Federico Milla, MD, Nikolaos Skubas, MD, William M

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Date of download: 6/25/2016 Copyright © The American College of Cardiology. All rights reserved. From: Mechanism, localization and cure of atrial arrhythmias.

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Epicardial beating heart cryoablation using a novel argon-based cryoclamp and linear probe Federico Milla, MD, Nikolaos Skubas, MD, William M. Briggs, MS, PhD, Leonard N. Girardi, MD, Leonard Y. Lee, MD, Wilson Ko, MD, Anthony J. Tortolani, MD, Karl H. Krieger, MD, O. Wayne Isom, MD, Charles A. Mack, MD The Journal of Thoracic and Cardiovascular Surgery Volume 131, Issue 2, Pages 403-411 (February 2006) DOI: 10.1016/j.jtcvs.2005.10.048 Copyright © 2006 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Clamp (A), linear probe (B), and assembled cryoclamp device (C). The Journal of Thoracic and Cardiovascular Surgery 2006 131, 403-411DOI: (10.1016/j.jtcvs.2005.10.048) Copyright © 2006 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Diagram of a canine heart with the cryoablation lesion-set. The left side of the image demonstrates the posterior side of the heart and the lesions performed on the left atrium. The right side of the image demonstrates the anterior view of the heart and right atrium. Circles represent cryoclamp lesions; lines represent linear cryolesions. The Journal of Thoracic and Cardiovascular Surgery 2006 131, 403-411DOI: (10.1016/j.jtcvs.2005.10.048) Copyright © 2006 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 A, Intraoperative view of the clamp device performing a cryolesion at the base of the left atrial appendage (large black arrow). B, The cryoclamp was then disassembled and the linear probe was used to ablate the right atrial appendage (black arrow head). The Journal of Thoracic and Cardiovascular Surgery 2006 131, 403-411DOI: (10.1016/j.jtcvs.2005.10.048) Copyright © 2006 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Magnetic resonance imaging with axial (A) and coronal (B) views of the right superior pulmonary vein (white arrow). No evidence of pulmonary vein stenosis is seen. The Journal of Thoracic and Cardiovascular Surgery 2006 131, 403-411DOI: (10.1016/j.jtcvs.2005.10.048) Copyright © 2006 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 A, Gross picture of the right pulmonary vein as seen from within the left atrium. Large black arrow points at the cryoclamp lesion completely encircling the opening of the RPV leading to complete conduction block. B, Histologic slide of the cryoclamp lesion stained with Masson’s trichrome. Large black arrow points at the transmural lesion. Black arrowhead shows the transition of left atrium to pulmonary vein. Viable cardiac muscle stains red, while connective tissue stains blue. The Journal of Thoracic and Cardiovascular Surgery 2006 131, 403-411DOI: (10.1016/j.jtcvs.2005.10.048) Copyright © 2006 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Histologic cross sections of linear epicardial lesions performed with the 10 cm malleable probe on both right and left atria. Tissue sections are stained with Masson’s trichrome. Blue color demonstrates fibrotic scar tissue, and red stain shows viable myocardium. Solid arrow points to viable myocardium within the lesion. A, Left atrial appendage to left pulmonary veins connecting lesion (LAA con) demonstrating complete transmurality. B, Right atrial appendage lesion (RAA) demonstrating areas of viable myocardium in the trabeculated regions of the appendage. C, Superior vena cava to inferior vena cava lesion (SVC to IVC) demonstrating a region at the mid-portion of the lesion with viable myocardium. D, Tricuspid flutter lesion with subendocardial sparing. Arrow points to the nontransmural segment. The Journal of Thoracic and Cardiovascular Surgery 2006 131, 403-411DOI: (10.1016/j.jtcvs.2005.10.048) Copyright © 2006 The American Association for Thoracic Surgery Terms and Conditions

Figure 7 Histologic longitudinal sections of cryolesions extending from the left inferior pulmonary vein across the coronary sinus and mitral valve annulus. Tissue sections are stained with Masson’s trichrome. Blue color demonstrates fibrotic scar tissue, and red stain shows viable myocardium. A, Nontransmural lesion showing fibrotic replacement along the epicardium, with subendocardial sparing. Partial ablation of the CS. B, Transmurality seen only in the right-most portion of the lesion, including the CS. Atrial tissue below the investing fat has been completely spared. Black areas represent artifact. C, Transmural ablation of nearly the entire lesion, including the CS. Atrial tissue below the CS has been spared. D, Nontransmural ablation of the right portion of the lesion and the CS. E, Transmural ablation of the CS and the tissue below the CS. Atrial tissue to the right and left of the CS has been spared completely. F, Transmural ablation of the right portion of the slide. The CS and atrial tissue below the investing fat have been spared completely. A, Atrium; CCA, circumflex coronary artery; CS, coronary sinus; MV, mitral valve; V, ventricle. The Journal of Thoracic and Cardiovascular Surgery 2006 131, 403-411DOI: (10.1016/j.jtcvs.2005.10.048) Copyright © 2006 The American Association for Thoracic Surgery Terms and Conditions