Comprehensive surgical approach to treat atrial fibrillation in patients with variant pulmonary venous anatomy.

Objectives: Catheter radiofrequency ablation procedures yield fairly successful results for the treatment of atrial fibrillation; however, patients with anatomic variant pulmonary veins (PV) are generally thought not to benefit from catheter ablation technique, with recurrence rates observed as high as 78%. We report a comprehensive surgical approach to treat this subset of patients with a modified full maze procedure.

Methods: From January 2002 to December 2009, 72 patients undergoing cardiac surgery who had drug-refractory and/or recurrent AF after catheter ablation were identified. PV variance was observed on preoperative multislice chest computed tomography. All patients underwent multiple PV epicardial circumferential isolation and epicardial-endocardial longitudinal PV ablations along with standard maze as an adjunct to the cardiac surgical procedure. Patients were followed up at 6 months, 1 year, and 2 years postoperatively.

Results: Typical patterns of PV variation were observed in 72 patients. Left common PV trunk was found in 49 patients (68%), with a mean length of 21 ± 4.6 mm, diameter of 28.6 ± 4.9 mm, and wall thickness of 2.1 ± 1.7 mm. Right PV variants, including right middle and right top PVs, were found in 23 patients (32%), with a length of 20 ± 2.1 mm, diameter of 9.9 ± 3.4 mm, and wall thickness of 1.9 ± 1.7 mm. Overall restoration of sinus rhythm was confirmed in 64 patients (94%) at 1-year follow-up. Twelve patients were defibrillated into sinus rhythm within 90 days after the operation.

Conclusions: A modified full maze procedure should be considered as a first choice treatment for atrial fibrillation with variant drainage of PVs because of the nature of PV size, wall thickness, and specific foci in the arrhythmogenic veins. Multiple PV isolation and epicardial-endocardial longitudinal PV ablations along with the standard maze are essential to success. Early referral for surgical ablation allows higher success rates.