Constantine Mavroudis, MD, Carl L. Backer, MD, Barbara J

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Ablation of Atrial Fibrillation with Concomitant Surgery

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Total cavopulmonary conversion and maze procedure for patients with failure of the Fontan operation Constantine Mavroudis, MD, Carl L. Backer, MD, Barbara J. Deal, MD, Christopher Johnsrude, MD, Janette Strasburger, MD The Journal of Thoracic and Cardiovascular Surgery Volume 122, Issue 5, Pages 863-871 (November 2001) DOI: 10.1067/mtc.2001.117840 Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Drs Mavroudis, Deal, and Backer (left to right ) The Journal of Thoracic and Cardiovascular Surgery 2001 122, 863-871DOI: (10.1067/mtc.2001.117840) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 1 Road map figure noting the outcome of the 11 patients with failed Fontan operations who were initially considered for cardiac transplantation. Six patients, who are included in our cohort of 40 patients, had Fontan conversion with arrhythmia surgery. Five are alive and well 1.1 ± 0.5 years postoperatively and 1 had a subsequent cardiac transplant and is alive and well 1.8 years after transplantation. Five, not included in our original cohort of 40 patients, were listed for cardiac transplantation. Two died on the waiting list and the other 3 had cardiac transplantation. Only 1 of these patients survives, 1.6 years postoperatively. The other 2 died 1 and 4.2 years after the transplant operation. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 863-871DOI: (10.1067/mtc.2001.117840) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 2 Atrial view of a patient who had an atriopulmonary Fontan operation after aortic crossclamping and cardioplegic arrest. The inferior and superior venae cavae have been transected, the atrial wall excision has been performed, and the atrial septal patch has been removed. No measures are taken to preserve the sinoatrial node, which is nonfunctional in a significant number of patients. Cryoablation lesions (-60°C for 90 seconds) are placed in 3 areas to complete the modified right-sided maze procedure. The first 2 cryoablation lesions are standard for all anatomic substrates and are performed by connecting (1) the superior portion of the atrial septal ridge with the incised area of the right atrial appendage and (2) the posterior portion of the atrial septal ridge with the posterior cut edge of the atrial wall, which extends through the crista terminalis. The third part is the isthmus ablation. These lines of block are dependent on the anatomic substrate. In patients with tricuspid atresia, as noted here, the cryoablation lesion is placed to connect (3) the posteroinferior portion of the coronary sinus os with the transected inferior vena cava os. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 863-871DOI: (10.1067/mtc.2001.117840) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 3 This drawing demonstrates the modified right -sided maze procedure in a patient with double-outlet right ventricle and mitral atresia. As noted in Figure 2, the 2 standard cryoablation lesions connecting the rim of the atrial septal defect with (1) the incised area of the right atrial appendage and (2) the posterior cut edge of the atrial wall, respectively, are shown. The isthmus block is accomplished by creating cryoablation lesions (3) to connect the posteroinferior portion of the coronary sinus os with the transected inferior vena cava os, and (4) to connect the tricuspid valve anulus with the transected inferior vena cava os. These isthmus block lesions are usually placed across the ridge of the resected atrial compartmentalization patch. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 863-871DOI: (10.1067/mtc.2001.117840) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 4 This drawing demonstrates the modified right-sided maze procedure in a patient with single ventricle and unbalanced atrioventricular canal. As noted in Figure 2, the 2 standard cryoablation lesions connecting the rim of the atrial septal defect with (1) the incised area of the right atrial appendage and (2) the posterior cut edge of the atrial wall, respectively, are shown. The isthmus block is accomplished by creating cryoablation lesions (3) to connect the posteroinferior portion of the coronary sinus os with the transected inferior vena cava os and (4) to connect the common atrioventricular valve anulus with the transected inferior vena cava os. These isthmus block lesions are usually placed across the ridge of the resected atrial compartmentalization patch. The Journal of Thoracic and Cardiovascular Surgery 2001 122, 863-871DOI: (10.1067/mtc.2001.117840) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 5 Left atrial view of a univentricular heart that shows the standard incisions, excisions, and cryoablation lesions which, when combined with the right atrial component (see Figures 2-4), complete the maze-Cox III procedure. The incisions include a partial encircling pulmonary vein isolation and a left atrial appendage resection. Standard cryoablation lesions (-60°C for 90 seconds) are placed to complete the pulmonary vein isolation, to create a cryoablation lesion from the isolated pulmonary veins toward the posterior mitral or tricuspid valve anulus, and to extend the pulmonary vein isolation to the cut edge of left atrial appendage base. A large cryoablation probe (15 mm) is used to place a lesion on the coronary sinus (-60° C for 180 seconds). (Copyright © 2001 R. F. Idriss.) The Journal of Thoracic and Cardiovascular Surgery 2001 122, 863-871DOI: (10.1067/mtc.2001.117840) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions

Fig. 6 Bar graph showing the results of exercise tolerance (Bruce protocol) before and after Fontan conversion and arrhythmia surgery (P ||.05; Student t test). The Journal of Thoracic and Cardiovascular Surgery 2001 122, 863-871DOI: (10.1067/mtc.2001.117840) Copyright © 2001 American Association for Thoracic Surgery Terms and Conditions