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J Thorac Cardiovasc Surg 2009;137:527-528
© 2009 The American Association for Thoracic Surgery

Point/Counterpoint

Counterpoint: Minimally invasive bipolar radiofrequency ablation of lone atrial fibrillation: Early multicenter results

Division of Cardiothoracic Surgery, Department of Surgery, UCLA Cardiovascular Center, Los Angeles, Calif

Received for publication August 29, 2008; revisions received October 3, 2008; accepted for publication October 26, 2008.

^_* Address for reprints: Richard J. Shemin, MD, Robert and Kelly Day Chair in Cardiothoracic Surgery, Professor and Chief, Division of Cardiothoracic Surgery, Executive Vice Chairman, Department of Surgery, Co-Director, UCLA Cardiovascular Center, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, 62-182 CHS, Los Angeles, CA 90095-1741. (Email: rshemin@mednet.ucla.edu).

The first 20% of the full text of this article appears below.

The challenges facing surgeons performing surgical ablation for atrial fibrillation include the evolution of techniques and development of technologies that will provide maximum cure rates, reducing the clinical burden of atrial fibrillation and thereby enhancing quality of life and reducing health care costs. The surgical procedure itself must minimize mortality, morbidity, and disability.

Less invasive surgical approaches have been developed to avoid a sternotomy, avoid cardiopulmonary bypass, and approach the atrium through minimal access incisions and through ports. As surgeons, we desire ergonomic devices to perform reliable and transmural lines of ablation. Several energy sources in clinical use have limitations, such as energy loss from epicardial fat and the circulating blood pool. These technical challenges are compounded by the difficulty related to device design. The size, flexibility, and shape of the device often are the limiting factors in delivering the energy to epicardial surfaces when minimal access incisions are preferred.

Controversy remains regarding the appropriate lesion set. Surgeons are motivated to offer less invasive approaches to improve their referral base by adopting minimal access procedures. The procedure requires an effective lesion set, with minimal complexity that can be easily and reliably performed by all cardiac surgeons.

The electrophysiology of paroxysmal atrial fibrillation is most likely due to triggers from the pulmonary veins and the left atrium. Therefore, approaches that solely isolate the pulmonary veins will inevitably produce failures, inasmuch as 20% of the other triggers in nonpulmonary vein sites are in both the left or right atrium.¹ In more complex forms of atrial fibrillation, in which the patient is continuously in atrial fibrillation, it is not possible to perform the recommended full or modified Cox maze lesion set easily with current minimal access techniques and technologies.²

The Heart Rhythm Society published a consensus . . . [Full Text of this Article]