J Thorac Cardiovasc Surg 2002;124:643
© 2002 The American Association for Thoracic Surgery
Reply
A. Marc Gillinov, MD,
Gosta Pettersson, MD,
Thomas Rice, MD
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH 44195
Reply to the Editor:
We thank Patwardhan, Lad, and Pai for their comments. Surgery for atrial fibrillation has enjoyed a tremendous resurgence during the past year or two. Although many surgeons perform the classic Cox maze III operation, there is a growing trend to embrace simpler procedures that use alternate energy sources to create lines of conduction block. Alternate energy sources used clinically include radiofrequency, microwave, and cryothermy. In the application of these new techniques, surgeons have also modified the lesion sets of the Cox maze III procedure. The combination of new energy sources and altered lesion sets has resulted in a group of new surgical procedures to treat atrial fibrillation.
These new operations must be simple, effective, and, most important, safe. With less cutting and sewing, most of these operations are simple and relatively rapid. Numerous reports document that pulmonary vein isolation with one or more connecting lesions cures atrial fibrillation in 70% to 80% of patients. Thus, these procedures are effective. Safety depends on device design and surgical technique.
With energy sources that create heat, collateral organ damage is a risk. Ideally, the device should be shielded and the energy delivery directional. As Patwardhan, Lad, and Pai note, bipolar application of radiofrequency energy is a safe modality. In fact, there is now a commercially available clamp that performs this function. Microwave energy, which can be delivered from the epicardial surface on a beating or arrested heart, also offers a safe alternative. Irrigated unipolar radiofrequency devices may also have a favorable safety profile.
This is a unique time in the history of the surgical treatment of atrial fibrillation. As surgeons develop new approaches using technological innovations, it is critical that they report their results. Then, careful analysis of these results will allow the safest and most effective therapies to be chosen.
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