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Box Lesion in the Open Left Atrium for Surgical Ablation of Atrial Fibrillation.
Leonid Sternik, Alexander Kogan, David Luria, Michael Glikson, Ateret Malachy, Shany Levin, Ehud Raanani.
Sheba Medical Center, Ramat-Gan, Israel.

OBJECTIVE: Maze with a "box lesion" around the pulmonary veins is currently the gold standard procedure. Recently, we changed our surgical ablation of atrial fibrillation technique from standard bilateral epicardial pulmonary vein isolation with interconnecting lesions, to a "box lesion" procedure with a bipolar radiofrequency ablator. Our study describes this new technique.
METHODS: Between March 2009 and June 2012 we performed 90 ablations by the "box" technique, using a bipolar radiofrequency device. Fifty-five (61%) patients had persistent and 21 (23%) long standing persistent atrial fibrillation. The left atriotomy was performed along the interatrial septum. Left atrial appendage was amputated. The "box" was made by connecting the left atriotomy to the base of the amputated appendage with lines along the transverse and oblique sinuses by epi- and endocardial application of a bipolar radiofrequency ablator. Left atrial isthmus was ablated by cryoprobe.
RESULTS: The mean follow-up was 13±11 months. The follow up was performed by electro physiologists and surgeons. There were no ablation-related complications. The "box" was easy to perform, with no dissection around the pulmonary veins. The "box" technique was found especially useful when surgery was performed through the right minithoracotomy incision (5 patients). At 6 months, 1 year and 2 years follow-up; 80 (94%), 69 (93%) and 47 (91%) patients were in sinus rhythm correspondently. The freedom from antiarrhythmic medications in patients with sinus rhythm at 6 months, 1 year and 2 years follow-up was 78%, 88% and 85% correspondently.
CONCLUSIONS: "Box lesion" provided excellent freedom from atrial fibrillation. "Box lesion" may improve transmurality due to ablation of one rather than two layers of atrial wall, as in epicardial pulmonary vein isolation. "Box lesion" deems dissection around the pulmonary veins unnecessary. This technique was found especially useful when surgery was performed through the right minithoracotomy incision.


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