Intraoperative verification of conduction block in atrial fibrillation surgery Yosuke Ishii, MD, Takashi Nitta, MD, Masaru Kambe, MD, Jiro Kurita, MD,

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Ablation of Atrial Fibrillation With Minimally Invasive Mitral Surgery

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Intraoperative verification of conduction block in atrial fibrillation surgery Yosuke Ishii, MD, Takashi Nitta, MD, Masaru Kambe, MD, Jiro Kurita, MD, Masami Ochi, MD, Yasushi Miyauchi, MD, Kazuo Shimizu, MD The Journal of Thoracic and Cardiovascular Surgery Volume 136, Issue 4, Pages 998-1004 (October 2008) DOI: 10.1016/j.jtcvs.2008.06.022 Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Confirmation of PV isolation. Each of the 4 PVs is paced using a bipolar electrode after the PV ablation. Conduction block between the PVs and left atrium is determined by the failure of atrial capture despite the maximum output of the stimuli of the PV pacing. If any residual conduction is demonstrated between any of the PVs and left atrium, repeat ablation is performed until a complete conduction block is confirmed. Pacing sites (rectangles). Rt. PVs, Right pulmonary veins; Lt. PVs, left pulmonary veins. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 998-1004DOI: (10.1016/j.jtcvs.2008.06.022) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Confirmation of conduction block in the CS. A multielectrode catheter is placed in the CS through a right atrial incision before termination of the cardiopulmonary bypass. The activation sequence in the CS is examined during continuous pacing from the distal or proximal pairs of electrodes to the ablation lesion. A, If the CS ablation is complete, the clockwise wavefront of the paced activation is blocked between electrodes 6 and 7. The other wavefront of the paced activation propagates around the mitral valve in a counterclockwise fashion and activates electrode 6. B, If the CS ablation is not complete, the clockwise activation can conduct across the ablation lesion and activate electrode 6. This activation collides with the counterclockwise activation propagating around the mitral valve. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 998-1004DOI: (10.1016/j.jtcvs.2008.06.022) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Typical postoperative AT resulted from an incomplete CS ablation. A, Electrocardiogram of a postoperative AT. AT developed in the patient (72-year-old man) 2 months after the radial procedure and mitral valve replacement. The cycle length of the AT is 250 ms. B, Postoperative electroanatomic mapping (CARTO) exhibits a macro-reentrant activation conducting through the incomplete CS ablation (left). Reentrant circuit (black arrows). The lesion set of the surgical procedure with the reentrant circuit of the postoperative AT is shown in the right panel. AP, Anteroposterior; PA, posteroanterior; SVC, superior vena cava; IVC, inferior vena cava; LA, left atrium; LSPV, left superior pulmonary vein; RSPV, right superior pulmonary vein; RA, right atrium; MV, mitral valve; TV, tricuspid valve; LAA, left atrial appendage; RAA, right atria appendage; FO, fossa ovalis; CS, coronary sinus. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 998-1004DOI: (10.1016/j.jtcvs.2008.06.022) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Incidence of postoperative AT. PV, Pulmonary vein; CS, coronary sinus. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 998-1004DOI: (10.1016/j.jtcvs.2008.06.022) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Typical activation sequence around the mitral valve after a complete CS ablation. The paced activation from the proximal (electrode No. 9) or distal (electrode No. 3) electrode to the CS ablation lesion is completely blocked at the ablation lesion. The activation propagated around the mitral valve in a counterclockwise (A) or clockwise (B) fashion from the pacing site to the opposite side across the ablation lesion. The activation sequence is shown (right). Propagation of the conduction (arrows). Conduction block (double bars). The Journal of Thoracic and Cardiovascular Surgery 2008 136, 998-1004DOI: (10.1016/j.jtcvs.2008.06.022) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions