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Eur J Cardiothorac Surg 2008;33:590-595. doi:10.1016/j.ejcts.2008.01.005
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Complete left atrial ablation with bipolar radiofrequency

Stefano Benussi*, Simona Nascimbene, Andrea Galanti, Andrea Fumero, Enrica Dorigo, Valerio Zerbi, Micaela Cioni, Ottavio Alfieri

Division of Cardiac Surgery, S Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy

Received 26 September 2007; received in revised form 29 December 2007; accepted 1 January 2008.

* Corresponding author. (Email: stefano.benussi{at}hsr.it).


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Objective: Despite its efficacy and swiftness, bipolar radiofrequency is generally not used on the left isthmus for concern of injuring a coronary branch. Incomplete lesion sets or use of an additional unipolar device are often considered. We report a technique to perform a full left lesion set involving the mitral line using a standard bipolar radiofrequency device. Methods: An innovative complete left atrial lesion set was performed using only bipolar radiofrequency in 70 consecutive patients (study group). In 67/70 patients (96%) mitral valve disease was the main indication to surgery. Atrial fibrillation was permanent in 42 patients (60%), persistent in 25 (36%) and paroxysmal in three patients (4%). After beating-heart pulmonary vein isolation on-pump, the coronary-free area of the AV groove was marked epicardially by sticking a needle into the left atrial wall, behind the coronary sinus. The projection of the needle marker on the mitral annulus was then identified through the atriotomy and an endo-epicardial ablation was performed with the bipolar device involving the atrial wall, the coronary sinus, up to the annulus. The lesion set was then completed by connecting the encirclings and the left appendage, which was then sutured. Follow-up was 100% complete. Results were compared with those of a control group of 33 patients receiving bipolar radiofrequency left atrial ablations and a mitral connecting line with a second unipolar device. Results: All patients survived. No major complication occurred. Haematoma of the AV groove was observed during retrograde cardioplegia in one case. No myocardial ischaemia or re-exploration for bleeding (median 325 cc, interquartile range 250–442) occurred. Two out of 70 patients required a permanent pacemaker for AV block. Freedom from atrial fibrillation was 84% (95% CI: 75%, 93%) at 6 months and 81% (95% CI: 70%, 93%) at 1 year. One patient had left flutter. Comparison with the control group did not show any difference in clinical outcomes, but revealed bipolar ablation to the mitral annulus to abate the per patient cost of the ablation devices (1245 ± 50 \#8364; vs 2403 ± 17 \#8364;; p < 0.0001). Conclusions: Performing the mitral line with bipolar radiofrequency is safe and cost-effective. A complete left atrial ablation with a single bipolar radiofrequency device yields excellent clinical mid-term results.

Key Words: Atrial fibrillation • Radiofrequency ablation • Bipolar radiofrequency • Cardiac surgery • Mitral valve disease • Left isthmus • Mitral line


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Intraoperative ablation of concurrent atrial fibrillation (AF) during open-heart surgery is today advised in most cases [1]. While pulmonary vein isolation (PVI) alone has proven quite effective in treating concomitant paroxysmal AF [2], it is generally agreed that patients affected by persistent and especially permanent AF require a complete left lesion set involving connections between the PV encirclings and from those to the mitral annulus [2–5].

Reports of coronary injury related to AV groove ablation to perform the mitral connecting line have given rise to some concern about the hazardous nature of such ablation [6,7].

Bipolar radiofrequency clamps are to date the most reliably transmural ablation devices available to the surgeon [4,8,9]. Nevertheless, due to its clamping nature and its deep tissue penetration, bipolar radiofrequency has not been used to perform the mitral connecting line. So, the rising popularity of bipolar radiofrequency has led many surgeons to either treat patients with incomplete lesion sets, which is clinically not convenient [2,4], or to use an additional unipolar device to complete the mitral line, which is probably not as efficient, and surely not cost-effective.

We describe here our results with an original technique to perform a complete left set of lines, entailing the mitral line, using bipolar radiofrequency only.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
The study population consists of 70 consecutive patients undergoing concomitant AF treatment with bipolar RF between May 2005 and March 2007. Indications for the ablation procedure were permanent AF in 42 patients (60%), persistent AF in 25 (36%) and paroxysmal AF in 3 (4%).

Sixty-seven patients (96%) had primary mitral valve disease (rheumatic in 42, degenerative in 23, functional in two) as the main indication to surgery. Preoperative data are summarised in Table 1 .


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  		Table 1 Preoperative data
 
Sixty-four patients (91%) had a preoperative coronary angiogram.

A series of 33 patients undergoing concomitant ablation of AF using two ablation devices, a bipolar and a unipolar RF handpiece, during open-heart surgery, 31/33 (94%) for mitral valve disease (rheumatic/degenerative = 20/13) from September 2004 to November 2006, was used as control group.

Male/female ratio (9/24), age (66 ± 9 years), NYHA class distribution (II/II/III: 1/21/55 patients), ejection fraction (53 ± 10%), left atrial diameter (54 ± 8 mm), type of AF (paroxysmal/persistent/permanent: 0/11/22 patients) did not differ from the study population. But the control group had a longer duration of persistent/permanent AF; median 60 months; interquartile range 36–117 (p = 0.007).

A transoesophageal echocardiography was performed within 24 h of surgery in all patients to rule out intracavitary thrombosis.

Informed written consent was signed by each patient before surgery.

2.1 Surgical technique
The specific anatomy of the circumflex and of the right coronary arteries was thoroughly considered at coronary angiogram, when available.

All ablations were performed using bipolar radiofrequency, the Cobra Bipolar (Estech Inc., Camino Ramon, CA) was used in 38 patients, the BP2 (Medtronic Inc., Minneapolis, MN) in 21, the Isolator (Atricure Inc., Cincinnati, OH) in 11.

The encircling ablations around the right and left PV orifices were performed epicardially, usually on cardiopulmonary bypass. Then coronary anatomy was inspected by lifting the fully decompressed beating heart. The terminal branch of the circumflex and of the right coronary artery were identified, and a 20 mm hypodermic needle was stuck in the posterior left atrial wall, just above the coronary sinus, to mark the middle of such coronary-free area of the AV groove (Fig. 1 ). Then, after aortic cross-clamping, the atrium was incised parallel to the Waterston groove. The projection of the needle on the posterior mitral annulus was identified (Fig. 2 ). The needle was removed. An ablation line was then carried out by clamping the left atrial wall in an endo-epicardial fashion, with the tip of the inner jaw clearly biting the posterior mitral annulus and the proximal portion of the clamp intersecting the atriotomy (Fig. 3 ). Another ablation was generally performed after slightly slipping the clamp backward, off the ventricular part of the groove which, being thicker, might prevent a proper contact of the jaws with the thin atrial wall. The coronary sinus, which lies totally on the atrial side of the AV groove, is thus circumferentially ablated. The resulting ablation might be inspected by lifting the back of the atrium (Fig. 4 ).


Figure 1
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  		Fig. 1. Epicardial inspection of the coronary anatomy and marking the coronary-free area of the AV groove by sticking a hypodermic needle in the left atrial wall, just beyond the coronary sinus.

 

Figure 2
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  		Fig. 2. Individuation of the target point on the mitral annulus through left atriotomy.

 

Figure 3
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  		Fig. 3. Posterior endo-epicardial mitral connecting lesion from the atriotomy to the aforementioned target point.

 

Figure 4
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  		Fig. 4. Inspection of the resulting mitral connecting ablation, which involves the coronary sinus.

 
One or two endo-epicardial connecting lines were performed between the two encirclings. At least one of such ablations was brought up to the atriotomy to connect the encirclings with the incision in case this did not intersect the right encircling line. One last connecting endocardial ablation was performed by clamping the device with one jaw in the appendage and one in a left PV. The appendage was obliterated endocardially with a double layer of 4-0 polypropylene continuous suture. In the control group, all the ablations were performed with bipolar radiofrequency as described, with the exception of the mitral line, which was completed using a unipolar radiofrequency catheter: Cobra (Estech Inc., Camino Ramon, CA) in 32 patients, Cardioblate (Medtronic Inc., Minneapolis, MN) in 1.

No ablation was generally carried out at the base of the appendage, based on the assumption that a watertight suture of its base would cause a fibrotic involution anyhow.

2.2 Postoperative management and follow-up
Perioperative antiarrhythmic prophylaxis with amiodarone was administered for 3–6 months in the absence of contraindications [10].

Standard 12 leads ECG, Holter and transthoracic echocardiography monitoring were performed 3, 6 and 12 months after operation.

2.3 Statistical analysis
Data are expressed as mean ± standard deviation unless stated otherwise. Non-normally distributed variables, as assessed by the Kolmogorov–Smirnov test, are expressed as median, interquartile range (25°–75° percentile) for continuous variables, and as N (%) for categorical variables.

Preoperative variables as listed in Table 1 and operative variables such as replacement versus reconstructive valve surgery, duration of cardiopulmonary bypass and of cardiac arrest and overall intensive care unit and hospital stay were analysed for a possible correlation with relapsing tachyarrhythmia after surgery.

Association between arrhythmia recurrence at each time point and all other variables was investigated by {chi} 2-test and by Mann–Whitney U-test as appropriate.

Preoperative variables, intraoperative variables (including cost of the ablation devices per patient) and clinical outcomes of the study group were assessed for differences versus the control group by means of {chi} 2-test or Student's t-test as appropriate.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
The open-heart procedures of the study group are detailed in Table 2 . Cardiopulmonary bypass time was 98 ± 23 min. Aortic cross-clamp duration was 76 ± 21 min.


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  		Table 2 Surgical procedures
 
No patient died. No major complication was recorded. In particular, no cases of myocardial ischaemia were observed. No patient required re-exploration for bleeding. Haematoma of the AV groove with initial bleeding during retrograde reperfusion before unclamping was observed in one patient, but solved spontaneously after reinstitution of antegrade coronary flow and did not require any further specific intervention. The median total chest tube output was 325 cc (interquartile range 250–442).

Overall, the median intensive care unit stay was 2 days (interquartile range 1–3) and the median postoperative hospital stay was 7 days (interquartile range 5–9).

Two patients (3%) were implanted with a permanent pacemaker after surgery for AV block: one after mitral valve replacement in a heavily calcified mitral annulus and one after aortic valve replacement, mitral valve repair involving implantation of a rigid ring and tricuspid rigid ring annuloplasty.

Follow-up was 100% complete (mean 11 ± 5.6 months, median 10 months; interquartile range 6–13.5).

At discharge 45/70 patients (64%; 95% CI: 53%, 75%) were in normal sinus rhythm. Subsequent freedom from AF was 84% (95% CI: 75%, 93%, 56/67 patients) at 6 months and 81% (95% CI: 70%, 93%, 35/43 patients) at 1 year (Fig. 5 ).


Figure 5
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  		Fig. 5. Rhythm after surgery. SR: sinus rhythm; AF: atrial fibrillation.

 
Left flutter, defined as any form of atypical flutter with isoelectric or negative P-waves in aVL and positive P-waves in V1 and III, occurred in one patient (1%) who refused percutaneous electrophysiological assessment and was therefore treated medically (rate control). No patient had right atrial flutter after surgery.

After excluding patients with paroxysmal AF, patients with permanent AF had a lower success rate at 6 months than those with persistent AF ({chi} 2 = 6.73; p = 0.009). None of the other preoperative or intraoperative variables correlated with rhythm outcome at any follow-up interval.

Among patients without a mechanical valve prosthesis, freedom from oral anticoagulation was 48% (22/42) at 6 months and 57% (12/21) at 12 months. No thromboembolic event was recorded. No patient died.

3.1 Control group
There was no significant difference between the study and the control groups in intra and postoperative clinical variables, namely cardiopulmonary bypass time (105 ± 19 min), aortic cross-clamp time (82 ± 17 min), bleeding (median 400 cc; interquartile range 300–600), intensive care unit (median: 2 days; interquartile range 1–4) and hospital stay (median: 7 days; interquartile range 6–9).

Instead, as predicted, the per patient cost of the ablation devices was nearly doubled: 2403 ± 17 \#8364; in the control group versus 1245 ± 50 \#8364; in the study group (p < 0.0001).

No difference was found in the sinus rhythm recovery rate, which was 55% (95% CI: 38%, 72%, 18/33 patients) at discharge, 76% (95% CI: 60%, 91%, 22/29 patients) at 6 months and 74% (95% CI: 57%, 81%, 20/27 patients) at 12 months. One patient (3%) in the control group experienced right flutter, while three patients (9%) had left flutter (p = ns vs study group).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
Anatomy based clamping of the AV groove makes complete left atrial ablation safely feasible with bipolar radiofrequency.

This is of no small consequence since growing evidence both from transcatheter ablation [11,12] and from AF surgery [2,4,13] points to the relevance of completeness of the lesion set and of transmurality and continuity of the ablations in determining clinical outcome. Gaita and colleagues showed that the final set of lines is particularly crucial to rhythm outcome in patients undergoing heart surgery with permanent AF [13]. In fact those missing the connecting lines at postoperative electrophysiological study, had more than a 70% chance of relapsing AF or flutter. In a review of the initial experience with bipolar ablation at the Cleveland Clinic, Gillinov et al. has recently confirmed that, while PV isolation alone may relate to a good rhythm outcome in patients with paroxysmal AF, connecting lines are also necessary to prevent arrhythmia recurrence in those with permanent AF [2,3].

Continuity and transmurality of the scars strongly relates to the adopted ablation tool. Unipolar devices have proven effective in creating transmural ablation endocardially on the arrested heart [14–16]. Nevertheless, shortcomings like scarce penetration during epicardial application on the beating heart [17,18], collateral damage due to thermal spreading [19], and a poor predictability of completeness of the lesions due to patient specific and operator dependent factors [20], have limited their popularity.

Since its first introduction in clinical practice, bipolar radiofrequency appeared as the natural answer to most of such shortcomings. The clamping design of bipolar devices clears out heat sink due to convective cooling exerted endocardially by circulating blood, thus rendering transmurality of the lines highly predictable after both epicardial and endocardial ablation [4,8,9,21]. Temperature or impedance feedback featured by bipolar radiofrequency devices improves the reproducibility of complete tissue penetration. Collateral damage is extremely unlikely; only clamped tissue can be significantly heated by bipolar devices.

Due to these features bipolar radiofrequency has quickly gained popularity in the field of open-heart ablation. Clinical results are actually satisfactory, both in left atrial and in biatrial ablation procedures [2,4,5]. PV isolation is easily achieved by epicardial clamping on the antral portion of the left atrium. Connections between the encirclings are easily feasible by clamping the atrial wall in an endo-epicardial fashion through the atriotomy. Actually, such posterior connecting lines can also be carried out epicardially on the beating heart [22]. But performing the connecting line to the mitral annulus with a bipolar clamp has not been reported so far. Such reluctance is understandably due to the concern of injuring a major coronary vessel in the AV groove with a transmurally ablating device. In fact, coronary injury has been described after endocardial ablation with virtually all sorts of energy sources, comprising unipolar radiofrequency and cryoablation [6,7]. In our initial experience with bipolar radiofrequency, we also omitted such line and concentrated on the quality of the remaining ablations. This turned into a disturbingly high rate of left flutter, occurring in 7% of the patients [4].

We devised a technique, which allows performing all left atrial ablations with a single bipolar device. We had already underlined the importance of coronary anatomy to safely perform the mitral connecting line with unipolar radiofrequency [23]. Of course, tailoring accurately the route of the mitral line on the individual coronary anatomy is crucial with bipolar radiofrequency due to its penetration properties. For this reason, a tangible marker such as a needle turned out to be particularly useful. Other marking techniques can be adopted such as dyeing the epicardium of the AV groove with methylene blue or analogues.

Clamping the posterior mitral annulus is routinely feasible provided there is no massive calcification. We did not record any major complication related to AV groove ablation. In particular, the absence of any significant case of bleeding and of any case of postoperative myocardial ischaemia is particularly comforting.

Clinical results of our preliminary series were actually satisfactory with 81% of the patients in stable sinus rhythm 1 year after surgery. The only variable related to a worse AF freedom after ablation was permanent AF, as opposed to persistent AF (p = 0.009). Of note, the study population was composed almost exclusively (all but three) of patients with permanent or persistent AF, since those with paroxysmal AF tended to receive simplified lesion sets. Therefore, the low rate of post ablation left flutter, occurring in only 1/70 patients, is particularly significant. This accounts for the efficacy of the mitral connecting line in our series. In fact, based on our prior experience with bipolar radiofrequency in a comparable series of patients, the absence of the mitral connecting line would have led to a tenfold incidence of postoperative left flutter [4].

Other authors described using a second unipolar device to complete the mitral line [24]. This is, on one hand, not cost-effective especially in Europe where no reusable ablation device is available for cardiac use; on the other hand, ablations performed with any unipolar surgical device are not as reliably transmural as those achieved with bipolar radiofrequency [21]. In past years, we have also used a second unipolar radiofrequency device to complete the lesion set on the mitral annulus in a series of 33 patients undergoing bipolar ablation of the left atrium (control group), basically before devising a way to perform all the ablation with bipolar radiofrequency. By comparison with the study group, no significant difference was found in any clinical endpoint, possibly due, to a certain extent, to the small size of the control group. But interestingly, although not surprisingly, the per patient cost of the ablation devices in the study group was nearly halved (1245 ± 50 \#8364; vs 2403 ± 17 \#8364;; p < 0.0001) thanks to the described technique.

The final result of ablating up to the mitral annulus with bipolar radiofrequency entails circumferential ablation of the coronary sinus. Such ablation is considered necessary to increase AF cure rate and to prevent left flutter [3] and is generally not achievable by ablating endocardially with unipolar devices. Although we did not record any major complication with this technique, despite the near routine use of retrograde cardioplegia, it may be safer to avoid cannulation of the ablated coronary sinus in elderly patients or when tissue frailty is any way suspected.

The presence of a coronary-free area in the AV groove may be difficult to identify in the presence of a left dominant coronary system [23]. Actually in such anatomical context, most frequently the posterior mitral annulus may be safely clamped in the area of the posteromedial commissure. In this case the needle marker can be positioned in a spot corresponding to the terminal branch of the left coronary artery and once the left atrium is opened, the mitral annulus must be clamped carefully medial to the needle projection on the valve.

When mitral replacement is not planned, excessive burning of the mitral valve can be of concern with the described technique since the consequent scarring can possibly lead to retraction of the posterior leaflet. When possible, such burning is positioned in the prolapsing segment of the posterior leaflet, which is then resected. Otherwise, limiting the mitral clamping to annulus is preferable. However, the risk of mitral malfunction due to surgical ablation is reasonably low considering that it has never been reported so far whatever the source of energy. On the other side care must be taken to always involve at least the fibrous structure of the valve annulus since an incomplete connecting line may frequently be the cause of relapsing arrhythmia [25].

Preoperative angiogram is kept in mind when inspecting the epicardium for coronary anatomy. Nevertheless, more frequently than not, the coronary-free area can be safely identified also in patients with no preoperative angiogram. In such patients, when the specific coronary anatomy cannot be clearly identified by epicardial inspection, either (careful) use of a second unipolar device or aborting the mitral line is suggested. A preoperative multi-slice CT scan can possibly obviate the problem.

Adding a right set of lines would have possibly improved the sinus rhythm recovery rate, but bipolar RF ablation of the tricuspid annulus does not appear to be feasible with the described technique and the intercaval line may increase the risk of postoperative sinus node dysfunction (absent in our series).

In conclusion, anatomy based tailoring of the mitral line allows performing a complete left atrial ablation with bipolar radiofrequency. Such a technique is safe and cost-effective and yields satisfactory mid-term freedom from AF and left flutter.


   Acknowledgments
 
We are grateful to Professor Umberto Giani for his invaluable reviewing and implementing the statistical analysis of our work. We wish to express our appreciation to Professor Bruno Pellegrini for his contributing all the artwork in this paper.


   Footnotes
 
{star} Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007.

{star}{star} Disclosure: Stefano Benussi is consultant for Estech Inc. and for Atricure Inc. and has received lecture fees from St Jude Medical Inc., Medtronic Inc., Cryocath Inc., Edwards-Lifesciences Inc. Valerio Zerbi is supported by a research grant offered by Medtronic Inc. Ottavio Alfieri is co-owner of patent rights related to prosthetic mitral rings commercialised by Edwards-Lifesciences Inc.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 

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