CA Lesion Sets

 

All sets would include some way to isolate the PVs to prevent electrical impulses originating there from disorganizing atrial function. At present (2009), the LAA is left intact (... although there are devices being developed that can be inserted as part of a CA to prevent clots from escaping from the LAA -- see "Update on the Watchman device" here). 

 

As noted previously, more and more EPs are becoming skilled enough to make lesion lines that duplicate those of Maze surgery. Here are areas targeted by Drs Jais and Haissagurre of Bordeaux, France,  with great success.

 

    Pulmonary Veins
    Coronary Sinus & Inferior Left Atrium
    Left Atrial Appendage
    Roof Line
    Septum
    Mitral Isthmus Line
    Posterior Left Atrium
    Superior Vena Cava
    Mid Anterior Left Atrium 

 

For other stepwise CA procedures, see these descriptions.

 

Surgery Lesion Sets

 

In all these approaches, the Left Atrial Appendage is removed -- although there is controversy about doing so.

 

PVI-Centered Surgeries

1) Dr Randall Wolf

 the Wolf "Mini-maze":

Partially de-enervates the Ganglionated Plexi based on EP detection of their location; removes or divides the Ligament of Marshall; does not do RA work to deal with typical Atrial Flutter

 

  

2) Dr Adam Saltman

 the Micro-maze:

For Intermittent AF: PVI using a box lesion, plus a lesion from it to the LAA to prevent LA (atypical) flutter.

For Continuous AF: Same as above, plus two RA  lesions: along the inter-caval groove from the superior to the interior vena cava and a perpendicular line from there to the tip of the RA appendage. (I do not believe that this would prevent typical Atrial Flutter.) 

* For more on the differences between these two procedures, see Differences between the Saltman and Wolf procedures ...

 

Totally Thoracoscopic Mini-maze or TT Maze Procedure

 

  

Dr James Edgerton; Dr James Longoria; Dr John Sirak; Dr John Pigott; Dr Bryan Steinberg:

PVI-Centered plus additional lesions (the "Dallas Extended Lesion Set" in the case of Dr Edgerton)

 Same as Wolf approach above, plus one or more of these lesions: 1) A line connection circles around the R and L PV's; 2) A line connecting the RPV circle with the LAA; 3) A line connecting the L PV circle with the mitral valve ring in the trigone area. These approaches have the potential for being as effective as the Maze surgeries (next table) for Continuous AF while being less invasive.

 

Cox Maze Lesion-set  Surgeries*

1) Dr James Cox (retired)

Modified Cox Maze

 Minimal Cox lesion set:: LA lesion across the isthmus between the inferior PV and the mitral valve annulus, coronary sinus lesion + RA isthmus lesion between the coronary sinus and the tricuspid valve

 

  

3) Dr Ralph Damiano:

The Cox Maze IV lesion set; sternotomy or thoracotomy incision; patient may be on the heart-lung-machine for part or all of the procedure.
   

4) Dr Niv Ad

 "Cryosurgical Full Maze": sternotomy or thoracotomy incision; patient may be on the heart-lung-machine for part  of the procedure; uses "cryo" (freezing) as  the energy source.

 

  

5) Dr Dale Geiss:

Some version of the Cox lesion set, plus another one that reportedly has Dr Cox’s approval; incisions only large enough to accommodate robotic arms (?); uses the heart-lung machine. 10/2007: Dr Geiss reportedly did a Full Maze on a patient who had had the Wolf "Mini-maze", something I understand most surgeons will not do because of scarring for the Wolf procedure.

 * For current information on lesion sets, you can contact the offices of the in whom you are interested (see the List of Doctors )

 

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