New ideas - Arrhythmia Subxyphoid approach for closed-chest atrial fibrillation surgery: the one hand operation

Although the classical Cox maze operation has been shown to be effective for curing atrial fibrillation, it is not popular due to its complexity and associated morbidity. This has led to the development of alternative methods for the creation of the Cox maze pattern. These methods are based on the creation of lines of tissue necrosis on the atrial tissue. These new methods have been shown to be equally as effective as the Cox maze operation. We describe a new technique for epicardial microwave atrial ablation for pulmonary vein isolation. This technique is performed on patients without sternotomy, through the subxyphoid process to reduce pulmonary complications. 2006 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. 1. Technique After anaesthetic induction, transoesophageal echocardi- ography is carried out in order to discard the presence of thrombi in the left atrial appendage. The use of a Swan- Ganz catheter is also useful in order to monitor the right ventricular function. As for a classical pericardial approach, a vertical subxy- phoid incision (approximately 10 cm long) is performed. The linea alba is carefully incised, taking care not to damage the peritoneum. An inverted 'T' vertical incision is then made in the inferior aspect of the pericardium. The surgeon's right hand is then carefully introduced into the pericardial cavity anterior to the heart. After a brief recognition of the heart's anatomy, the dissection is started. The posterior aspect of the inferior vena cava is dissected using the thumb and the index finger allowing the passage of the index itself. This manoeuver can be done without difficulty, as those adherences are usually relatively weak (Fig. 1a). The second part of the dissection includes a deeper introduction of the right hand into the pericardial cavity, laterally to the right atrium, in order to reach the space between the superior vena cava and the right superior pulmonary vein. The thumb is first placed in the beginning of the right aspect of the superior vena cava. The index finger is then carefully inserted within the space limited laterally by the superior vena cava and the aorta, and between the right superior pulmonary vein and the right pulmonary artery. The dissection of the posterior aspect of