Andy C. Kiser, MD1, Gerhard Wimmer-Greinecker, MD, PhD2, Boguslaw Kapelak, MD, PhD3, Krzysztof Bartus3, Jerzy Sadowski, MD, PhD3.
1Arrhythmia Center of the Carolinas, Pinehurst, NC, USA, 2Flinik fur Herz-Thorax-Chirurgie, Bad Bevensen, Germany, 3Jagiellonian University, Department of Cardiovascular Surgery and Transplantology, Krakow, Poland.
OBJECTIVE: Pulmonary vein isolation alone is not an effective treatment solution for most patients with wavelet, non-focal atrial fibrillation. The Ex-Maze procedure is a comprehensive, bi-atrial lesion pattern that has demonstrated early success during open chest, concomitant cardiac procedures. Paracardioscopy provides trans-diaphragmatic visualization of the epicardial surface of the beating heart and allows the creation of a complete Ex-Maze lesion pattern via port access alone.
METHODS: Twenty two patients with isolated AF (paroxysmal=2, persistent=8, permanent=12; mean AF duration=6.7 years; mean left atrial size=4.9 cm) underwent the Paracardioscopic Ex-Maze Procedure. Radiofrequency energy was delivered through a vacuum-assisted device to create the epicardial lesion pattern (Fig. 1). All patients had lesions created on the posterior left and right atria (1,2,3) which were contiguous with lesions on the anterior pulmonary veins and the roof of the left atrium (4,5,6) to electrically isolated the pulmonary veins. Ablation lines extended from the left to the right atrium across Waterson’s Groove (7 & 9) and from the SVC to the IVC (8).
RESULTS: The complete Paracardioscopic Ex-Maze lesion pattern was successfully created in all patients without device or procedure related complication. No patient required conversion to sternotomy; one patient required cardiopulmonary bypass. The average procedure time (skin-to-skin) was 4.2 hours (2.5 to 6 hours). Pulmonary vein exit block was confirmed in 82% patients tested. At one and three months, 7/7 (100%) & 3/3 (100%) patients were in sinus rhythm without Class I or III antiarrhythmic medications.
CONCLUSIONS: The Paracardioscopic Ex-Maze procedure enables a totally port access, minimally invasive surgical treatment for patients with all types of atrial fibrillation. Early results are encouraging. Long term follow up is ongoing. 
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