J Thorac Cardiovasc Surg 2007;133:1683-1684
© 2007 The American Association for Thoracic Surgery
Letter to the Editor
Division of Cardiac Surgery, S Raffaele University Hospital, Milan, Italy
Dr Patwardhan complains that two seminal papers describing his pioneering experience in surgical ablation with bipolar coagulation1,2 were not given due consideration in articles published by us3 and by others.
We recognize that Patwardhans intuitions opened the way to the modern scenario of surgical ablation. Nevertheless, only 2 of 74 articles among PubMed-listed clinical papers focusing on atrial fibrillation (AF) ablation with bipolar radiofrequency (RF) (by matching AF with bipolar RF) quote Patwardhans works.
There are different possible reasons for this reiterated omission:
First of all, Patwardhan and colleagues reported using a standard electrocautery in the bipolar mode to ablate the atrial myocardium. This is not perceived by us (and probably by most surgeons) as being in accordance with some fundamental safety issues: Power-based RF can lead to charring and to excessive endocardial trauma, potentially leading to an increased risk of thromboembolism. Furthermore, also due to the absence of any feedback controlling energy delivery, electrocoagulation can cause excessive tissue weakening, possibly leading to bleeding. Re-exploration for bleeding occurred in 20% of survivors in Patwardhans initial series.1 Temperature and impedance feedback, featured by commercially available bipolar devices, are actually meant to address such problems.
It is then not irrelevant that bipolar electrocautery, despite sharing the same physical principles of commercially available RF ablation devices, is not CE- or Food and Drug Administrationmarked for cardiac ablation. As a result, most surgeons, including our group, would rather avoid the "off-label" use of a bipolar electrocautery and indulge in the use of more recognized commercially available alternatives.
Furthermore, Patwardhans spot-by-spot ablation without tissue feedback can admittedly lead to the creation of incomplete ablation lines, rendering the ablation procedure not reproducible and clinical result possibly suboptimal.
It is finally worth mentioning that Pathwardhans electrocautery ablation is an open-heart procedure. Electrocautery forceps, in fact, despite being bipolar, do not share the epicardial clamping feature that makes modern bipolar devices more appealing and, to our advice, the real breakthrough in the arena of AF surgery. Such a characteristic is actually the greatest aspect of modern bipolar devices since, by clearing out the convective cooling of circulating blood on the target area, it allows an effective and reproducible ablation of a double layer of atrial wall epicardially, on the beating heart.
This notwithstanding, we respectfully acknowledge Patwardhans contribution to innovation in this field. We express our empathy with his feelings at not being quoted in the context of bipolar RF. It is the same feeling we experience every time an author writes about epicardial ablation (be it bipolar or not) without mentioning our initiating clinical report4 or when we realize that most authors reporting on surgical ablationincluding Patwardhan in his later experience2describe administering amiodarone prophylactically, but nobody seems to be aware that such pharmacologic strategy was first proposed for AF surgery by our group.4,5
We tend to blame the omission on a poor "conceptual copyright" protection policy on our side rather than suspecting the scientific accuracy of highly respected colleagues with whom we share the passion for finding new solutions to challenging clinical situations.
1 Stefano Benussi reports consulting fees from Atricure and Estech and lecture fees from St Jude Medical, Medtronic, and Cryocath.
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