title: Complete left atrial ablation with bipolar radiofrequency.
abstract: OBJECTIVE
  Despite its efficacy and swiftness, bipolar radiofrequency is generally not used on the left isthmus for concern of injuring a coronary branch. Incomplete lesion sets or use of an additional unipolar device are often considered. We report a technique to perform a full left lesion set involving the mitral line using a standard bipolar radiofrequency device.
  
  
  METHODS
  An innovative complete left atrial lesion set was performed using only bipolar radiofrequency in 70 consecutive patients (study group). In 67/70 patients (96%) mitral valve disease was the main indication to surgery. Atrial fibrillation was permanent in 42 patients (60%), persistent in 25 (36%) and paroxysmal in three patients (4%). After beating-heart pulmonary vein isolation on-pump, the coronary-free area of the AV groove was marked epicardially by sticking a needle into the left atrial wall, behind the coronary sinus. The projection of the needle marker on the mitral annulus was then identified through the atriotomy and an endo-epicardial ablation was performed with the bipolar device involving the atrial wall, the coronary sinus, up to the annulus. The lesion set was then completed by connecting the encirclings and the left appendage, which was then sutured. Follow-up was 100% complete. Results were compared with those of a control group of 33 patients receiving bipolar radiofrequency left atrial ablations and a mitral connecting line with a second unipolar device.
  
  
  RESULTS
  All patients survived. No major complication occurred. Haematoma of the AV groove was observed during retrograde cardioplegia in one case. No myocardial ischaemia or re-exploration for bleeding (median 325 cc, interquartile range 250-442) occurred. Two out of 70 patients required a permanent pacemaker for AV block. Freedom from atrial fibrillation was 84% (95% CI: 75%, 93%) at 6 months and 81% (95% CI: 70%, 93%) at 1 year. One patient had left flutter. Comparison with the control group did not show any difference in clinical outcomes, but revealed bipolar ablation to the mitral annulus to abate the per patient cost of the ablation devices (1245+/-50 euro vs 2403+/-17 euro; p<0.0001).
  
  
  CONCLUSIONS
  Performing the mitral line with bipolar radiofrequency is safe and cost-effective. A complete left atrial ablation with a single bipolar radiofrequency device yields excellent clinical mid-term results.
authors.affiliation: Division of Cardiac Surgery, S Raffaele University Hospital, via Olgettina 60, 20132 Milan, Italy. stefano.benussi@hsr.it
authors.forename: Stefano
authors.initials: S
authors.lastname: Benussi
authors.forename: Simona
authors.initials: S
authors.lastname: Nascimbene
authors.forename: Andrea
authors.initials: A
authors.lastname: Galanti
authors.forename: Andrea
authors.initials: A
authors.lastname: Fumero
authors.forename: Enrica
authors.initials: E
authors.lastname: Dorigo
authors.forename: Valerio
authors.initials: V
authors.lastname: Zerbi
authors.forename: Micaela
authors.initials: M
authors.lastname: Cioni
authors.forename: Ottavio
authors.initials: O
authors.lastname: Alfieri
mesh_terms: D001281:Atrial Fibrillation / Q000191:economics / Q000473:pathology / Q000601:surgery*; D017115:Catheter Ablation / Q000191:economics / Q000379:methods*; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000473:pathology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000191:economics / Q000473:pathology / Q000601:surgery*; D012307:Risk Factors; D016896:Treatment Outcome