title: Box lesion in the open left atrium for surgical ablation of atrial fibrillation.
abstract: OBJECTIVE
  Cut-and-sew maze with a box lesion around the pulmonary veins is currently the criterion standard procedure for surgical ablation of atrial fibrillation. Recently, we changed our technique from standard bilateral epicardial pulmonary vein isolation with interconnecting lesions to a box lesion procedure with a bipolar radiofrequency ablation device. Our study describes this technique.
  
  
  METHODS
  Between March 2009 and June 2012, we performed 90 ablations by the box technique with a bipolar radiofrequency device. Fifty-five patients (61%) had persistent atrial fibrillation, and 21 (23%) had long-standing persistent atrial fibrillation. The left atriotomy was performed along the interatrial septum and the left atrial appendage amputated. The box was made by connecting the left atriotomy to the base of the amputated appendage with lines along the transverse and oblique sinuses by epicardial and endocardial application of a bipolar radiofrequency ablation device. The left atrial isthmus was ablated by cryoprobe.
  
  
  RESULTS
  There were no ablation-related complications. The box was easy to perform, with no dissection around the pulmonary veins. At 6-month, 1-year, and 2-year follow-ups, 80 (94%), 69 (93%), and 47 (91%) patients, respectively, were in sinus rhythm. Freedoms from antiarrhythmic medications in patients in sinus rhythm at 6 months, 1 year, and 2 years were 78%, 88%, and 85%, respectively.
  
  
  CONCLUSIONS
  The box lesion provided excellent freedom from atrial fibrillation and may improve transmurality through ablation of 1 rather than 2 layers of atrial wall, as in epicardial pulmonary vein isolation. With the box lesion, dissection around the pulmonary veins is unnecessary.
authors.affiliation: Department of Cardiac Surgery, Chaim Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address: Leonid.Sternik@sheba.health.gov.il.
authors.forename: Leonid
authors.initials: L
authors.lastname: Sternik
authors.affiliation: Department of Cardiac Surgery, Chaim Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Alexander
authors.initials: A
authors.lastname: Kogan
authors.affiliation: Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: David
authors.initials: D
authors.lastname: Luria
authors.affiliation: Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Michael
authors.initials: M
authors.lastname: Glikson
authors.affiliation: Department of Cardiac Surgery, Chaim Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Ateret
authors.initials: A
authors.lastname: Malachy
authors.affiliation: Department of Cardiac Surgery, Chaim Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Shany
authors.initials: S
authors.lastname: Levin
authors.affiliation: Department of Cardiac Surgery, Chaim Sheba Medical Center, Tel Hashomer, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Ehud
authors.initials: E
authors.lastname: Raanani
mesh_terms: D000368:Aged; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D020517:Atrial Appendage / Q000503:physiopathology / Q000601:surgery; D001281:Atrial Fibrillation / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D054087:Atrial Septum / Q000503:physiopathology / Q000601:surgery; D017115:Catheter Ablation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D003452:Cryosurgery / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D004867:Equipment Design; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000889:Anti-Arrhythmia Agents