Intraoperative verification of conduction block in atrial fibrillation surgery

Atrial tachycardia is a troublesome and medically refractory complication after surgery for atrial fibrillation. Incomplete surgical ablation during atrial fibrillation surgery can result in residual conduction over the lesions and postoperative atrial tachycardia. Intraoperative verification of conduction block would detect incomplete ablation lesions and direct repeat ablations to prevent postoperative atrial tachycardia.

The incidence of postoperative atrial tachycardia was examined in 218 patients who underwent atrial fibrillation surgery between November of 1994 and October of 2007. No conduction block across any ablation lesions was confirmed intraoperatively in the first 128 patients (group C). Isolation of each pulmonary vein was verified by intraoperative pulmonary vein pacing in the following 72 patients (group PV). In the recent 18 consecutive patients, conduction block in the coronary sinus, in addition to pulmonary vein isolation, was confirmed by intraoperative coronary sinus pacing (group PV/CS). Postoperative atrial tachycardia was characterized by electroanatomic mapping.

The incidence of postoperative atrial tachycardia in groups C and PV was 7% and 1%, respectively (P = .0985). No patients exhibited any postoperative atrial tachycardia in group PV/CS. The postoperative electroanatomic mapping revealed that the mechanisms of the atrial tachycardia were macro-reentry through incomplete coronary sinus and mitral valve ablation lesions (n = 9), and focal activation in the coronary sinus (n = 1). Intraoperative verification of conduction block directed the repeat ablation lesions to the pulmonary veins.

The majority of postoperative atrial tachycardia was associated with an incomplete coronary sinus ablation. Intraoperative verification of conduction block may be helpful to prevent the occurrence of postoperative atrial tachycardia.