P1252428292xSkwL

1
What are the take home messages from ISMICS for
the surgeon interested in surgical control of
ablation?

• That adhering to the concepts of isolation of the
  probable ectopic triggers, as well as ablation of
  the macro re-entry circuit pathways is essential
  to get good results
• That goals can be achieved through incision or
  through all energy sources
• Cryo is the safest energy source from an
  endocardial perspective

2
What are the major strengths and limitations of
cryo?

• It has been proven to be as efficacious as the
  cut and sew Maze procedure.
• Simple to use, fast, very little likelihood of
  collateral injury
• Its utility in an epicardial fashion is in
  question, many want an off-pump beating heart
  platform with which they can obtain efficacy that
  rivals the Cox Maze. Whether thats possible at
  all remains to be seen.
• With cryothermia there is a heat sink effect from
  the blood moving past the endocardium, creating
  uncertainty in the epicardial approach
• With the Frostbite device, we can clamp the
  tissue within the jaws and temporarily interrupt
  that flow of blood, may allow this technology to
  be applied epicardially 

3
Is there an ideal lesion pattern?

• There are as many modifications of the Maze
  procedure as there are surgeons
• The one lesion pattern that we know works for all
  forms of supraventricular arrhythmias is the
  Cox-Maze III lesion set
• It is difficult to say which modified lesion sets
  work and in what instances, Maze III is probably
  not needed for all cases
• There is no standard nomenclature and everyone
  has to describe their lesion set clearly
• The more lesion lines you make the more
  likelihood of success, both for atrial
  fibrillation and for preventing recurring atrial
  flutter
• Different energy sources have inherent
  limitations, cryo is the safest
• Many of the operative procedures seem to be
  modified to fit the technology rather than the
  principles espoused by Doctor Cox

4
What is the next major question that needs to be
answered in the field?

• A large, standardized, prospective study of
  lesion sets
• Must determine what the characteristics are that
  may require larger lesion sets
• For instance, paroxysmal atrial fibrillation may
  be able to be treated solely with pulmonary vein
  isolation and ablation of the left atrial
  appendage
• No clear answer yet

5
Why arent more atrial fibrillation surgeries
being done?

• Many surgeons feel atrial fibrillation is only a
  nuisance that can be adequately treated with
  Coumadin
• The Maze procedure is daunting, they dont know
  that other energy sources are equally effective
• Many surgeons are reluctant to extend the length
  of the operating time by adding this procedure to
  a very sick patient
• Surgeons may change their mind when the long-term
  consequences in morbidity and mortality from the
  presence of atrial fibrillation are made clear