Anatomic aspects of the atrioventricular junction influencing radiofrequency Cox maze IV procedures Manuel Castellá, MD, PhD, Antonio García-Valentín,

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Anatomic aspects of the atrioventricular junction influencing radiofrequency Cox maze IV procedures Manuel Castellá, MD, PhD, Antonio García-Valentín, MD, Daniel Pereda, MD, Andrea Colli, MD, Antonio Martinez, MD, Daniel Martinez, MD, José Ramirez, MD, Jaime Mulet, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 136, Issue 2, Pages 419-423 (August 2008) DOI: 10.1016/j.jtcvs.2008.03.049 Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Similar line patterns, different type of lesions: Images 1 to 3 show the lines described by Cox in the cut-and-sew Cox maze III technique. Images A, B, and C show the pattern for a Cox maze IV, combining incisions and bipolar radiofrequency ablation (dotted lines). This lesion set was performed in the ninth heart studied. LAA, Left atrial aappendage; MV, mitral valve; CS, coronary sinus. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 419-423DOI: (10.1016/j.jtcvs.2008.03.049) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Two examples of left dominant coronary circulation. A, Inferior aspect of the heart, where both the coronary sinus (with pick-ups inside) and the circumflex artery run in the atrial side of the atrioventricular junction. B, A heart with a dominant circumflex artery (Cx) that it is been cut together with the coronary sinus (CS) to reach the mitral annulus. MPL, Mitral posterior leaflet. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 419-423DOI: (10.1016/j.jtcvs.2008.03.049) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Radiofrequency bipolar clamp positioned to carry out the ablation line from the left auriculotomy to the mitral annulus. The clamp is placed as close as possible to reach the annulus at the level of P2 of the posterior leaflet. The maximum level of positioning is dictated by the ventricular muscle mass that impedes clamping further at the epicardial side. Nevertheless, the coronary sinus (CS) is compromised within the clamp. The posterolateral artery (PL) of the right coronary can be seen in its epicardial path. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 419-423DOI: (10.1016/j.jtcvs.2008.03.049) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 The radiofrequency clamp is positioned to reach the tricuspid annulus. Limited by the right coronary artery in the epicardial side (A), the endocardial jaw of the clamp does not reach the annulus (B). In a side view (C) the arrows show the atrial myocardium from the electrodes to the annulus that is free from the thermal ablation. TAL, Tricuspid anterior leaflet. The Journal of Thoracic and Cardiovascular Surgery 2008 136, 419-423DOI: (10.1016/j.jtcvs.2008.03.049) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Complement C9 immunostaining of the posterior wall of the left atrium showing transmural necrosis approximately 8 hours after ablation was performed (original magnification ×20). Inset, Zoomed view in the left inferior corner of a section of the same picture (original magnification ×200). The Journal of Thoracic and Cardiovascular Surgery 2008 136, 419-423DOI: (10.1016/j.jtcvs.2008.03.049) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions