Interim Results of the 5-Box Thoracoscopic Maze Procedure

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Interim Results of the 5-Box Thoracoscopic Maze Procedure John H. Sirak, MD, David Schwartzman, MD The Annals of Thoracic Surgery Volume 94, Issue 6, Pages 1880-1884 (December 2012) DOI: 10.1016/j.athoracsur.2012.06.010 Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Initial dissection of transverse sinus. Mobilized superior vena cava is retracted anteriorly, and areolar fat between right pulmonary artery and dome of left atrium is divided. The Annals of Thoracic Surgery 2012 94, 1880-1884DOI: (10.1016/j.athoracsur.2012.06.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Dissection of transverse sinus is completed across ligament of Marshall to pericardial reflection of left superior pulmonary vein. Overlying areolar fat is removed. The Annals of Thoracic Surgery 2012 94, 1880-1884DOI: (10.1016/j.athoracsur.2012.06.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 With gentle balloting of noncoronary root of aorta by multifunctional linear pen device, corresponding motion is seen on transesophageal echocardiography at anterior trigone of mitral annulus. Note partial compression of noncoronary sinus during this maneuver. The Annals of Thoracic Surgery 2012 94, 1880-1884DOI: (10.1016/j.athoracsur.2012.06.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 With thoracoscope in upper lateral port, retraction is applied to aorta medially, superior vena cava laterally, and right atrium caudad, resulting in excellent visualization of aortic root. A line of ablations is begun at left noncoronary commissure, carried across base of left atrial appendage, and terminated on left superior pulmonary vein. The Annals of Thoracic Surgery 2012 94, 1880-1884DOI: (10.1016/j.athoracsur.2012.06.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Enclosed triangle of ablations on dome of left atrium comprises connecting ablations to anterior mitral trigone and line connecting 2 superior pulmonary veins. Integrity of constituent ablations is confirmed with demonstration of bidirectional block using probe placed on untreated atrium in center of triangle. The Annals of Thoracic Surgery 2012 94, 1880-1884DOI: (10.1016/j.athoracsur.2012.06.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Exposure of posterior left atrium enables ablations connecting 2 inferior pulmonary veins, thereby completing 4-sided box isolating entire posterior left atrium. Integrity of constituent ablations is confirmed with bidirectional block using probe placed on untreated atrium inside box. The Annals of Thoracic Surgery 2012 94, 1880-1884DOI: (10.1016/j.athoracsur.2012.06.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 The 5-box lesion set consists of 4 contiguous compartments isolating the pulmonary antra, the posterior left atrium, and a triangle on the dome of the left atrium connecting to the anterior mitral trigone, as well as the superior vena cava. Additional linear ablations connect the right pulmonary antrum to the distal coronary sinus and the left pulmonary antrum to the left atrial appendage. The Annals of Thoracic Surgery 2012 94, 1880-1884DOI: (10.1016/j.athoracsur.2012.06.010) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions