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Concomitant Cox Maze IV Ablation Procedure Performed Entirely by Bipolar Clamp through Right Lateral Minithoracotomy
Ju Mei, Zhaolei Jiang, Nan Ma, Hao Liu, Fangbao Ding, Chunrong Bao.
Department of Cardiothoracic Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong Univers, Shanghai, China.

OBJECTIVE: To introduce the technique of performing concomitant Cox Maze IV ablation procedure entirely by bipolar clamp through right lateral minithoracotomy for patients with atrial fibrillation (AF) associated with mitral valve diseases.
METHODS: Ablation procedure was performed through right lateral minithoracotomy entirely by bipolar radiofrequency clamp as following: A six-centimeter right lateral incision was made over the 4th intercostal space. After peripheral cardiopulmonary bypass (CPB) was established, tissues between pericardial transverse and oblique sinuses were bluntly dissected. Then, one 16 Fr catheter was placed inferior to the left pulmonary veins (PVs), and another catheter was placed superior to the left PVs. Both of the two catheters were connected to the upper and lower jaws of the bipolar clamp and used to guide the clamp to clamp and ablate the left PVs. Then, ablation line around right PVs, ablation line from the right superior PV to the left superior PV; ablation line from the right inferior PV to the left inferior PV; ablation line from the right inferior PV to the mitral valve annulus; excision of the left atrial appendage; ablation line from the base of left atrial appendage to the left superior PV, and right atrial ablation were performed.
RESULTS: All patients successfully underwent this minimally invasive concomitant Maze IV ablation procedure and mitral valve surgery. The mean CPB time was 130.3±17.7 minutes. The mean aortic crossclamp time was 91.8±12.7 minutes. No patient needed conversion to sternotomy during the surgery. There was no early death or pacemaker implantation in the perioperation. The average length of hospital stay was 9.8±3.3 days. At discharge, 65 patients (65/69, 94.2%) maintained sinus rhythm. At a mean follow-up time of 21.0±8.6 months, sinus rhythm was restored in 62 patients (62/69, 89.9%). Cumulative maintenance of normal sinus rhythm without AF recurrence at 2 years postoperatively was 85.1±5.8%.
CONCLUSIONS: This procedure is safe, feasible, and effective. This procedure did not require an additional unipolar or cryothermal energy device for completing all ablation lines, which may reduce costs. Therefore, this technique deserves further usage and implementation.

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