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• W1996932406 abstract "Surgical treatment of atrial fibrillation during open heart surgery using alternative energy sources to create lesions has become the standard of care at many institutions, including ours. This is particularly common in mitral valve patients because they have a very high preoperative incidence of atrial fibrillation and the necessary exposure required to perform an ablation is gained by accessing the left atrium for the valve surgery. Using energy sources to create lesions in lieu of standard “cut and sew” techniques may offer advantages in that they can be performed more rapidly and are not associated with the same risk for bleeding. Laser energy is one of several available energy sources that recently has been used for this purpose. The potential advantages of this energy source include its optimal tissue penetration, rapid lesion times, flexibility, and ability to penetrate fat. This energy source has the potential to create rapid, effective, and safe lesions from both the endocardium and epicardium of the heart to treat atrial fibrillation. Currently, laser energy has been used clinically from the endocardium and experimentally from the epicardium with encouraging results. Ultimately, the goal of the alternative energy sources including the laser will be their ability to create lesions from the epicardium of the beating heart using minimally invasive techniques in patients with lone atrial fibrillation. Laser ablation of atrial fibrillation using diffusing tip technology provides a rapid and safe way of creating lesions in the atrium. The isolated left atrial procedure described has been performed in as little as 4 minutes. In a small clinical pilot study, 8 of 9 patients were in sinus rhythm at 3 months and 8 of 8 in sinus at 6 months without any device-related complications. This technology is simple to use and appears to facilitate this operation. The energy source is particularly encouraging in that it provides very controlled heating of the tissue while creating effective lesions. This will be particularly relevant as the device is modified for epicardial applications. 2The probe has both a malleable shaft and diffusing tip that can be conformed to create any lesion. The actual ablation distance is 5 cm per lesion. The laser energy transmits down a fiberoptic cable and joins to the diffusing tip. To keep the gold foil cool, it is necessary to irrigate the tip with normal saline via the central lumen of the device.View Large Image Figure ViewerDownload (PPT) 3The energy delivered to the handpiece is a 980-nm near-infrared diode laser. This wavelength is not significantly absorbed by myoglobin and thus the energy is not all absorbed at the device-tissue interface. Since this wavelength is not visible to the human eye, a HeNe aiming beam also is directed out of the device to aid in directionality and positioning. Each ablation is performed at 5 W for 36 seconds. The generator has an emergency shut-off mechanism, which in addition to the diffuse energy from the diffusing tip makes the device a Class I laser and, thus, no protective eyewear is necessary. (Color version of figure is available online.)View Large Image Figure ViewerDownload (PPT) 4Like all energy sources other than cryothermy, the ultimate mechanism of ablation is to heat tissue to 50°C yet not allow it to get much higher than 100°C. Based on the diffusing tip construction and the wavelength, laser ablation occurs in a very uniform manner, providing for controlled heating of the tissue. While there is a component of conductive heating, most of the depth of the ablation occurs via direct heating of the tissue from the laser energy. This provides for a very well controlled heating of the tissue with a relatively uniform thermal distribution within the tissue. This prevents charring of the tissue adjacent to the device and avoids rapid heating of the tissue to prevent wall disruption from occurring. (Color version of figure is available online.)View Large Image Figure ViewerDownload (PPT) 5Most commonly, ablations are performed on patients during concomitant mitral valve surgery. Either a standard sternotomy or right minithoracotomy can be utilized. In the case of the minithoracotomy, the patient is positioned supine with the right side elevated 30°. An 6-cm incision is made in the fourth intercostal space, beginning just lateral to the midclavicular line. Cardiopulmonary bypass is accomplished via central aortic and peripheral venous cannulatrion. Occlusion of the aorta is accomplished with a Chitwood transaxillary crossclamp.View Large Image Figure ViewerDownload (PPT) 6The interatrial groove is dissected and the left atrium is entered directly, anterior to the right pulmonary veins. A left atrial retractor is placed such that visualization of the posterior left atrium and pulmonary veins is optimized. The atrium is carefully inspected for any pulmonary vein aberrancy or presence of left atrial appendage thrombus. The ablation is always performed before the valve surgery since manipulation can be difficult or even dangerous after valve repair or replacement and access to the mitral valve annulus is lost after placement of a valve or annuloplasty ring.View Large Image Figure ViewerDownload (PPT) 7The device is bent in such a fashion to mimic the intended lesion. We typically create one large lesion around the posterior left atrium, isolating the pulmonary veins in one large circumferential lesion. Care must be taken when creating lesions to avoid damaging structures directly behind the left atrium, particularly the esophagus. To prevent collateral injury a simple insulating material such as a sponge is placed in the oblique sinus. Additionally, when creating lesions traversing across the atrium, special care is taken to move them closer to the dome when superior and closer to the mitral annulus when inferior so the lesion does not directly overlie the esophagus. During ablation, the saline that is irrigated onto the field from the device is simply suctioned away. The device function is not impaired if submerged in blood or saline though visualization is obviously more difficult.View Large Image Figure ViewerDownload (PPT) 8The lesion is completed by connecting the superior part of the atriotomy to the inferior part of the atriotomy while including all the pulmonary veins but not the atrial appendage. This creates an entire isolating lesion of the pulmonary veins with the incision serving as the right side of the lesion. Depending on the size of the heart, this generally takes from two to four ablations. If a trans-septal approach is used, an entire circumferential laser lesion must be created because using the septal incison as part of the lesion will not provide isolation of the veins. Since the laser creates very controlled heating of the tissue there is no char formation and at times the lesion can be difficult to see. This can be aided by either paying close attention to previous lesion location or if necessary marking the end of the lesion with a suture or marking pen, though this is rarely required.View Large Image Figure ViewerDownload (PPT) 9The left atrial appendage is always closed in an effort to reduce the stroke risk in the event that atrial fibrillation persists. We do not routinely remove the appendage but rather close it from within. If the procedure is performed via a right thoractomy, the appendage is always closed in a running fashion in the longitudinal axis from the inside of the heart. If the procedure is performed via a sternotomy, it is either closed similarly from the inside of the heart or stapled closed from the outside using a gastrointestinal stapler with 3.5-mm staples. It is best not to use a purse-string closure method unless the orifice is very small because this results in a high residual patency rate.View Large Image Figure ViewerDownload (PPT) 10Occasionally, a lesion is created from the pulmonary veins to the mitral valve annulus. It has been suggested that this lesion is necessary for maximal effectiveness and for the prevention of postoperative atypical atrial flutter. We, however, no longer routinely add this lesion. If this lesion is created, cold retrograde cardioplegia is given to prevent injury to the circumflex artery. The lesion is aimed toward the P3 scallop of the mitral valve, as this is the site where the circumflex artery is furthest from the annulus.View Large Image Figure ViewerDownload (PPT)" @default.
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• W1996932406 date "2004-01-01" @default.
• W1996932406 modified "2023-09-29" @default.
• W1996932406 title "Endocardial atrial ablation using the edwards optimaze laser probe to treat atrial fibrillation" @default.
• W1996932406 doi "https://doi.org/10.1053/j.optechstcvs.2004.01.003" @default.
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