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Minimally Invasive Cox Maze IV Ablation Procedure Performed Entirely by Bipolar Clamp Concomitant to Mitral Valve Surgery through Right Lateral Minithoracotomy
Ju Mei, Zhaolei Jiang, Nan Ma, Hao Liu, Fangbao Ding, Chunrong Bao, Jianbing Huang.
Xinhua Hospital, School of Medicine, Shanghai Jiaotong Univers, Shanghai, China.
OBJECTIVE: To introduce the technique of performing minimally invasive 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: Sixty nine patients (43 males, 52 to 71 years) with mitral valve disease and long-standing persistent AF received minimally invasive Cox Maze IV ablation procedure combined with mitral valve surgery from June 2012 to January 2015. Diameter of the left atrium ranged from 42 to 60 mm. Left ventricle ejection fraction ranged from 45% to 67%. A six-centimeter right lateral incision was made over the 4th intercostal space. After peripheral cardiopulmonary bypass (CPB) was established, left PV was ablated by bipolar clamp through right lateral minithoracotomy (Figure1). 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 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: The minimally invasive concomitant Maze IV ablation procedure performed entirely by bipolar clamp through right lateral minithoracotomy was a safe, feasible, and effective technique for patients with AF associated with mitral valve diseases. 
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