RU2613445C1 - Method for atrial fibrillation surgical treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: epicardial ablation of heart ganglia is performed in the intercaval interval, at the confluence of the left superior pulmonary vein to the left atrium, transmural ablation of the left atrium walls is performed along the lines bordering the mouths of the right and left pulmonary veins, along the line of the left atrial appendage base, along the line from the top left pulmonary vein to the left atrial appendage base. Epi-endocardial transmural ablation of the left atrium walls is performed through the right superior pulmonary vein along the line through the mouth of the left superior pulmonary vein, and the line from said mouth to the mitral-aortic contact. Epi-endocardial transmural ablation of the left atrium walls is performed via the access in the intercaval space along the line, to the mouth of the left inferior pulmonary vein. Then the ablation line is continued to the aortic valve fibrous ring. Right atrium 3-5 cm long atriotomy is performed parallel to the border groove along the outer wall of the right atrium, resection of right atrial appendage is performed. Epi-endocardial transmural ablation of the right atrium walls is performed along the line from the lower cut edge to the mouth of the inferior vena cava, along the line from the top cut edge to the right atrial appendage base, along the line from the middle of the right atrial appendage base to the anterior commissure of the tricuspid valve. Ablation of cavo-tricuspid isthmus is performed.

EFFECT: reduction of surgical aids trauma and complexity, thereby reducing surgery time, while maintaining its efficacy and safety.

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Description

The invention relates to medicine, namely to cardiovascular surgery, and can be used in the treatment of atrial fibrillation.

Atrial fibrillation is one of the most common cardiac arrhythmias. With ineffective antiarrhythmic therapy, surgical intervention is required. All types of atrial fibrillation have 3 components: (1) the atrial circulation macrochain (chains), (2) the atrial passive conduction in the part not included in the excitation circulation macrochain (chains), and (3) atrioventricular conduction. Surgical treatment is aimed at interrupting any or all of the macrocirculation of excitation circulation that could occur in the atria.

There is a method of surgical treatment of atrial fibrillation, proposed by J. Cox (Cardiovascular Surgery / Edited by V.I. Burakovsky, L.A. Bokeria, 1996, S. 514-516), in which instead of three interstitial pathways functioning between sinus-atrial and atrial-ventricular nodes, one begins to function, covering the entire myocardium of both atria. This method of surgical treatment is called the Labyrinth operation, which involves interrupting the pathological chain of intracardiac conduction by performing successive incisions in the atria, followed by suturing of their edges, which allows achieving high results in treatment and considering this technique as the “gold standard” in the surgical treatment of atrial fibrillation. However, in recent decades, the issue of replacing the classical surgical technique of the “Labyrinth” operation “incision-seam” with methods that use alternative energy sources to create transmural damage to the atrial tissue remains relevant.

In world practice, at the present time, along with the classical technique of the Labyrinth operation, modifications of the operation are also used, most of which use cryothermal and bipolar radio frequency energy as a source of energy for causing transmural damage.

One of the latest modifications to the Labyrinth operation is the Labyrinth IV procedure (The Cox-Maze IV procedure for lone atrial fibrillation. Multimedia Manual Cardio-Thoracic Surgery. 2007 Jan 1, Damiano RJ Jr, Bailey M.) (prototype). The operation is performed under conditions of pharmacological cold cardioplegia and cardiopulmonary bypass (IR). It includes the implementation of 2 stages: a stage on the left atrium and a stage on the right atrium. The stage in the left atrium is characterized by performing epicardial bipolar radiofrequency ablation of the mouth of the pulmonary veins on the right and left, performing atriotomy of the left atrium, performing epi-endocardial lines of bipolar radiofrequency ablation along the upper wall of the left atrium between the upper right and left pulmonary veins connecting the and left upper pulmonary veins. A line is also drawn from the lower edge of the atriotomic incision in the left atrium to the mouth of the left lower pulmonary vein, connecting the line with the ablation line of the mouths of the pulmonary veins. Next, an endocardial line is drawn from the lower edge of the atriotomic incision in the left atrium to the fibrous ring of the mitral valve and is complemented by cryotherapy. The ablation line from the superior pulmonary vein to the base of the left atrial ear is epi-endocardial. The stage ends with the execution of a resection of the left atrial ear. The stage in the right atrium is characterized by performing a right-sided atriotomy along the outer wall of the left atrium, then the bipolar ablation lines from the lower edge of the atriotomy incision in the direction of the lower and upper vena cava are performed epi-endocardially. After opening the ear of the right atrium, an epi-endocardial line of bipolar ablation from the base of the ear of the right atrium, along the front wall of the right atrium to the anterior commissure of the tricuspid valve, and the epi-endocardial line along the anterior wall of the right atrium to the septal commissure of the tricuspid valve are performed. Atrial suturing is performed. The end of the operation.

The advantages of this operation are the replacement of the “incision-suture” technique used in the classic “Labyrinth” operation with all lines in the left and right atria using radiofrequency and cryogenic ablation, which is not only a simplification of the operation technique itself, but also provides an opportunity its implementation through minimally invasive approaches.

The disadvantages of the prototype method: the inability to intraoperatively control the effectiveness of operations on a stopped heart by restoring sinus or the correct atrial rhythm; the additional use of cryodestruction techniques, as well as the complications inherent in the operation under conditions of pharmacological cold cardioplegia and the complexity of the surgical manual, which involves performing incisions in both the left and right atria.

We set the task: to develop an effective and safe method for the surgical treatment of atrial fibrillation, which can be performed on a working heart without the use of cryodestruction, pharmacological cold cardioplegia under the electrophysiological control of its adequacy.

The technical result achieved by the implementation of the proposed method consists in

- simplification and reduction of the time of surgical intervention while maintaining its radicalism;

- the elimination of complications caused by the use during the operation of cryodestruction, pharmacological cold cardioplegia;

- ensuring the effectiveness of the intervention due to the possibility of using intraoperative electrophysiological control of the isolation zones of the heart, which are dangerous in terms of circulation of pathological excitation, in the left and right atria; restoration and retention of sinus rhythm by the patient.

In the surgical treatment of atrial fibrillation, we have proposed original accesses on the left atrium and improved lines on the left and right atria for performing radiofrequency ablation, which allow, on the one hand, to reliably isolate pathological circulation zones of excitation and, on the other hand, to reduce the trauma and complexity of surgical intervention , reduce the time of the operation, which, in turn, allows you to abandon pharmacological cold cardioplegia, cryodestruction, evaluate and confirm the result operations directly in the operating room by performing an electrophysiological study.

The figure shows a diagram of the proposed operation, where:

1 - isolation line of the right pulmonary veins;

2 - isolation line of the left pulmonary veins;

3 - ablation line along the upper wall of the left atrium from the right superior pulmonary vein to the mouth of the left superior pulmonary vein;

4 - ablation line from the intercaval space to the mouth of the left lower pulmonary vein along the posterior wall of the left atrium;

5 - “box” (box lession);

6 - bandaged ear of the left atrium, supplemented by a line of bipolar ablation;

7 - line of ablation from the left upper pulmonary vein to the base of the ear of the left atrium;

8 is an ablation line connecting a line along the upper wall of the left atrium and the fibrous ring of the aortic valve in the left fibrous triangle of the heart;

9 - ablation line from the right superior pulmonary vein to the mitral-aortic contact;

10 - ablation line on the outer wall of the right atrium from the lower edge of the atriotomic incision towards the mouth of the inferior vena cava;

11 - line of ablation from the upper edge of the atriotomic incision to the base of the ear of the right atrium along the outer surface of the right atrium;

12 - ablation line from the middle of the base of the ear of the right atrium to the anterior commissure of the tricuspid valve;

13 - line of ablation of the cavo-tricuspid isthmus of the heart (isthmus block);

14 - atriotomy of the right atrium;

15 - line of resection of the ear of the right atrium;

16 - purse string suture and section of the wall of the left atrium.

The invention consists in the following.

In the surgical treatment of atrial fibrillation, surgery is performed under normothermic cardiopulmonary bypass. Epicardial ablation of the ganglia of the heart is performed in the intercaval space, at the place where the right upper pulmonary vein flows into the left atrium. Epicardially transmural ablation of the walls of the left atrium is performed along the lines bordering the mouth of the right (line 1) and left (line 2) pulmonary veins, along the line passing along the posterior and anterior surface of the base of the left atrial ear (line 6), along the line from the left upper pulmonary veins to the base of the ear of the left atrium along the upper wall of the left atrium (line 7). Epi-endocardially transmural ablation of the walls of the left atrium is performed through the right upper pulmonary vein along the line located on the upper wall of the left atrium to the mouth of the upper left pulmonary vein (line 3), and the line from the said mouth to the mitral-aortic contact along the upper wall of the left atrium ( line 9). Epi-endocardially transmural ablation of the walls of the left atrium is performed through access in the intercaval space along the line located on the posterior wall of the left atrium to the mouth of the left lower pulmonary vein (line 4). Next, epicardially transmural ablation of the left atrial wall is performed, continuing line 3 to the fibrous ring of the aortic valve along the upper and then the front wall of the left atrium (line 8). An atriotomy of the right atrium is performed, 3-5 cm long, parallel to the border groove along the outer wall of the right atrium. Resection of the ear of the right atrium is performed. Epi-endocardially transmural ablation of the walls of the right atrium is performed along the line from the lower edge of the section to the mouth of the inferior vena cava along the outer wall of the right atrium, along the line from the upper edge of the section to the base of the ear of the right atrium along the outer wall of the right atrium, along the line from the middle of the base of the right ear atria along its front wall to the anterior commissure of the tricuspid valve. An epi-endocardial linear transmural ablation of the cavo-tricuspid isthmus is performed. In this case, closed contours of the ablation lines in the left atrium are formed, connecting lines 1 and 2 with line 3 along the upper wall of the left atrium and line 4 on the posterior wall of the left atrium, line 7 is connected with line 2 and 6, lines 8 and 9 start from lines 2 and 1, respectively, and connected at the fibrous ring of the aortic valve in the left fibrous triangle of the heart. The intervention is completed by suturing the wall of the right atrium.

In a particular case, the ablation of the ganglia of the heart is performed using an electrode for linear radiofrequency ablation.

There is an option in which the ablation of the ganglia of the heart in the intercaval space is supplemented by their electrocoagulation.

There is an option in which epicardial ablation of the walls of the left atrium along lines 1 and 2 is performed using a bipolar clamp for radiofrequency ablation, and the clamp is applied so that part of the atrium in the area of the mouth of the pulmonary veins with an indent of 0.5-1 cm from them is between the branches with full closing the clamp, and ablation along line 2 is performed after dislocation of the heart into the wound and dissection of the Marshall ligament.

There is an option in which epi-endocardial ablation of the walls of the left atrium through the upper right pulmonary vein along lines 3 and 9 is performed using a bipolar clamp for radiofrequency ablation, while one of the jaws of the clamp is inserted into the heart cavity through the said upper right pulmonary vein.

There is an option in which epi-endocardial ablation of the walls of the left atrium through access in the intercaval space along line 4 is performed using a bipolar clamp for radiofrequency ablation, while one of the jaws of the clamp is inserted into the heart cavity through the access in the intercaval space.

In a particular case, access to the heart cavity through the right upper pulmonary vein is performed after preliminary application of a purse string suture around the heart wall incision with its subsequent tightening around the jaw of the clamp for bipolar ablation introduced into the heart cavity.

In a particular case, access to the heart cavity in the intercaval space is performed after preliminary application of a purse string suture around the incision of the heart wall with its subsequent tightening around the jaw of the clamp for bipolar ablation introduced into the heart cavity.

There is an option in which an electrophysiological study is carried out to determine a bi-directional impulse block along the lines of bipolar radio frequency ablation (monitoring the electrical insulation of the lines of ablation performed).

The method is as follows.

After the implementation of the stage of access to the heart and cannulation of the great vessels, the beginning of cardiopulmonary bypass and the allocation of the sinuses of the pericardium, bypass the right and then the left pulmonary veins. Next, proceed to the implementation of the main stage of the operation. The main stage of the operation consists of two successive stages: a stage performed on the left atrium, and a stage on the right atrium.

Stage on the left atrium.

On the epicardial side, electrocoagulation is performed on the right side in the intercaval space, supplemented by radiofrequency ablation of the ganglia of the heart using an electrode for linear radiofrequency ablation, connected to the radiofrequency energy generator in a mode preset by the manufacturer, for example, AtriCure Ablation and Sensig Unit (ASU 2-115). On the epicardial side, ten times, bipolar epicardial ablation of the right pulmonary veins is performed using a bipolar clamp for radiofrequency ablation, for example AtriCure isolator synergy, until transmurality is achieved (coagulation necrosis of all layers of the heart tissue: epicardium, myocardium, endocardium, by which electrical isolation of the heart tissue is achieved ) Technical characteristics of ablation using a bipolar clamp connected to a radio frequency energy generator in the mode preset by the manufacturer: electric current frequency - 460.8 kHz ± 5% - Quasi-sinusoidal, maximum electric current power - 25.8W, maximum electric current resistance - 114 Ω, maximum voltage of electric current - 57 Vrms.

Then the heart is dislocated into the wound, the Marshall ligament is dissected, and bipolar epicardial transmural ablation of the left pulmonary veins is performed ten times using a bipolar clamp for radiofrequency ablation. The bipolar clamp is applied so that the atrial tissue is between the jaws of the clamp when it is tightly closed. When ablation is performed on the right and left pulmonary veins, the effects are applied in the atrial so-called antrum of the atrium, departing from the mouth of the pulmonary veins 0.5-1 cm, thus avoiding subsequent stenosis of the mouth of the pulmonary veins.

An electrophysiological study is performed using a complex for endocardial electrophysiological research, for example EP-TRACER (Schwarzer Cardiotek), confirm the electrical block isolation of the pulmonary veins. The ear of the left atrium, at its base, is ligated with two lavsan threads and complement the isolation with epicardial transmural ablation using a bipolar clamp for radiofrequency ablation (four times).

Through the right upper pulmonary vein, having previously applied a purse string suture and making an incision in the area of the mouth of the right upper pulmonary vein on the upper wall of the left atrium, epi-endocardially, a bipolar clamp for radiofrequency ablation along the upper wall of the left atrium is carried out to the mouth of the left upper pulmonary vein and is performed 10 transmural ablation effects. Next, the bipolar clamp for radiofrequency ablation is shifted towards the mitral-aortic contact and 10 transmural ablation effects are performed epi-endocardially.

On the left atrium, in the intercaval space above the mouth of the right lower pulmonary vein, a pouch is applied and an atrial wall is cut, an epi-endocardial bipolar clamp for radiofrequency ablation is performed through it, along the posterior wall of the left atrium to the mouth of the left lower pulmonary vein, and 10 transmural ablation effects.

Thus, the pulmonary veins remain completely isolated with a small area of the left atrium, the so-called “box lesion”.

Using an electrode for linear bipolar radiofrequency ablation, such as AtriCure isolator linear pen, linear radiofrequency ablation of the ganglia of the heart is performed on the left (at the place where the left superior pulmonary vein flows into the left atrium).

Technical characteristics of ablation using an electrode for linear radiofrequency ablation connected to a radiofrequency energy generator in a mode preset by the manufacturer: electric current frequency - 460.8 kHz ± 5% - Quasi-sinusoidal, maximum electric current power - 20 W, maximum electric current resistance - from 31 to 300 Ω, the maximum voltage of the electric current is 77.5 Vrms.

Using an electrode for linear bipolar radiofrequency ablation, epicardially, a transmural line is made connecting the line along the upper wall of the left atrium and the fibrous ring of the aortic valve in the left fibrous triangle of the heart.

Further, also using an electrode for linear bipolar ablation, epicardially, a transmural line from the left superior pulmonary vein to the base of the left atrial ear is performed.

The final stage in the left atrium using the electrode for linear bipolar ablation is that the intersection of the ablation lines is epicardially supplemented with transmural bipolar radiofrequency ablation and an electrophysiological study is carried out using a complex for endocardial electrophysiological examination to confirm the electrical isolation of the “box lesion” and Exit blockade.

Stage on the right atrium. An atriotomy (incision) is performed in the right atrium (3-5 cm parallel to the border groove on the outer wall of the right atrium). Resection of the ear of the right atrium is performed. From the lower edge of the atriotomic incision, using a bipolar clamp for radiofrequency ablation, epi-endocardially, a transmural line is made along the outer wall of the right atrium, in the direction of the mouth of the inferior vena cava (10 transmural ablation effects).

Then bluntly separated epicardial fat in the projection of the anterior commissure of the tricuspid valve. The next step is 2 epi-endocardial lines using a clamp for bipolar radiofrequency ablation (10 transmural ablation actions): 1) a line from the upper edge of the atriotomic incision to the base of the ear of the right atrium along the outer surface of the right atrium; 2) a line from the middle of the base of the ear of the right atrium to the anterior commissure of the tricuspid valve.

The final stage in the right atrium is epi-endocardial transmural ablation of the cavo-tricuspid isthmus of the heart using an electrode for linear bipolar radiofrequency ablation. Suture the wall of the right atrium. Hollow veins are released to fill the heart with blood. An electrophysiological study is performed to confirm the bidirectional electrical blockade of the conduction of pulses along all completed lines. Superfrequent stimulation of the right and left atria causes atrial fibrillation, which normally stops on its own within 30 seconds.

The final stage (stage of completion of the operation). Finish cardiopulmonary bypass. Temporary electrodes for pacing are sutured to the myocardium of the right ventricle (2 electrodes) and the right atrium (2 electrodes). Finish the operation.

We provide evidence of the possibility of realizing the claimed purpose and achieving the specified technical result.

Example 1

Patient K., 48 years old. From the anamnesis, it is known that he considers himself ill for about 5 years, when he began to notice bouts of rapid irregular heartbeat, when contacting a doctor, a paroxysmal form of atrial fibrillation was revealed - antiarimic therapy was prescribed (sotalol, allapinin) with a relative effect. He noted the deterioration in the last year, when the arrhythmia attack was not stopped by either drug or repeated electric cardioversion and catheter radiofrequency isolation of the pulmonary veins, the patient was offered a strategy for controlling heart rate, but this only worsened the clinical picture of the disease. During the examination of the patient, the following data were obtained: the volume of the left atrium according to the MSCT of the left atrium and pulmonary veins was 172 ml, the anteroposterior size of the left atrium according to the echocardiography was 5.3 cm. The ejection fraction of the left ventricle was 45%. According to Holter ECG monitoring: atrial fibrillation with an average heart rate per day of 135 beats per minute. The patient was hospitalized for surgical treatment of atrial fibrillation in the department. After the necessary preoperative preparation, the patient was taken to the operating room at the rhythm - atrial fibrillation with a heart rate of 134 beats per minute. The operation of the proposed method. Normothermic cardiopulmonary bypass began. The vena cava was squeezed. On the right side of the epicardium in the intercaval space, ganglia were electrocoagulated and supplemented with linear radiofrequency ablation. On the epicardial side, bipolar epicardial ablation of the right pulmonary veins was performed ten times (line 1), the AtriCure isolator synergy bipolar clamp for radiofrequency ablation was used. Then the heart was dislocated into the wound, the Marshall ligament was dissected, the bipolar epicardial ablation of the left pulmonary veins was performed ten times (line 2), and the AtriCure isolator synergy was used for radiofrequency ablation. We conducted an electrophysiological study, used the complex for endocardial electrophysiological study EP-TRACER (Schwarzer Cardiotek): confirmed the electrical block isolation of the pulmonary veins. The ear of the left atrium at its base was ligated with 2 dacron threads and supplemented with four-fold bipolar radiofrequency ablation (line 6), using the AtriCure isolator synergy bipolar clamp. A bipolar clamp for radiofrequency ablation of AtriCure isolator synergy was carried out through an incision with a purse string suture on the right upper right pulmonary vein (16), along the upper wall of the left atrium to the mouth of the left upper pulmonary vein (line 3), 10 ablation procedures were performed. Next, the AtriCure isolator synergy bipolar forceps were shifted towards the mitral-aortic contact and 10 ablation actions were performed epi-endocardially (line 9). On the left atrium, in the intercaval space, after performing an incision, a purse string suture was made near the mouth of the right lower pulmonary vein (16) and an AtriCure isolator synergy was bipolar clamped to the left lower pulmonary vein (line 4), 10 ablation procedures were performed. Using an AtriCure isolator linear pen, a linear radiofrequency ablation of the ganglia of the heart on the left (at the place where the left superior pulmonary vein enters the left atrium) was performed using the AtriCure isolator linear pen. Using an AtriCure isolator linear pen for bipolar ablation, the line connecting the line along the upper wall of the left atrium and the fibrous ring of the aortic valve in the region of the left fibrous triangle was epicardially performed (line 8). Further, also using the AtriCure isolator linear pen, an epicardial line was drawn from the left superior pulmonary vein to the base of the left atrial ear (line 7). The final stage in the left atrium, the intersection of the ablation lines was supplemented with epicardial radiofrequency ablation using an electrode for linear bipolar radiofrequency ablation of the AtriCure isolator transpolar pen and conducted an electrophysiological bidirectional study using the EP-TRACER electrical endocardial electrophysiological study unit (to confirm the Schwarzeriotek block) - isolation of an isolated area of the left atrium - “box” (box lesion) (5). The patient lacked electrical activity in the posterior wall of the left atrium and pulmonary veins, but atrial fibrillation persisted.

Next, a 4 cm right-side atriotomy was performed parallel to the border groove on the outer surface of the right atrium (14). From the lower edge of the atriotomic incision, vertically, towards the mouth of the inferior vena cava, a line was drawn epi-endocardially using the AtriCure isolator synergy clamp for bipolar radiofrequency ablation on the outer wall of the right atrium (10 ablation actions) (line 10). Then bluntly separated epicardial fat in the region of the anterior commissure of the tricuspid valve, resected the ear of the right atrium (15) and performed 2 lines epi-endocardially using the AtriCure isolator synergy clamp (10 ablation actions): 1) line from the upper edge atriotomic incision to the base of the ear of the right atrium along the outer surface (line 11); 2) a line from the middle of the ear along the front wall of the right atrium to the anterior commissure of the tricuspid valve (line 12). Atrial fibrillation turned into atrial flutter with a cycle duration of 240 ms. The final step was the epi-endocardial ablation of the cavo-tricuspid isthmus of the heart (line 13) using an AtriCure isolator transpolar pen for linear bipolar radiofrequency ablation. Sinus rhythm recovered. The wall of the right atrium was sutured. Hollow veins were released to fill the heart with blood. An electrophysiological study was performed to confirm the bidirectional blockade of the impulse conduction along all completed lines. Superfrequent stimulation of the right and left atria caused atrial fibrillation, which stopped on its own within 9 seconds. Finished cardiopulmonary bypass. Temporary electrodes were sutured to the myocardium of the right ventricle (2 pieces) and the right atrium (2 pieces). Hemostasis. Healed the wound. The end of the operation.

The patient was discharged from the department on the 9th day after surgery in satisfactory condition. Sinus rhythm with a heart rate of 74 beats per minute. There were no hospital or operational complications.

When the patient appears for examination after 7 months, a sinus rhythm with a heart rate of 68 beats per minute is recorded. According to seven-day Holter ECG monitoring, atrial fibrillation was not detected.

Example 2

Patient B., 54 years old. From the anamnesis it is known that he considers himself a patient of the order of 6 years, when the paroxysmal form of atrial fibrillation was first detected. Antiarrhythmic therapy was prescribed with propanorm, sotalol without effect. After 3 years, catheter radiofrequency ablation (RFA) was performed - isolation of the pulmonary veins - with a relative effect (resumption of atrial fibrillation attacks after 4 months). After 4 months, repeated catheter RFA isolation of the pulmonary veins was performed with a similar result. Deterioration over the past 1.5 years, when the attack was not stopped by an attempt at medical cardioversion and continued until the operation. The patient is hospitalized for the surgical treatment of atrial fibrillation. According to the MSCT data of drugs and drugs, the volume of drugs, taking into account the abalone, was 140 ml. The anteroposterior size of the LP according to ECHO KG was 4.6 cm. The left ventricular EF was 52%. According to Holter ECG monitoring, the average heart rate per day was 112 beats per minute. The patient was prepared and delivered to the operating room at the rhythm of atrial fibrillation with ChES 118 beats per minute. Next, the operation of the proposed method. Sinus rhythm was restored by performing ablation of line 7. When trying to induce arrhythmia by hyperfrequent stimulation, arrhythmia is not caused.

The patient was discharged in satisfactory condition on the 7th day after the operation. There were no hospital or operational complications.

When the patient appears for examination after 6 months, a sinus rhythm with a heart rate of 71 beats per minute is recorded. According to seven-day Holter ECG monitoring, atrial fibrillation was not detected.

The authors performed 42 operations for the surgical treatment of atrial fibrillation in this way. There were no operational, hospital and long-term mortality and complications of the operation during the observation period (12 months).

The proposed method for the surgical treatment of atrial fibrillation is highly effective and safe in the treatment of the most difficult categories of patients: with persistent and long-existing persistent forms of atrial fibrillation, in patients after repeated ineffective catheter procedures, as well as in patients with increased volume and size of the left atrium, which, along with with the relative simplicity of the surgical aid, may be the basis for widespread use of the method in practical cardiac surgery: ntrah and clinics of cardiovascular surgery.

Claims (19)

1. The method of surgical treatment of atrial fibrillation, characterized in that the surgical intervention is carried out in the conditions of normothermic cardiopulmonary bypass, perform: epicardial ablation of the ganglia of the heart in the intercaval space, at the confluence of the left superior pulmonary vein into the left atrium; epicardial transmural ablation of the walls of the left atrium along the lines bordering the mouth of the right (line 1) and left (line 2) pulmonary veins, along the line passing along the posterior and anterior surface of the base of the left atrial ear (line 6), along the line from the left superior pulmonary vein to the base of the ear of the left atrium along the upper wall of the left atrium (line 7); epi-endocardial transmural ablation of the walls of the left atrium through the upper right pulmonary vein along a line located on the upper wall of the left atrium to the mouth of the left upper pulmonary vein (line 3) and the line from the said mouth to the mitral-aortic contact along the upper wall of the left atrium (line 9 ), through access in the intercaval space along the line located on the posterior wall of the left atrium to the mouth of the left lower pulmonary vein (line 4); then epicardially transmural ablation of the left atrial wall is performed, continuing line 3 to the fibrous ring of the aortic valve along the upper and then the front wall of the left atrium (line 8); in this case, closed contours of ablation lines in the left atrium are formed, connecting lines 1 and 2 with line 3 along the upper wall of the left atrium and line 4 on the posterior wall of the left atrium, line 7 is connected with line 2 and 6, lines 8 and 9 start from lines 2 and 1, respectively, and connected at the fibrous ring of the aortic valve in the left fibrous triangle of the heart; perform: atriotomy of the right atrium 3-5 cm long parallel to the border groove along the outer wall of the right atrium, resection of the ear of the right atrium; epi-endocardial transmural ablation of the walls of the right atrium along the line from the lower edge of the section to the mouth of the inferior vena cava along the outer wall of the right atrium, along the line from the upper edge of the section to the base of the ear of the right atrium along the outer wall of the right atrium, along the line from the middle of the base of the ear of the right atrium along its front wall to the anterior commissure of the tricuspid valve; epi-endocardial linear transmural ablation of the cavo-tricuspid isthmus; complete the intervention by suturing the wall of the right atrium. 2. The method according to p. 1, characterized in that the ablation of the ganglia of the heart is performed using an electrode for linear radiofrequency ablation. 3. The method according to p. 1, characterized in that the ablation of the ganglia of the heart in the intercaval space is supplemented by electrocoagulation. 4. The method according to p. 1, characterized in that the epicardial ablation of the walls of the left atrium along lines 1 and 2 is performed using a bipolar clamp for radiofrequency ablation, and the clamp is applied so that part of the atrium in the area of the mouth of the pulmonary veins is indented with 0.5-1 cm from them was between the branches with the clamp completely closed, and ablation along line 2 is performed after dislocation of the heart into the wound and dissection of the Marshall ligament. 5. The method according to p. 1, characterized in that the epi-endocardial ablation of the walls of the left atrium through the right superior pulmonary vein along lines 3 and 9 is performed using a bipolar clamp for radiofrequency ablation, while one of the jaws of the clamp is inserted into the heart cavity through the aforementioned right superior pulmonary vein. 6. The method according to p. 1, characterized in that the epi-endocardial ablation of the walls of the left atrium through access in the intercaval space along line 4 is performed using a bipolar clamp for radiofrequency ablation, while one of the branches of the clamp is inserted into the heart cavity through the access intercaval space. 7. The method according to claim 1, characterized in that access to the heart cavity through the right upper pulmonary vein is performed after preliminary application of a purse string suture around the heart wall incision, followed by its tightening around the jaw of the clamp for bipolar ablation inserted into the heart cavity. 8. The method according to p. 1, characterized in that access to the heart cavity in the intercaval space is performed after preliminary application of a purse string suture around the heart wall incision, followed by its tightening around the jaw of the clamp for bipolar ablation introduced into the heart cavity. 9. The method according to p. 1, characterized in that conduct an electrophysiological study to control the electrical insulation of the lines performed ablation.

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