Rochus K. Voeller

Isolating the entire posterior left atrium improves surgical outcomes after the Cox maze procedure.

OBJECTIVES The importance of each ablation line in the Cox maze procedure for treatment of atrial fibrillation remains poorly defined. This study evaluated differences in surgical outcomes of the procedure performed either with a single connecting lesion between the right and left pulmonary vein isolations versus 2 connecting lesions (the box lesion), which isolated the entire posterior left atrium. METHODS Data were collected prospectively on 137 patients who underwent the Cox maze procedure from April 2002 through September 2006. Before May 2004, the pulmonary veins were connected with a single bipolar radiofrequency ablation lesion (n = 56), whereas after this time, a box lesion was routinely performed (n = 81). The mean follow-up was 11.8 +/- 9.6 months. RESULTS The incidence of early atrial tachyarrhythmia was significantly higher in the single connecting lesion group compared with that in the box lesion group (71% vs 37%, P < .001). The overall freedom from atrial fibrillation recurrence was significantly higher in the box lesion group at 1 (87% vs 69%, P = .015) and 3 (96% vs 85%, P = .028) months. The use of antiarrhythmic drugs was significantly lower in the box lesion group at 3 (35% vs 58%, P = .018) and 6 (15% vs 44%, P = .002) months. CONCLUSIONS Isolating the entire posterior left atrium by creating a box lesion instead of a single connecting lesion between the pulmonary veins showed a significantly lower incidence of early atrial tachyarrhythmias, higher freedom from atrial fibrillation recurrence at 1 and 3 months, and lower use of antiarrhythmic drugs at 3 and 6 months. A complete box lesion should be included in all patients undergoing the Cox maze procedure.

Trends in the indications and survival in pediatric heart transplants: a 24-year single-center experience in 307 patients.

BACKGROUND Heart transplantation is the only viable treatment for children with end-stage heart failure due to congenital heart disease (CHD) or cardiomyopathy. This study reviewed the trends in the indications for transplant and survival after transplant during the past 24 years. METHODS A retrospective review was performed of the 307 heart transplants performed at our center since 1986. To analyze the trends in the indications for transplant as well as operative death and late-survival, the data were divided into three periods in 8-year increments: 1986 to 1993 (50 patients), 1994 to 2001 (116 patients), and 2002 to 2009 (141 patients). RESULTS The indications for transplantation were 39% cardiomyopathy, 57% CHD, and 4% retransplant. Of the 173 with CHD, 139 (80%) had single-ventricle (SV) anomalies. In the CHD group, transplantation for failed SV palliation, including Fontan procedure, became the predominant indication in the last 8-year interval of our program. Survival after transplant was the best in patients with cardiomyopathy and the worst in patients with failed palliations for SV anomalies, including failed Fontan procedures. CONCLUSIONS Transplantation for heart failure related to failed SV palliation has become the most common indication for patients with CHD. The high-risk nature of these transplants will have significant implications for heart transplant programs as more infants with SV anomalies survive palliative procedures performed during infancy.

Animal studies of epicardial atrial ablation

The Cox maze procedure is an effective treatment of atrial fibrillation, with a long-term freedom from recurrence greater than 90%. The original procedure was highly invasive and required cardiopulmonary bypass. Modifications of the procedure that eliminate the need for cardiopulmonary bypass have been proposed, including use of alternative energy sources to replace cut-and-sew lesions with lines of ablation made from the epicardium on the beating heart. This has been challenging because atrial wall muscle thickness is extremely variable, and the muscle can be covered with an epicardial layer of fat. Moreover, the circulating intracavitary blood acts as a potential heat sink, making transmural lesions difficult to obtain. In this report, we summarize the use of nine different unidirectional devices (four radiofrequency, two microwave, two lasers, one cryothermic) for creating continuous transmural lines of ablation from the atrial epicardium in a porcine model. We define a unidirectional device as one in which all the energy is applied by a single transducer on a single heart surface. The maximum penetration of any device was 8.3 mm. All devices except one, the AtriCure Isolator pen, failed to penetrate 2 mm in some nontransmural sections. Future development of unidirectional energy sources should be directed at increasing the maximum depth and the consistency of penetration.

Acquisition of oral phencyclidine self-administration in rhesus monkeys: Effect of sex

Abstract  Rationale: There are increasing reports of sex differences in the etiology of drug abuse in humans. A nonhuman primate model is useful for examining sex as a variable in drug abuse. Objectives: To determine whether there are sex differences in the acquisition of oral phencyclidine (PCP) self-administration and to compare the effect of altered feeding conditions on drug self-administration in male and female monkeys. Methods: Acquisition of orally delivered PCP was studied using 7 female and 11 male adult rhesus monkeys. Initially, the monkeys were not food restricted, and they were given access to water under concurrent fixed-ratio (FR) 1 schedules during daily 3-h sessions. Each lip-contact response on a drinking spout resulted in a 0.3 ml liquid delivery. After baseline levels of water intake were obtained for 5 days, water was replaced with PCP (0.125 mg/ml) at both drinking spouts. Body weights were then reduced to 85% of free-feeding weights, and the monkeys were fed 30 min before the session began. The FR value was increased from 1 to 2, 4, and 8, at both drinking spouts. As a final step in the procedure, water and PCP were concurrently available at the two spouts under FR 8 schedules. Acquisition of PCP-reinforced behavior was considered to have occurred if PCP intake was consistently greater than water intake. Results: Lip-contact responses and liquid deliveries were not significantly different between the females and males throughout the acquisition period, but there was a significant increase in responding and decrease in liquid intake as FR increased, and a significant increase in PCP consumption due to food restriction that did not differ in males and females. On a milligram per kilogram basis, female monkeys consumed nearly twice as much PCP as the males; however, this effect was not significant. The females showed significantly higher PCP than water intake while the males consumed approximately equal amounts of PCP and water. Of the seven females, 100% met the acquisition criterion of significantly greater PCP than water intake, while only 36.4% of the males met the criterion. Conclusion: These results concur with previous rat studies and indicate that female monkeys are more likely than males to acquire drug-reinforced behavior.

The effects of the Cox maze procedure on atrial function

OBJECTIVE The effects of the Cox maze procedure on atrial function remain poorly defined. The purpose of this study was to investigate the effects of a modified Cox maze procedure on left and right atrial function in a porcine model. METHODS After cardiac magnetic resonance imaging, 6 pigs underwent pericardiotomy (sham group), and 6 pigs underwent a modified Cox maze procedure (maze group) with bipolar radiofrequency ablation. The maze group had preablation and immediate postablation left and right atrial pressure-volume relations measured with conductance catheters. All pigs survived for 30 days. Magnetic resonance imaging was then repeated for both groups, and conductance catheter measurements were repeated for the right atrium in the maze group. RESULTS Both groups had significantly higher left atrial volumes postoperatively. Magnetic resonance imaging-derived reservoir and booster pump functional parameters were reduced postoperatively for both groups, but there was no difference in these parameters between the groups. The maze group had significantly higher reduction in the medial and lateral left atrial wall contraction postoperatively. There was no change in immediate left atrial elastance or in the early and 30-day right atrial elastance after the Cox maze procedure. Although the initial left atrial stiffness increased after ablation, right atrial diastolic stiffness did not change initially or at 30 days. CONCLUSIONS Performing a pericardiotomy alone had a significant effect on atrial function that can be quantified by means of magnetic resonance imaging. The effects of the Cox maze procedure on left atrial function could only be detected by analyzing segmental wall motion. Understanding the precise physiologic effects of the Cox maze procedure on atrial function will help in developing less-damaging lesion sets for the surgical treatment of atrial fibrillation.

Biatrial lesion sets

The Cox-Maze procedure was developed more than 20 years ago at our institution. This traditional cut-and-sew operation had high success rates but was very invasive. To simplify this procedure, our group developed an operation, the Cox-Maze IV procedure, that replaces most of the incisions with linear lines of ablation while preserving the traditional biatrial lesion set. The technical aspects of the procedure are discussed in detail. Initial operative results with this new procedure have been good, with a freedom from atrial fibrillation of 90% at 1 year. The success rate is not significantly different from the traditional cut-and-sew procedure.

Novel use of plasmapheresis in a patient with heparin-induced thrombocytopenia requiring urgent insertion of a left ventricular assist device under cardiopulmonary bypass.

From the Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes–Jewish Hospital, St Louis, Mo. Disclosures: None. Received for publication Nov 7, 2009; revisions received Feb 24, 2010; accepted for publication June 9, 2010. Address for reprints: Rochus K. Voeller, MD, Department of Surgery, Washington University School of Medicine, 660 South Euclid Ave, Box 8234, Saint Louis, MO 63110 (E-mail: voellerr@wustl.edu). J Thorac Cardiovasc Surg 2010;140:e56-8 0022-5223/

Myocardial Viability Mapping by Magnetic Resonance-Based Multiparametric Systolic Strain Analysis

36.00 Copyright 2010 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2010.06.018

Surgical ablation for atrial fibrillation: The efficacy of a novel bipolar pen device in the cardioplegically arrested and beating heart

BACKGROUND Regional myocardial contractility can be characterized by three-dimensional left ventricular (LV) multiparametric strain maps generated from sequential magnetic resonance imaging of radiofrequency tissue-tagging grid point displacements. METHODS Normal average and standard deviation values for each of three strain indices at 15,300 LV points were determined from a normal volunteer human strain database (n = 50) by application of magnetic resonance-based three-dimensional strain analysis. Patient-specific multiparametric strain data from each ischemic cardiomyopathy patient (n = 20) were then submitted to a point-by-point comparison (n = 15,300 LV points) to the normal strain database. The resulting 15,300 composite multiparametric Z-score values (standard deviation from normal average) were color-contour mapped over patient-specific three-dimensional LV geometry to detect the abnormal contractile patterns associated with myocardial infarction and nonviable myocardium. RESULTS The average multiparametric strain composite Z-score from each LV region (n = 120) was compared with the respective clinical standard viability testing result and used to construct a receiver-operator characteristic curve. The area under the curve was 0.941 (p < 0.001; 95% confidence interval: 0.897 to 0.985). A regional average Z-score threshold of 1.525 (> 1.525 being nonviable) resulted in a sensitivity of 90% and a specificity of 90%. Corresponding positive and negative predictive values were 84% and 95%, respectively. CONCLUSIONS The clinical application of magnetic resonance-based multiparametric strain analysis allowed accurate regional characterization and visualization of LV myocardial viability.

Differential modulation of right ventricular strain and right atrial mechanics in mild vs. severe pressure overload.

OBJECTIVE The introduction of ablation technology has simplified surgical intervention for atrial fibrillation. However, most ablation devices cannot create focal transmural lesions on the beating heart and have difficulty ablating specific regions of the atria, such as the atrioventricular isthmus, coronary sinus, and ganglionated plexus. The purpose of this study was to examine the efficacy of a pen-type bipolar radiofrequency ablation device on both arrested and beating hearts. METHODS Endocardial and epicardial atrial tissues in the free wall, left atrial roof, atrioventricular annuli, and coronary sinus were ablated for varying time intervals (2.5-15 seconds) in porcine cardioplegically arrested (n = 6) and beating (n = 9) hearts. The hearts were stained with 1% 2,3,5-triphenyl-tetrazolium chloride solution and sectioned to determine lesion depth and width. In 5 animals epicardial fat pads containing ganglionated plexus were stimulated and ablated. RESULTS Lesion depth increased with ablation time similarly in both arrested and beating hearts. Transmurality was fully achieved in the thin atrial tissue (<4 mm) at 10 seconds in the beating and arrested hearts. The device had a maximal penetration depth of 6.1 mm. Epicardial ablation of the coronary sinus showed complete penetration through the left posterior atrium only in the arrested heart. Seven of 17 fat pads demonstrated a vagal response. All vagal responses were eliminated after ablation. CONCLUSION The bipolar pen effectively ablated atrial tissue in both arrested and beating hearts. This device might allow the surgeon to ablate tissue in regions not accessible to other devices during atrial fibrillation surgery.