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(Circulation. 2003;108:3108-3114.)
© 2003 American Heart Association, Inc.

Clinical Investigation and Reports

Role of the Posterior Left Atrium and Pulmonary Veins in Human Lone Atrial Fibrillation

Electrophysiological and Pathological Data From Patients Undergoing Atrial Fibrillation Surgery

Derick M. Todd, MB ChB; Allan C. Skanes, MD; Gerard Guiraudon, MD; Colette Guiraudon, MD; Andrew D. Krahn, MD; Raymond Yee, MD; George J. Klein, MD

From the Arrhythmia Service, Division of Cardiology (D.M.T., A.C.S., A.D.K., R.Y., G.J.K.), and Department of Pathology (C.G.), University of Western Ontario, and the Canadian Surgery Technologies and Advanced Robotics (CSTAR) (A.C.S., G.G., G.J.K.), London, Ontario, Canada.

Correspondence to Dr Allan Skanes, Arrhythmia Service, London Health Sciences Centre, 339 Windermere Rd, London, Ontario, Canada N6A 5A5. E-mail allan.skanes{at}lhsc.on.ca

Received April 24, 2003; de novo received July 16, 2003; revision received September 19, 2003; accepted September 22, 2003.

Background— Surgery can eliminate atrial fibrillation (AF), but data confirming the rationale for specific lesion sets are lacking. We used postoperative electrophysiological studies to test the rationale and effects of operative pulmonary venous isolation.

Methods and Results— Fourteen patients undergoing surgical pulmonary venous isolation for drug-refractory lone AF were studied. Successful isolation was confirmed postoperatively in 13 of 14 patients. Spontaneous sustained AF was recorded from the isolated pulmonary venous region (PVR) in 4 and was induced by extrastimulus testing in another. The remaining atrial region (RAR) was in sinus rhythm in 13 patients and nonsustained AF in 1. Atrial extrastimulus testing and burst pacing in the RAR failed to induce sustained AF. In follow-up, 1 patient developed paroxysmal AF, and electrical continuity between the PVR and RAR was confirmed. Isolation was achieved with radiofrequency ablation with no further AF. Another patient developed typical atrial flutter that required ablation. AF has not recurred in any patient at 25.1±11.9 months (range, 6 to 56 months) after surgery. Atrial histopathology was consistent with tachycardia-induced changes.

Conclusions— Total electrical isolation of the PVR controlled AF with excellent clinical outcome and appeared necessary for success. The isolated PVR can sustain spontaneous or induced AF, whereas the considerably larger RAR does not. These data provide a sound rationale for PVR in eliminating AF.

Key Words: fibrillation • arrhythmia • surgery • pathology

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