The Impact of Radiofrequency Wide Circumferential Pulmonary Vein Isolation on Left Atrial Geometry in Patients with Recurrent Atrial Fibrillation.

PURPOSE: The aim of the study was to investigate the effect of wide area circumferential radiofrequency catheter ablation (WACA) pulmonary vein isolation on left atrium (LA) geometry. METHODS: Seventy-one patients underwent WACA, for recurrent paroxysmal (n = 31) and persistent (n = 40) atrial fibrillation (AF). A three-dimension rotational angiography of the LA was obtained immediately prior to index and repeat procedure. RESULTS: Significant reduction of LA volume (65.6 ± 14 mL/m2 vs. 62.2 ± 15 mL/m2, p < 0.001) and surface (74.4 ± 11.2 vs. 70.4 ± 11.2 cm2/m2, p < 0.001) was noted. LA sphericity increased significantly (82 ± 2% vs. 83 ± 2%, p = 0.004) in all 71 patients. Patients with paroxysmal AF showed significant reduction of LA volume (121.8 ± 25.7 vs. 116 ± 32 mL, p = 0.008) and increase of LA sphericity (82.3 ± 2.1 vs. 83.1 ± 2%, p = 0.009). Patients with persistent AF showed significant decrease of LA volume (133.5 ± 32 vs. 126 ± 32 mL, p = 0.005) and LA surface area (76.3 ± 12.3 vs. 71.8 ± 12.4 cm2/m2, p = 0.005). LA sphericity (82.4 ± 2.8 vs. 83 ± 2.4%, p = ns) remained unchanged. CONCLUSIONS: WACA results into significant reduction of LA volume and surface area. Increased LA sphericity is observed in paroxysmal AF only.

Clinical symptoms of limited exercise capacity linked to AAI-DDD functionality: An in silico and in vivo approach.

BACKGROUND: Exercise capacity is an important aspect of quality of life in patients undergoing pacemaker implantation. Device algorithms for ventricular pacing avoidance have been developed to avoid unnecessary and potentially harmful effects of right ventricular pacing. However, little data exists on the immediate response of these algorithms to sudden AV block during exercise. METHODS: The ventricular pacing avoidance algorithms of four pacemaker manufacturers were tested in an ex-vivo model. The RSIM-1500-USB Device-Interactive Heart Simulator (Rivertek Medical Systems, Inc.) was used to simulate three different scenarios: the first one starting with an initially conducted atrial pacing rate of 60 min-1 , the second one starting with an atrial rate of 120 min-1 and finally a scenario starting with an atrial rate of 150 min-1 . In all three scenarios, the initially conducted atrial rate was followed by a sudden, long lasting episode of third-degree AV-block. The response to those scenarios was recorded for each of the (brand-specific) ventricular pacing avoidance algorithms. RESULTS: In the first scenario, the simulation resulted in a ventricular pause of 1333 ms (Boston Scientific), 2000 ms (Medtronic and Microport), and 2340 ms (Biotronik). In the second and third scenario, different results were observed across devices. All simulations of the second and third scenario resulted in repetitive 2:1 block response (during eight cycles) in Boston Scientific and Biotronik devices. These scenarios were confirmed in patient cases. CONCLUSION: Simulator based observations of unanticipated pacemaker-induced 2:1 block response during exercise may explain clinical symptoms experienced by some patients having a two-chamber pacemaker.

High efficiency single-catheter workflow for radiofrequency atrial fibrillation ablation in the QDOT catheter era.

BACKGROUND: High-power short-duration (HPSD) ablation may improve the consistency and efficiency of pulmonary vein isolation (PVI). The novel QDOT Micro™ catheter (Biosense Webster, Inc.) with temperature feedback and microelectrodes aims to enhance PVI efficiency and safety. This study wants to evaluate the feasibility, safety, and efficiency of a standardized single-catheter workflow for PVI using QDOT (Q-FLOW). METHODS: The Q-FLOW includes single transeptal access, radiofrequency encircling of the PVs using a power of 50 W in a temperature/flow-controlled mode, and validation of the circles with microelectrodes. A 1:1 propensity-matched cohort of patients treated with conventional power-controlled ablation using a circular mapping catheter (CMC-FLOW) was used to compare procedural and clinical outcomes. RESULTS: A total of 150 consecutive atrial fibrillation patients (paroxysmal 67%, persistent 33%) were included. First-pass isolation rate was 86%. Procedural time, X-ray time, and dose were significantly lower for the Q-FLOW vs the CMC-FLOW (67.2 ± 17.9 vs 88.3 ± 19.2 min, P < 0.001; 3.0 ± 1.9 vs 5.0 ± 2.4 min, P < 0.001; 4.3 ± 1.9 vs 6.4 ± 2.3 Gycm2, P < 0.001). Complications were numerically but not significantly lower in the Q-FLOW group (2 [1.3%] vs 7 [4.7%], P = 0.091). There was no difference in arrhythmia recurrence at 12 months (atrial arrhythmia-free survival rate, 87.5% vs 84.4%, P = 0.565). CONCLUSION: A streamlined single-catheter workflow for PVI using QDOT was feasible and safe, resulting in a high rate of first-pass isolation and a low complication rate. The Q-FLOW further improved the efficiency of PVI compared to the standard CMC-FLOW, without difference in the 12-month outcome.

Current practice of ventricular tachycardia ablation in patients with implantable cardioverter-defibrillators.

We performed a survey on current practice of ventricular tachycardia (VT) ablation in patients with implantable cardioverter-defibrillators among the European Heart Rhythm Association Research Network. The main indication for the procedure is the occurrence of multiple shocks or electrical storm, while prophylactic ablation is only rarely performed. The epicardial approach is seldom used and mostly only after failure of endocardial ablation. The main ablation strategy is targeting the clinical VT only by substrate mapping and ablation, and by targeting fractionated potentials with utilization of modern electroanatomical mapping systems. Still, a considerable number of centres frequently perform the procedure using conventional mapping catheters only.

Adenosine plus dipyridamole: a novel strategy to enhance adenosine-induced conduction recovery after pulmonary vein isolation.

AIMS: Intravenous administration of adenosine after a pulmonary vein (PV) isolation procedure can unmask residual, so-called 'dormant', conduction that would otherwise remain unnoticed. Elimination of these dormant potentials is challenging because of the transient effect of adenosine, often requiring repeated injections. We tested the hypothesis that dipyridamole, a drug which inhibits adenosine deamination, can provoke longer-lasting unmasking of dormant conduction. METHODS AND RESULTS: In 191 patients with drug refractory paroxysmal atrial fibrillation, a bolus of 12-24 mg of adenosine was administered after all 764 PVs were isolated. In the case of transient dormant conduction, a short infusion of dipyridamole 50 mg was given and a bolus of adenosine was repeated. In all cases, re-isolation was attempted guided by the activation pattern in the PV on a circular mapping catheter. Duration of adenosine-induced dormant conduction before and after dipyridamole was recorded as the time between administration of adenosine and cessation of dormant conduction either spontaneously or by catheter ablation. Transient dormant conduction was re-established by a single bolus of adenosine in 24 of 191 patients (12.6%). Mean duration of adenosine-induced dormant conduction before dipyridamole was 13.1 ± 6.4 s, whereas it was significantly longer at 218.9 ± 165.6 s after dipyridamole (P < 0.0001). Eighteen of the 24 PVs were re-isolated by catheter ablation before spontaneous cessation of dormant conduction, and in 6 cases dormant conduction disappeared spontaneously before PV re-isolation was achieved. CONCLUSION: Dipyridamole significantly prolongs the effect of adenosine to unmask dormant conduction after PV isolation and may thus facilitate its elimination by catheter ablation.

Catheter Ablation of Atrial Fibrillation in Patients with Previous Lobectomy or Partial Lung Resection: Long-Term Results of an International Multicenter Study.

INTRODUCTION: Data regarding the efficacy of catheter ablation in patients with atrial fibrillation (AF) and patients' previous history of pulmonary lobectomy/pneumonectomy are scanty. We sought to evaluate the efficacy and long-term follow-up of catheter ablation in this highly selected group of patients. MATERIAL AND METHODS: Twenty consecutive patients (8 females, 40%; median age 65.2 years old) with a history of pneumonectomy/lobectomy and paroxysmal or persistent AF, treated by means of pulmonary vein isolation (PVI) at ten participating centers were included. Procedural success, intra-procedural complications, and AF recurrences were considered. RESULTS: Fifteen patients had a previous lobectomy and five patients had a complete pneumonectomy. A large proportion (65%) of PV stumps were electrically active and represented a source of firing in 20% of cases. PVI was performed by radiofrequency ablation in 13 patients (65%) and by cryoablation in the remaining 7 cases. Over a median follow up of 29.7 months, a total of 7 (33%) AF recurrences were recorded with neither a difference between patients treated with cryoablation or radiofrequency ablation or between the two genders. CONCLUSIONS: Catheter ablation by radiofrequency ablation or cryoablation in patients with pulmonary stumps is feasible and safe. Long-term outcomes are favorable, and a similar efficacy of catheter ablation has been noticed in both males and females.

Screening for, and management of, possible arrhythmogenic syndromes (channelopathies/ion channel diseases).

This survey assesses the current management strategies for individuals with electrocardiographic features, suggesting an arrhythmogenic syndrome [including long QT syndrome (LQTS), Brugada syndrome (BS), catecholaminergic polymorphic ventricular tachycardia (CPVT) or short QT syndrome] or family members of patients with a known arrhythmogenic syndrome, in 44 large European centres. The principal findings of this survey were: (i) the number of new patients with arrhythmogenic syndromes (symptomatic and asymptomatic) is relatively small; (ii) the clinical work-up of these patients consists mainly of non-invasive tests; (iii) a relatively high use of genetic testing is noted, especially in LQTS and CPVT; (iv) EP testing is commonly performed in asymptomatic BS patients and in family members of symptomatic BS patients; and (v) the majority of European electrophysiologists focus on first-degree relatives when dealing with family members of an index patient.

Ablation of a therapy-resistant posteroseptal accessory atrioventricular pathway: going for gold.

Posteroseptal accessory pathways are sometimes resistant to ablation because of the complex anatomy of this region. Ex-vivo experiments have demonstrated that gold-tip radiofrequency ablation catheters create deeper lesions than conventional platinum-iridium tip catheters. This case of a 62-year-old man with Wolf-Parkinson-White syndrome illustrates that the ability to create such lesions can be a very useful option when previous attempts with platinum-iridium tip catheters have failed.

The industrialization of ablation: a highly standardized and reproducible workflow for radiofrequency ablation of atrial fibrillation.

BACKGROUND OR PURPOSE: The purpose of this analysis was to report on efficacy of a standardized workflow for atrial fibrillation (AF) ablation using technology advances such as 3D imaging and contact force sensing in a real-world setting. METHODS: Consecutive AF ablations from 2014 to 2015 at a high-volume site in Belgium were included. The workflow consisted of a pre-specified procedure sequence including 3D modeling followed by radiofrequency encircling of the pulmonary veins (25 W posterior wall, 35 W anterior wall) with a THERMOCOOL SMARTTOUCH® Catheter guided by CARTO VISITAG™ Module (2.5 mm/5 s stability, 50% > 7 g) and ablation index (targets: 550 anterior wall, 400 posterior wall). Efficiency endpoints were procedure time, fluoroscopy time, and radiation dose. The primary effectiveness endpoint was freedom from atrial arrhythmia recurrence. RESULTS: A total of 605 paroxysmal AF (PAF) and 182 persistent AF (PsAF) patients were followed for 436 ± 199 days. Mean procedure times were short (PAF: 96.1 ± 26.2 min; PsAF: 109.2 ± 35.6 min) with most procedures (90.6% PAF; 81.3% PsAF) completed in ≤ 120 min. Minimal fluoroscopy was utilized (PAF: 6.1 ± 3.8 min, 5.9 ± 3.4 Gy*cm2; PsAF: 6.9 ± 4.7 min, 7.4 ± 4.9 Gy*cm2). Freedom from atrial arrhythmia recurrence was higher for PAF than PsAF patients (OR: 2.0, 95% CI: 1.4-2.9, p = 0.0003), but adjusted mean rates were high in both groups (81.0% vs. 67.9%). Rates were adjusted for prior ablation and age (at 65 years). CONCLUSION: AF ablation using a standardized workflow resulted in low procedure times and variability, with minimal fluoroscopy exposure. Long-term freedom from atrial arrhythmia recurrence was high in both PAF and PsAF populations.

Performance and survival of transvenous defibrillation leads: need for a European data registry.

Although the use of implantable cardioverter defibrillator (ICD) therapy has increased over the last decades, the reporting of ICD lead performance is inadequate. So far, there is neither a European nor worldwide registry on ICD leads. The published long-term results from national or multicentre registries encompass relatively small patient cohorts. Nevertheless, the failure of ICD leads may have substantial clinical consequences, including failure to sense, failure to pace, failure to defibrillate, inappropriate shocks, and even death of the patient. The reported ICD lead survival varies significantly between studies: 91-99% at 2 years, 85-95% at 5 years, and 60-72% at 8 years. Thus, the true incidence of lead malfunction cannot be defined as outlined in the present review. One current initiative of the European Heart Rhythm Association is to initiate and develop a Europe-wide registry to monitor, over a prolonged follow-up period, the performance of ICDs and ICD leads.

Novel use of a subcutaneous shock lead to create an epicardial implantable cardioverter/defibrillator system via a limited thoracotomy.

We report the case of a novel use of a subcutaneous shock lead to create an epicardial implantable cardioverter/defibrillator (ICD) system via a limited thoracotomy in a patient with poor vascular access. Performance of the system is comparable to the conventional ICD system without the disadvantages of other available epicardial ICD systems.

Twiddling with an implantable cardioverter-defibrillator.

A 64-year-old woman underwent implantation of a single-chamber implantable cardioverter-defibrillator. The active fixation lead was positioned in the right ventricular apex and the generator in a left pre-pectoral pocket. Device interrogation 4weeks after implantation revealed inappropriate sensing and failure of pacing. A chest X-ray showed the entire lead coiled behind the device. The patient admitted manipulating the device and a diagnosis of Twiddler's syndrome was made. After repositioning the lead, the generator was re-located in the sub-pectoral position to help prevent recurrence by reducing the ability to externally manipulate the device.

Intensive recreational athletes in the prospective multinational ICD Sports Safety Registry: Results from the European cohort.

BACKGROUND: In the ICD Sports Safety Registry, death, arrhythmia- or shock-related physical injury did not occur in athletes who continue competitive sports after implantable cardioverter-defibrillator (ICD) implantation. However, data from non-competitive ICD recipients is lacking. This report describes arrhythmic events and lead performance in intensive recreational athletes with ICDs enrolled in the European recreational arm of the Registry, and compares their outcome with those of the competitive athletes in the Registry. METHODS: The Registry recruited 317 competitive athletes ≥ 18 years old, receiving an ICD for primary or secondary prevention (234 US; 83 non-US). In Europe, Israel and Australia only, an additional cohort of 80 'auto-competitive' recreational athletes was also included, engaged in intense physical activity on a regular basis (≥2×/week and/or ≥ 2 h/week) with the explicit aim to improve their physical performance limits. Athletes were followed for a median of 44 and 49 months, respectively. ICD shock data and clinical outcomes were adjudicated by three electrophysiologists. RESULTS: Compared with competitive athletes, recreational athletes were older (median 44 vs. 37 years; p = 0.0004), more frequently men (79% vs. 68%; p = 0.06), with less idiopathic ventricular fibrillation or catecholaminergic polymorphic ventricular tachycardia (1.3% vs. 15.4%), less congenital heart disease (1.3% vs. 6.9%) and more arrhythmogenic right ventricular cardiomyopathy (23.8% vs. 13.6%) ( p < 0.001). They more often had a prophylactic ICD implant (51.4% vs. 26.9%; p < 0.0001) or were given a beta-blocker (95% vs. 65%; p < 0.0001). Left ventricular ejection fraction, ICD rate cut-off and time from implant were similar. Recreational athletes performed fewer hours of sports per week (median 4.5 vs. 6 h; p = 0.0004) and fewer participated in sports with burst-performances ( vs. endurance) as their main sports: 4% vs. 65% ( p < 0.0001). None of the athletes in either group died, required external resuscitation or was injured due to arrhythmia or shock. Freedom from definite or probable lead malfunction was similar (5-year 97% vs. 96%; 10-year 93% vs. 91%). Recreational athletes received fewer total shocks (13.8% vs. 26.5%, p = 0.01) due to fewer inappropriate shocks (2.5% vs. 12%; p = 0.01). The proportion receiving appropriate shocks was similar (12.5% vs. 15.5%, p = 0.51). Recreational athletes received fewer total (6.3% vs. 20.2%; p = 0.003), appropriate (3.8% vs. 11.4%; p = 0.06) and inappropriate (2.5% vs. 9.5%; p = 0.04) shocks during physical activity. Ventricular tachycardia/fibrillation storms during physical activity occurred in 0/80 recreational vs. 7/317 competitive athletes. Appropriate shocks during physical activity were related to underlying disease ( p = 0.004) and competitive versus recreational sports ( p = 0.004), but there was no relation with age, gender, type of indication, beta-blocker use or burst/endurance sports. The proportion of athletes who stopped sports due to shocks was similar (3.8% vs. 7.5%, p = 0.32). CONCLUSIONS: Participants in recreational sports had less frequent appropriate and inappropriate shocks during physical activity than participants in competitive sports. Shocks did not cause death or injury. Recreational athletes with ICDs can engage in sports without severe adverse outcomes unless other reasons preclude continuation.

Left atrial volume computed by 3D rotational angiography best predicts atrial fibrillation recurrence after circumferential pulmonary vein isolation.

Left atrium (LA) size is a well-studied predictor of atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). Yet, there is still little agreement on the best imaging technique to size the LA, and on the most appropriate sizing parameter. Volumetric assessment of LA with three-dimensional rotational angiography (3DRA LA volume index) might be a valid alternative to the commonly used transthoracic echocardiography (TTE LA volume index). The aim of our study was to investigate whether LA volume by 3DRA at the time of PVI is able to predict the risk of atrial fibrillation recurrence. We analysed 352 consecutive patients with symptomatic paroxysmal or persistent atrial fibrillation referred for PVI to our Institution. In all patients, LA volume index (LAVI) was assessed by TTE and by 3DRA. Sinus rhythm was restored after PVI in 348 patients (99%). Average TTE-LAVI and 3DRA-LAVI were 37 ± 12 and 83 ± 18 ml/m2, respectively. At a median follow-up of 19 (12, 24) months, 27% of patients had AF recurrence after the first PVI. At the univariate analysis, persistent AF (p < 0.01), use of anti-arrhythmic drugs (AAD) (p < 0.05) and 3DRA-LAVI (p < 0.01) were significantly associated with AF recurrence. In contrast, none of the echocardiographic parameters considered, including TTE-LAVI, was associated with AF recurrence (p = 0.29). At the multivariate analysis, 3DRA-LAVI was the only independent predictor for AF recurrence (HR 1.01 [1.00-1.03], p = 0.017). Left atrial volume measured with 3DRA is superior to TTE assessment and to AF history in predicting atrial fibrillation recurrence after PVI.

Improvement of left ventricular function after cardiac resynchronization therapy is predicted by tissue Doppler imaging echocardiography.

BACKGROUND: Cardiac resynchronization therapy was shown to reverse left ventricular (LV) remodeling in patients with congestive heart failure (CHF). However, the prediction of benefit is controversial. We aimed to investigate predictive factors of LV functional recovery and reversed remodeling after biventricular pacing. METHODS AND RESULTS: Forty-nine consecutive patients with CHF and a wide QRS complex (182+/-32 ms) were studied by echocardiography before resynchronization. Intraventricular and interventricular asynchrony and their combination were assessed by pulsed-wave tissue Doppler imaging from measurements of regional electromechanical coupling times in basal segments of the right and left ventricle. At 6-month follow-up, responders were defined by a relative increase in LV ejection fraction > or =25% compared with baseline (n=27). Receiver operating curve analysis revealed the degree of intraventricular asynchrony (area under the curve=0.77), interventricular asynchrony (area under the curve=0.69), and their combination (area under the curve=0.84) as the best predictors of functional recovery after resynchronization. In addition, the degree of intraventricular and interventricular asynchrony correlated significantly with the improvement of LV ejection fraction (r=0.73, P<0.0001), end-diastolic diameter (r=-0.59, P<0.0001), and end-systolic diameter (r=-0.48, P<0.001) at follow-up. QRS duration and conventional echo-Doppler indices were not predictive of reversed LV remodeling. CONCLUSIONS: In patients with CHF, the degree of intraventricular and interventricular asynchrony and their combination are the best predictive factors of LV functional recovery and reversed remodeling after cardiac resynchronization therapy.

Recurrent cardiac events in patients with idiopathic ventricular fibrillation, excluding patients with the Brugada syndrome.

BACKGROUND: The recurrence of cardiac events in patients with idiopathic ventricular fibrillation (VF) excluding patients with the Brugada syndrome is unclear since this entity remains present in previous studies. METHODS: Since 1992, 18 patients (72% male) with idiopathic VF out of 455 ICD implants were treated with an implantable cardioverter defibrillator (ICD). The mean age at first ICD implantation was 42 +/- 14 years. Brugada syndrome, as well as other primary electrical diseases (e.g. long QT), were systematically excluded in all patients by the absence of the typical electrocardiogram (ST elevation in the right precordial leads) at rest and/or after pharmacological tests (ajmaline, flecainide, or procainamide). Recurrence of cardiac events was prospectively assessed. RESULTS: During a mean follow-up period of 41 +/- 27 months, VF recurrence with appropriate shock occurred in 7 patients (39%) covering a total of 27 shocks. The median time to first appropriate shock was 12 +/- 9 months. There were no deaths. In the electrophysiological study, 39% of patients were inducible, but inducibility failed to predict subsequent arrhythmic events. Forty-four percent of patients suffered 21 inappropriate shocks, which were caused by sinus tachycardia, atrial arrhythmias or lead malfunction. CONCLUSION: Idiopathic ventricular fibrillation patients have a high recurrence rate of potentially fatal ventricular arrhythmias, excluding patients with the Brugada syndrome or other known causes. ICD prevents sudden cardiac death but inappropriate shocks remained a major issue in this young and active population.

Tailored echocardiographic interventricular delay programming further optimizes left ventricular performance after cardiac resynchronization therapy.

BACKGROUND: The aim of cardiac resynchronization therapy is correction of left ventricular (LV) dyssynchrony. However, little is known about the optimal timing of LV and right ventricular (RV) stimulation. OBJECTIVES: The purpose of this study was to evaluate the acute hemodynamic effects of biventricular pacing, using a range of interventricular delays in patients with advanced heart failure. METHODS: Twenty patients with dilated ischemic (n = 12) and idiopathic (n = 8) cardiomyopathy (age 66 +/- 6 years, New York Heart Association class III-IV, LV end-diastolic diameter >55 mm, ejection fraction 22% +/- 18%, and QRS 200 +/- 32 ms) were implanted with a biventricular resynchronization device with sequential RV and LV timing (VV) capabilities. Tissue Doppler echocardiographic parameters were measured during sinus rhythm before implantation and following an optimal AV interval with both simultaneous and sequential biventricular pacing. The interventricular interval was modified by advancing the LV stimulus (LV first) or RV stimulus (RV first) up to 60 ms. For each stimulation protocol, standard echocardiographic Doppler and tissue Doppler imaging (TDI) echo were used to measure the LV outflow tract velocity-time integral, LV filling time, intraventricular delay, and interventricular delay. RESULTS: The highest velocity-time integral was found in 12 patients with LV first stimulation, 5 patients with RV first stimulation, and 3 patients with simultaneous biventricular activation. Compared with simultaneous biventricular pacing, the optimized sequential biventricular pacing significantly increased the velocity-time integral (P <.001) and LV filling time (P = .001) and decreased interventricular delay (P = .013) and intraventricular delay (P = .010). The optimal VV interval could not be predicted by any clinical nor echocardiographic parameter. At 6-month follow-up, the incidence of nonresponders was 10%. CONCLUSION: Optimal timing of the interventricular interval results in prolongation of the LV filling time, reduction of interventricular asynchrony, and an increase in stroke volume. In patients with advanced heart failure undergoing cardiac resynchronization therapy, LV hemodynamics may be further improved by optimizing LV-RV delay.

Combined atrial fibrillation and mitral valve surgery using radiofrequency technology.

Recently, intraoperative radiofrequency ablation of the left atrium combined with mitral valve surgery has become widely used. In our center, 30 patients underwent this combined procedure; median sternotomy was used in 16 patients, and port access was used in 14 patients. At hospital discharge, 18 patients (60%) were no longer in atrial fibrillation, and at 6 months, 19 patients (65%) remained in sinus rhythm. All sinus rhythm patients had a well-defined transmitral A wave detectable by echocardiography. One patient sustained a major stroke. Two patients required pacemaker implantation. Such encouraging preliminary results have triggered worldwide interest in the percutaneous and surgical treatment of atrial fibrillation. However, the excellent long-term results with the classic Cox-Maze III operation have not yet been achieved with these newer approaches. Further basic and clinical research is required before a predictable simple and safe technique can be introduced as a new standard for the surgical treatment of atrial fibrillation in patients with or without structural heart disease.