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Epicardial treatment of concomitant atrial fibrillation in non-mitral valve surgery.

Clinical vignette A 57-year-old male patient with a history of paroxysmal atrial fibrillation (AF) came to the emergency room with symptoms of angina during an episode of AF. A coronary angiography confirmed a significant stenosis at the bifurcation of the left anterior descendens (LAD) and the first diagonal (D). The patient was planned for an on- pump left internal mammary artery D-LAD and epicardial pulmonary vein isolation and isolation of the posterior left atrium with a bipolar clamp. into the area between the right pulmonary artery and the right superior PV. Both fingers will touch each other, only separated by a thin layer of fatty tissue which can easily be opened by rubbing both fingers. A braid or rubber catheter is passed. This maneuver is similar to the blunt dissection of the pericardial reflection of the IVC we often do during cardiac surgery. The technique is repeated on the left PVs. Importantly, this dissection is more easily performed medial to the ligament of Marshall (LOM), since the tissues are less resistant in that area. Furthermore, this will also isolate the LOM, a potential trigger of AF. The lower jaw of the clamp is guided behind the left atrial cuff adjacent to the right PVs. The braid or rubber catheter is then removed, and correct positioning of the clamp on the atrium and not on the PVs is verified by means of direct inspection of the device after closing the jaws of the clamp. Several ablations are performed. The technique is repeated on the left side. The endpoint of PV isolation is entrance and exit blocks. The next step is a connecting lesion between the right PVs and left PVs. This can be achieved by inserting the tip of the upper jaw of the clamp into the created anatomical space between the right superior PV and the right pulmonary artery, posterior to the SVC. The tip of the lower jaw is inserted in the created anatomical space between the right inferior PV and the IVC. The clamp is then gently moved forward, with the upper jaw crossing the transverse sinus (posterior to the great arteries) and the lower jaw crossing the oblique sinus. The clamp is then closed, crossing the previous ablation line on the antrum of the left PVs. This will create a bipolar roof and inferior line in a similar way as when performing PV isolation. Clamping of the posterior left atrium between the two jaws excludes