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OBJECTIVE: Mini-maze procedure was successfully performed for the patient with the past history of heart surgery and the complex venous return anomalies.
METHODS: The patient was 36-years-old male. At the age of two, he underwent patent ductus arteriosus division through a left thoracotomy and permanent pacemaker implantation. He developed paroxysmal atrial fibrillation at the age of 34. Anti-arrhythmic agents were reinforced but tachycardia became uncontrollable. Catheter ablation was tried through the right axillary vein but failed because the pacing leads jammed. There was no other route to the heart; the inferior vena cava is defective and the left superior vena cava joins the left azygos vein on the top of the left pulmonary vein and the trunk vein empties itself into the coronary sinus. Thus, the surgical treatment was indicated. Preoperatively, 3D enhanced computed tomography was taken to investigate the impact of the venous anomalies on surgery. On this occasion, a marker was placed at the mid-point of the old thoracotomy to know the precise mini-thoracotomy site. The 3D images revealed the thick trunk vein into the coronary sinus was lying between the left appendage and left pulmonary vein, where the isolation line should be drawn. A mini-thoracotomy was made one-intercostal-space higher than the previous thoracotomy, the pleural and pericardial adhesions were dissected, and the trunk vein was safely taped and maneuvered to achieve the left pulmonary vein isolation using a radiofrequency ablation clamp and the stapled left appendectomy as well. The right-side operation was accomplished thoracoscopically.
RESULTS: The procedure was completed in 108 minutes without conversions to cardiopulmonary bypass nor standard thoracotomy. The patient has been followed up for three months after surgery with no atrial fibrillation attack despite the discontinued anti-arrhythmic drugs.
CONCLUSIONS: Paroxysmal atrial fibrillation of the patient with the history of patent ductus arteriosus divison and the venous return anomalies - inferior vena cava defect and persistent left superior vena cava and left azygos vein draining into the coronary sinus - was successfully treated using a mini-maze technique. The preoperative 3D enhanced computed tomography was instrumental for understanding the procedure-associated anatomical information and designing the mini-thoracotomy.