusion
This novel technique provides further advancement in the less invasive, closed chest treatment of atrial fibrillation. It may be an alternative or adjunct to incomplete percutaneous ablations in patients with a single symptomatic atrial fibrillation or a first step approach to treat atrial fibrillation without other concomitant cardiac diseases.
References
Cox JL, Jaquiss RD, Schuessler RB, Boineau JP. Modification of the maze procedure for atrial flutter and atrial fibrillation. Surgical technique of the maze III procedure. J Thorac Cardiovasc Surg 1995; 110:485–495.
Khargia K, Hutten BA, Lemke B, Deneke T. Surgical treatment of atrial fibrillation; a systematic review. Eur J Cardio-thorac Surg 2005; 27:258–265.
Williams MR, Knaut M, Berube D, Oz MC. Application of microwave energy in cardiac tissue ablation: from in vitro analyses to clinical use. Ann Thorac Surg 2002; 74:1500–1505.
Gillinov AM, Sirak J, Blackstone EH, McCarthy PM, Rajeswaran J, Pettersson G, Sabik FJ 3rd, Svensson LG, Navia JL, Cosgrove DM, Marrouche N, Natale A. The Cox maze procedure in mitral valve disease: predictors of recurrent atrial fibrillation. J Thorac Cardiovasc Surg Dec 2005; 130:1653–1660. Epub 2005 Oct 26.
Damiano RJ Jr. Alternative energy sources for atrial ablation: judging the new technology. Ann Thorac Surg Feb 2003; 75:329–330.
Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, Le Mouroux A, Le Metayer P, Clementy J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339:659.
Kalil RA, Lima GG, Leiria TL, Abrahao R, Pires LM, Prates PR, Nesralla IA. Simple surgical isolation of pulmonary veins for treating secondary atrial fibrillation in mitral valve disease. Ann Thorac Surg 2002; 73:1169–1173.
Bisleri G, Manzato A, Argenziano M, Vigilance DW, Muneretto C. Thoracoscopic epicardial pulmonary vein ablation for lone paroxysmal atrial fibrillation. Europace Mar 2005; 7:145–148.(Rafael Rodriguez Lecoq, J)
Abstract
Although the classical Cox maze operation has been shown to be effective for curing atrial fibrillation, it is not popular due to its complexity and associated morbidity. This has led to the development of alternative methods for the creation of the Cox maze pattern. These methods are based on the creation of lines of tissue necrosis on the atrial tissue. These new methods have been shown to be equally as effective as the Cox maze operation. We describe a new technique for epicardial microwave atrial ablation for pulmonary vein isolation. This technique is performed on patients without sternotomy, through the subxyphoid process to reduce pulmonary complications.
Key Words: Atrial fibrillation; Cardiac surgery; Minimally invasive
1. Technique
After anaesthetic induction, transoesophageal echocardiography is carried out in order to discard the presence of thrombi in the left atrial appendage. The use of a Swan-Ganz catheter is also useful in order to monitor the right ventricular function.
As for a classical pericardial approach, a vertical subxyphoid incision (approximately 10 cm long) is performed. The linea alba is carefully incised, taking care not to damage the peritoneum. An inverted ‘T’ vertical incision is then made in the inferior aspect of the pericardium.
The surgeon's right hand is then carefully introduced into the pericardial cavity anterior to the heart. After a brief recognition of the heart's anatomy, the dissection is started.
The posterior aspect of the inferior vena cava is dissected using the thumb and the index finger allowing the passage of the index itself. This manoeuver can be done without difficulty, as those adherences are usually relatively weak (Fig. 1a).
The second part of the dissection includes a deeper introduction of the right hand into the pericardial cavity, laterally to the right atrium, in order to reach the space between the superior vena cava and the right superior pulmonary vein. The thumb is first placed in the beginning of the right aspect of the superior vena cava. The index finger is then carefully inserted within the space limited laterally by the superior vena cava and the aorta, and between the right superior pulmonary vein and the right pulmonary artery. The dissection of the posterior aspect of the superior vena cava begins while continuously feeling the vena cava itself. In case of bradycardia or hypotension it is strongly recommended to discontinue the procedure and to withdraw the hand. After restoration of normal haemodynamics, the operation can be resumed (Fig. 1b).
After completing the superior vena cava dissection, the first phase of the operation is completed.
The hand is withdrawn and the Flex 10 device (Guidant, Santa Clara, CA) is prepared. A little perforated ball (1 cm diameter) is knotted to the proximal part of the Flex 10. Another two large knots are made with a 0 silk suture at the beginning (segment 1) and the end (segment 10) of the ablating section of the sheath, in order to be able to sense them inside the pericardial cavity.
While having the ball-tip between the index finger and the thumb, the hand is introduced into the pericardial cavity behind the inferior vena cava. After pushing the ball-tip with the index finger, the distal part of the Flex 10 sheath can be pulled through the lateral aspect of the right atrium. When reaching the second dissected space, the ball is pushed with the thumb, in order to be placed in the transverse sinus, above the roof of the left atrium. As this is the most demanding manoeuver, it is strongly recommended to do it gently and to withdraw the hand in case of bradycardia or hypotension, mainly due to a right ventricular disturbance.
Once in the transverse sinus, the ball is pushed through, in order to reach the posterior aspect of the left atrial appendage. Then, the device can be cautiously pulled out until the tip of the Flex 10 is extracted out of the pericardial cavity.
It is important to sense the two knots made at the beginning and at the end of the active section of the ablation sheath (segments 1 and 10), in order to cross them over (Fig. 2). To insure the correct orientation of the Flex 10 relative to the left atrium, it is easy to recognise the round part (not active) which has to be completely sensed all around the left atria, to avoid any possible twisting of the device. The hand has to sense the left main coronary trunk, which is usually located far away from the roof of the left atrium. Since the Flex 10 is positioned posterior to the left appendage, there is no risk of injuring the circumflex artery. It is also important to feel some distance to the coronary sinus in order to avoid any damage.
The ablation is then carried out by setting the power at 65 watts and performing segmental ablation of 90 s each, according to the guidelines from the manufacturer.
Once the 10 lesions are created, an additional eleventh overlapping lesion is performed in order to ensure lesion continuity between the first and the last ablation of the ablation line, therefore, closing the box lesion.
We have performed this technique in at least 10 patients, with a single rubber, before the sternotomy, without any haemodynamic problem. With the Flex 10, the procedure has been done in a 45-year-old woman, 155 cm tall who presented with a severe mitral regurgitation, right ventricular hypertrophy, and permanent atrial fibrillation. The subxyphoid ablation procedure was performed before the mitral procedure, which allowed the verification of the correct location of the device, the continuity of the ablation line and to assess any damage to the surrounding tissue, or to the heart. After the mitral procedure, the patient was in sinus rhythm, as well as during her hospital stay. A coronary CT scan was also performed and no lesion was seen.
2. Discussion
The Cox-Maze III procedure considered as the gold standard for treating atrial fibrillation, has shown a high morbi-mortality [1,2] resulting in the development of lesser invasive techniques [2–5]. The work of Haissaguerre [6] and more surgical practice has resulted in the development of pulmonary vein isolation based techniques, including some minimally invasive thoracotomy: left, right or bilateral. Nevertheless this last technique, always requiring lung deflation [7,8], can lead to lung complications such as atelectasia, pleural effusion, empyema and other pulmonary problems in the peri-operative period. Furthermore, these minimally invasive techniques require dissection of the pericardial reflections using endoscopic instruments which may lead to bleeding.
This review of a classical approach can avoid such complications, and could be an alternative to percutaneous pulmonary ablation, not always complete, in the case of patients with lone atrial fibrillation.
The only concern in this approach could be the right ventricular impairment. Before doing the procedure, we performed the process at least 10 times in previous patients with a simple cotton rubber. In all cases, patients with mitral, coronary or aortic disease, the right ventricular function was sometimes impaired, but in all cases it was immediately restored after the withdrawal of the surgeon's hand.
The technique that we have described does not require lung deflation and the dissection of the pericardial reflection is performed with the surgeon's finger, thus allowing continuous direct tactile feedback, therefore reducing the risk of bleeding.
Further attempts will include a broncoscope camera vision in order to have a direct vision of the possible lesion points.
3. Conclusion
This novel technique provides further advancement in the less invasive, closed chest treatment of atrial fibrillation. It may be an alternative or adjunct to incomplete percutaneous ablations in patients with a single symptomatic atrial fibrillation or a first step approach to treat atrial fibrillation without other concomitant cardiac diseases.
References
Cox JL, Jaquiss RD, Schuessler RB, Boineau JP. Modification of the maze procedure for atrial flutter and atrial fibrillation. Surgical technique of the maze III procedure. J Thorac Cardiovasc Surg 1995; 110:485–495.
Khargia K, Hutten BA, Lemke B, Deneke T. Surgical treatment of atrial fibrillation; a systematic review. Eur J Cardio-thorac Surg 2005; 27:258–265.
Williams MR, Knaut M, Berube D, Oz MC. Application of microwave energy in cardiac tissue ablation: from in vitro analyses to clinical use. Ann Thorac Surg 2002; 74:1500–1505.
Gillinov AM, Sirak J, Blackstone EH, McCarthy PM, Rajeswaran J, Pettersson G, Sabik FJ 3rd, Svensson LG, Navia JL, Cosgrove DM, Marrouche N, Natale A. The Cox maze procedure in mitral valve disease: predictors of recurrent atrial fibrillation. J Thorac Cardiovasc Surg Dec 2005; 130:1653–1660. Epub 2005 Oct 26.
Damiano RJ Jr. Alternative energy sources for atrial ablation: judging the new technology. Ann Thorac Surg Feb 2003; 75:329–330.
Haissaguerre M, Jais P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, Le Mouroux A, Le Metayer P, Clementy J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998; 339:659.
Kalil RA, Lima GG, Leiria TL, Abrahao R, Pires LM, Prates PR, Nesralla IA. Simple surgical isolation of pulmonary veins for treating secondary atrial fibrillation in mitral valve disease. Ann Thorac Surg 2002; 73:1169–1173.
Bisleri G, Manzato A, Argenziano M, Vigilance DW, Muneretto C. Thoracoscopic epicardial pulmonary vein ablation for lone paroxysmal atrial fibrillation. Europace Mar 2005; 7:145–148.(Rafael Rodriguez Lecoq, J)