The Saltman micro-maze -- in his own words,

 July, 2006

"FOR A PAROXYSMAL FIBRILLATOR I perform a left-sided ablation that includes a pulmonary isolation with a box lesion and a lesion to the left atrial appendage to prevent LA flutter. I also remove the LA appendage. This is treatment tailored to the PAROXYSMAL FIBRILLATOR because (as you know) probably 90% of triggers come from either the PV's or the posterior left atrial free wall. The box lesion isolates all of this tissue. As a comparison, bilateral (clamp) lesion sets do not isolate the posterior left atrial free wall and therefore should - and do - have a higher failure rate.

FOR THE PERSISTANT/PERMANENT FIBRILLATOR, I perform as much of the Maze lesion set as possible, as I believe there is bi-atrial involvement in the perpetuation of the arrhythmia. So I make the same L-sided lesions but add two R-sided lesions: One along the inter-caval groove from superior to inferior vena cava and a perpendicular one from that to the tip of the RA appendage. I cannot make the truly "intra-cardiac" lesion to the RA isthmus, as that would
require opening the heart... This allows me to extend therapy with a more complete "Maze" lesion set for those patients with the more "complex" form of AF.

Now, as for EPs - I do not routinely involve my EP colleague in the operating room as the lesions are made by "anatomy" and not by "physiology"; that is, I am not looking for a response to the lesions just that I have made them. So their assistance usually doesn't add anything... However, as we grow more sophisticated in our approach, particularly when attacking the ganglionated plexi and/or using a combined (hybrid) approach, I think the EP's involvement will become more and more important. As for who can make which lesions from which approach, there is a great deal of overlap - they can do a lot of what I do and I can do a lot of what they do. The major advantage of the *epicardial* ("surgeons") approach is and always will be fantastic direct visualization of the target as well as the lesion, speed of lesion creation and overall procedure time, and avoidance of any collateral damage."

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