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Right arrow Electrophysiology - arrhythmias

J Thorac Cardiovasc Surg 2008;135:894-900
© 2008 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Pulmonary vein isolation and the Cox maze procedure only partially denervate the atrium

Shelly C. Lall, MD, Kelley V. Foyil, MS, Shun-Ichiro Sakamoto, MD, Rochus K. Voeller, MD, John P. Boineau, MD, Ralph J. Damiano, Jr., MD, Richard B. Schuessler, PhD*

Division of Cardiothoracic Surgery, Washington University School of Medicine, Saint Louis, Mo

Received for publication June 21, 2007; revisions received September 20, 2007; accepted for publication November 26, 2007.

* Address for reprints: Richard B. Schuessler, PhD, Washington University School of Medicine, 660 South Euclid Ave, Box 8234, Saint Louis, MO 63110. (Email: schuesslerr{at}wustl.edu).

Objectives: The effects of ablation lines on myocardial innervation and response to autonomic stimuli are unclear. This study examined the effects of radiofrequency ablation on atrial autonomic innervation and compared pulmonary vein isolation and the biatrial Cox maze procedure.

Methods: In 12 acute canines right and left vagosympathetic trunks and right and left stellate ganglia were isolated. Each nerve was stimulated before bipolar ablation, after pulmonary vein isolation, and after the Cox maze procedure. Nadolol (n = 6) and atropine (n = 6) were administered to block sympathetic and parasympathetic responses, respectively. Changes in heart rate and atrioventricular interval were compared. Changes in QRST area relative to an isoelectric baseline (index of local innervation) were calculated.

Results: Sympathetic stimulation of each nerve and parasympathetic stimulation of the vagosympathetic trunks caused significant changes in heart rate and atrioventricular interval. After pulmonary vein isolation, the effect of 33% of the nerves on heart rate changes was eliminated. The Cox maze procedure eliminated right stellate sympathetic effects on heart rate. Fifty percent of the nerves caused heart rate changes after the Cox maze procedure. There was no significant effect of either lesion set on atrioventricular interval changes. Stimulation of 50% of nerves after pulmonary vein isolation produced local area changes significantly different from control area. After the Cox maze procedure, a different 50% of the nerves produced local changes different from those seen after pulmonary vein isolation.

Conclusions: Surgical ablation procedures disrupted innervation, affecting heart rate but not atrioventricular interval. Autonomic innervation affecting the atria was changed by pulmonary vein isolation and additionally by the Cox maze procedure. Residual autonomic effects were present even after the complete Cox maze procedure.

Abbreviations and Acronyms AF = atrial fibrillation; AV = atrioventricular; CM = Cox maze; LVST = left cervical vagosympathetic trunk; PVI = pulmonary vein isolation; RFA = radiofrequency ablation; RVST = right cervical vagosympathetic trunk






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