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Ann Thorac Surg 2004;77:1879-1880
© 2004 The Society of Thoracic Surgeons

Correspondence

Efficacy of the "box" lesion pattern in the treatment of atrial fibrillation in the presence of mitral valve disease

Gianluigi Bisleri, MD, Deon W. Vigilance, MD, Jeffrey A. Morgan, MD, Michael Argenziano, MD

Division of Cardiothoracic Surgery, Columbia University—Columbia Presbyterian Medical Center, Milstein Hospital Building, 7GN Floor, Room 435, 177 Fort Washington Ave, New York, NY, USA10032

e-mail: gianluigi_bisleri{at}katamail.com

To the Editor:

The article by Kalil and associates [1] reports their experience using surgical isolation of the pulmonary veins to treat chronic atrial fibrillation in the presence of mitral valve disease in a small cohort of patients. The authors described a simplification of the surgical technique used by Cox and colleagues [2] by creating a simple circumferential incision around the ostia of all the pulmonary veins and excluding the left atrial appendage. No additional lesions are made in the mitral annulus or the left atrial appendage.

Kalil and associates reported sinus rhythm in 14 of 15 patients at 6 months, results that compare favorably with those reported by Cox and co-authors [3] (98% of patients in normal sinus rhythm), and observed postoperative atrial flutter in only 1 patient. They concluded, that their technique is easy and does not require the technology or the expertise associated with many of the currently available ablation systems.

Although the technique described in this report represents a simplification of Cox's original maze operation, it has some limitations. The "cut-and-sew" technique can be cumbersome in many patients, does not eliminate the risk of suture line bleeding, and still prolongs cross-clamp and cardiopulmonary bypass times. For these reasons, the advantages of this technique, both in terms of clinical outcome and hospital costs, might be more apparent if the authors had compared their patients with a cohort undergoing an alternative approach. Another important limitation is the fact that although a cut-and-sew approach is clearly less expensive than a lesion set created with one of a number of available ablative energy sources, it is not feasible in the off-pump beating heart setting (a requirement for any technique that is to be part of a minimally invasive operation for atrial fibrillation).

Despite these limitations, this study demonstrates that the pulmonary vein–encircling ("box") lesion alone can be effective in restoring sinus rhythm in the presence of structural heart disease; conversely, it suggests that the mitral annulus–"connecting lesion" may not be absolutely necessary. To the extent that the more promising of the minimally invasive approaches currently under development combine the convenience of ablative devices with the simplicity of a "box" lesion pattern, this study makes an important contribution.

References

  1. Kalil R.A.K., Lima G.G., Leiria T.L.L., et al. Simple surgical isolation of pulmonary veins for treating secondary atrial fibrillation in mitral valve disease. Ann Thorac Surg 2002;73:1169-1173.[Abstract/Free Full Text]
  2. Cox J.L., Schuessler R.B., D'Agostino H.J., Jr, et al. The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg 1991;101:569-583.[Abstract]
  3. Cox J.L., Ad N., Palazzo T., et al. The Maze-III procedure combined with valve surgery. Semin Thorac Cardiovasc Surg 2000;12:53-55.[Medline]




This Article
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Deon W. Vigilance
Michael Argenziano
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