The radial procedure for atrial fibrillation

Abstract

Sequence of the Procedures. If the radial procedure is not the lone procedure and is concomitant to other cardiac procedures, there are considerations for the sequence of the procedures. A mitral valve repair or replacement is safely performed after all the radial incisions are made. After completion of the mitral valve surgery, the displacement of the heart can be unsafe and the exposure of the left atrial appendage and inside of the LA is limited to some extent. Coronary artery bypass grafting is also performed after completion of the radial procedure for the same reason. The distal coronary anastomosis can be performed even on the beating heart after the release of the aortic cross-clamp. Aortic valve replacement, particularly in patients with aortic valve regurgitation, is performed before the LA incisions are made, after the aorta is cross-clamped. In this way, the time for selective infusion of cardioplegic solution directly into the coronary artery ostia can be saved. The atrial septal defect is closed at the time of closure of the septal incision of the radial procedure. The tricuspid valve repair is usually performed after the LA is closed, and the aortic cross-clamp is released. Modifications of the Radial Procedure. In the radial procedure, the longitudinal septal incision, which is extended down to the mitral valve annulus, provides an excellent exposure of the mitral valve, which is satisfactory to undergo complex valve repair. The septal incision can be replaced by a right-sided LA incision in patients who do not require complex mitral valve repair. In that case, the postero-inferior inter-atrial septum should be ablated by crythermia or RF energy to interrupt the potential reentrant circuit around the fossa ovalis. Recently developed ablation devices may enable minimally invasive procedures for AF without undergoing cardiopulmonary bypass. It is extremely important to preserve the concept of the radial procedure in the lesion set for the off-pump AF procedure to resume a physiological atrial activation and sufficient atrial transport function, and to most surely prevent thromboembolism. Clinical Results. Between October 1997 and December 2003, we performed the radial procedure in 100 patients. There were 53 male and 47 female patients, and the average age was 62 ± 10 years. Of those patients, 82 patients had valvular heart disease and 9 patients were associated with congenital heart disease, while the remaining 9 patients had no structural heart disease. There were 67 patients with continuous AF and 33 with intermittent AF. Thirteen patients had experienced thromboembolic events before the surgery. Seven patients had left atrial thrombi present at the time of surgery. There were two surgical mortalities, not related to the radial procedure. The success rate for AF was 91%. A pacemaker implantation was required in six patients. In all the patients who were cured of AF, a significant contraction of the LA was detected by transthoracic Doppler echocardiography postoperatively. During the follow-up period of up to 74 months (median 35 months), no patient has experienced thromboembolic events. These results suggest that the radial procedure provides a greater atrial transport function and prevents thromboembolism, and thus may represent a physiological alternative to the maze procedure as a surgical procedure for AF. © 2004 Elsevier Inc. All rights reserved.