CHAPTER 1

My name is Marco Zenati, I’m a cardiac surgeon at the VA Boston. I serve as Division Chief. I'm also a Professor of Surgery at Harvard Medical School and an Associate Surgeon at Brigham and Women’s Hospital. So today's case will be a complex, combined procedure including a full biatrial Cox-Maze IV and mitral valve repair or replacement, and a single vessel CABG with mammary to LAD. So this gentleman suffered from congestive heart failure for - for many years, recent worsening effort intolerance and shortness of breath, transition from class II to class III, and he was really keen on getting relief of symptomatic and also life prolongation because in the course of the workup, we found he had a very tight, 95% stenosis of the left anterior descending coronary artery.

So the procedure will involve a little bit of kind of going back and forth between the procedure because we don't complete the full MAZE and then move to the mitral and the CABG. We kind of do part of the MAZE and then we go back. The reason being that we try to - because it’s a long and complex procedure - to minimize the global ischemic time to the heart, and to do so, we are going to do procedure - part of the procedure - on the beating heart prior to stopping it. So of course, you know, this is open heart surgery; requires a full median sternotomy, requires cardiopulmonary bypass, and requires opening of both left and right atrium.

Specifically, the MAZE procedure that we are going to perform today is the most recent evolution of the procedure that was developed by Dr. Jim Cox, first in the 1980s and then perfected to what we call the Cox-MAZE III in the 1990s. Today's procedure is the most recent evolution of that original Cox-MAZE III, we call it Cox-MAZE IV, and the major difference compared to Dr. Cox’s teaching is that the majority of the lesions that we create on both left and right atrium are created using alternative energy rather than a surgical incision that requires a suture to close it. And specifically we are going to be using a combination of radio frequency energy and cryoablation.

The procedure will be a biatrial Maze, both left and right atria will be treated, and fundamentally, there are four components of the Cox-Maze IV: one, which is the mainstay, is bilateral pulmonary vein isolation, and this will be performed using a bipolar radiofrequency clamp; the second component is the right atrial lesions of the Cox-Maze, which we'll target at right atrium and the right isthmus; and the third component is the left atrial lesions of the Maze, the most important part because atrial fibrillation is originating primarily from left atrium and is designed to interrupt large reentry circuits. The fourth component is the treatment of the left atrial appendage. 90% of patients that have a stroke, a cardioembolic stroke, secondary to atrial fibrillation, have a thrombus in the appendage, so it is paramount to to treat it. There are several ways to do it. Today we plan to use a left atrial appendage clip that has to be placed carefully at the base and completely exclude the appendage from the circulation.

CHAPTER 2

Incision!

So the first part of the procedure, this is a full median sternotomy. The first part of the procedure will be the harvesting of the conduit for the bypass, so we’ll - we’ll do the median sternotomy, followed by the mammary harvest. And we'll do that using a skeletonization technique.

[Resident]: And why are we skeletonizing this mammary?

Well it’s my preferred technique. I like to do it actually for everybody. But as you… with this yesterday, it's especially important when you do bilateral mammary. I think that it's the best technique, and I use it routinely.

[Resident]: Especially on a younger patient, or diabetic?

The data supports skeletonization, actually for - for all patients.

[Resident]: For all patients?

Yeah.

[Resident]: Even non-diabetics?

Yeah.

[Resident]: It also helps with length, right?

Yeah, so the advantages are length, so you - you never have an issue of reaching a distal target. If you have to do a sequential graft or a composite, it’s much easier when you have the mammary without any surrounding muscle tissue. And also devascularization of the sternum is - is better.

So what’s this hematoma from? A cath or something? The right-heart cath?

[Resident]: Maybe. Oh you know what, he has all these hematomas after he had his teeth removed, but I don't know what that’s from. Ecchymosis on his cheek or his abdomen.

We’re gonna go deeper. I just stay on top of here.

[Resident]: Divide the ligament?

It is the deep cervical fascia. There's no ligament.

[Resident]: So it’s important to stay midline?

Yeah and I - I feel the interspace is here as I go down.

Okay, saw. The lungs down please. Okay, lungs up. Tidal volume 450 please. Okay, Okay, Army-Navy.. Vanco paste.

So the next step, I will sit down and will perform the left internal mammary harvest using a skeletonization technique, that's a preferred technique especially when bilateral mammary surgery is performed. We use a Vancomycin paste as a hemostatic agent and also provide topical antibiotic coverage. Okay, good. So take a - you want to step back -- and I'll take a Rultract.

CHAPTER 3

So this completes the median sternotomy part of the procedure, and now we move to the harvest of the left internal mammary artery. There are two of these mammary arteries running inside the chest wall - one to the left, one of the right - right - we are going to mobilize the one in the left. We need a special retractor to expose the internal chest wall.

[Resident]: I’m gonna watch him skeletonize the mammary so I'm going to go to the other side.

So the first step is to expose the internal chest wall on the left side. We mobilize this fat and pleura in order to provide optimal exposure. It’s very important to have a comfortable position for the surgeon with the head aligned with the mammary. So we enter routinely the pleura - the left pleural space. This is the left lung, and you can see the inside of the chest - of the left chest. This is the preferred conduit to revascularize the left anterior descending. It's an arterial conduit with excellent long-term patency by 95% to 10 years. So the first step is to, again provided a nice dry exposure to the - the anterior chest wall. And you - we can see now the mammary artery and the two veins that run parallel to it. So normally the harvest, called the pedicle harvest, will take fascia, muscle, and both veins with the artery. It will create a very large pedicle. That's the standard technique. This technique instead harvests the artery itself without any surrounding vessels or tissue. So we start by identifying the artery and then grabbing the fascia right underneath. The Bovie is a very low 15 to 20 joules. Then we start by incising the fascia and following the course of the mammary. Keep it dry.

So a very short burst of cautery, then we can use the tip as a spatula once it cools. So you have to be careful not to apply the tip of the cautery immediately after using for cutting to avoid thermal injury to the mammary.

[Resident]: So do you skeletonize also in patients who are non-diabetics?

I do. Because as I said, it does preserve blood flow to the chest wall better and provide extra length, up to an inch extra length. So it allows me never to worry about not reaching my target. We try to avoid manipulation - direct manipulation of the mammary as much as possible - use the adventitia. You can see the mammary now starting to show up underneath the fascia. I tried to stop right before the bifurcation between the superior epigastric and the pericardial phrenic, because beyond that location, the media of the mammary artery becomes more muscular while the rest is mostly elastic, and that's what provides long-term patency as a conduit. The fact that there's a little muscular component. And also the mammary has this property of pretty much never getting athersclerotic disease. You can have patients with severe perivascular disease, amputations, severe diabetic disease and pretty much always the mammary is pristine. You have noticed that in your practice, I'm sure. And that is because the endothelium of the mammary has the properties of releasing nitric oxide at a much higher rate that's protective. So it is a special, special conduit and it actually provides protection to the distal vessels once it’s used as a bypass conduit.

[Resident]: Does the radial artery have the same properties?

To a lesser extent. The radial artery has very thick muscular media so that makes it less desirable. So by far the left internal mammary artery and also the right are better conduits. So I'm using a high-quality micro clip. The first clip, to divide branches, is applied flush with the artery, and the other one is a short distance away. Then we use a scissor to divide in between. So this technique allows collateral circulation from the intercostal arteries from different interspaces to be preserved while it is interrupted with the pedicle technique as you know. See we’re starting to develop the artery. There is a branch coming up in front of us. So another clip please. And you see that then my exposure is obtained by grabbing on adventitia, never holding on the vessel itself. A clip nicely applied flush with the artery - another short distance away and the tenotomy scissors and a nice sharp dissection. So basically it's cut, clip, clip, cut, clip, clip, cut. You see we’re developing and the vessel is coming out by itself without any surrounding muscle or vein. So this is a technique that you have to do, but you cannot rush so I would not use it on an emergency case. You have to be able to kind of take your time. Proceed, you know, expeditiously but without rushing because this conduit is very important for the patient so you want to minimize the risk of damaging the conduit. So this technique is more involved. It's a little more complex than the pedicle, but it can be taught and is very reproducible. And again, it's mandatory if you were going to do multi-arterial-like bilateral mammary revascularization. If that's your practice, you’re going to have to use this technique. Although, as you know, the recent five-year data published in New England Journal of Medicine on the ART trial, did not show superiority of the bilateral mammary approach. You familiar with the ART trial? Kelly?

[Trial mentioned: http://www.nejm.org/doi/full/10.1056/NEJMoa1610021#t=article]

[Resident]: I’m familiar with it, but I don’t know the details of it.

Dr. Taggert actually was a lecturer at Harvard. So it was just published in the New England Journal of Medicine. So they randomized patients to either single mammary and vein or bilateral mammary and vein. And they gonna continue the follow-up to 10 years,, but the one-year and five-year data did not show a difference for the chosen primary outcome measure, which was a composite of major adverse cardiac events. So that kinda dampened a little bit the enthusiasm, but we’ll have to see the long term data.

So as you can see I'm developing the conduit, you know, I'm always applying indirect tension on the mammary. There's another branch back there. I'm going to clean surrounding issue. Clip please.

[Resident]: So when you take it as a pedicle, you still divide these branches. How is this different from taking it and preserving the blood flow to the chest wall?

Yeah, so this is an excellent question. Where you divide the branches will be probably down here as opposed to right next to the artery, so this way this branch and the branch above remain connected to a network based on the intercostal arteries. So intercostal arteries run below each rib and currently are connected to the mammary and to the intercostal artery above and below. If you divide with the pedicle at this level, you will interrupt them. If you let - divide the branch at this level, you will not interrupt them, so that is the difference. Make sense?

[Resident]: Yes.

So this is the xiphoid and pretty much at this level, you expect the mammary to bifurcate into the two terminal branches, the superior epigastric and the pericardial phrenic. So I'm going to go just a little bit more distal here and then I'm going to stop for the distal harvest. See we're trying to keep a dry field, no bleeding, so I have a very good exposure. There’s another branch back there I'm going to divide. Clip please. So this - our technique requires high-quality instruments like this, so we have to really have dedicated clip appliers and very, the best you can get in order to perform this approach. Sometimes the mammaries are routed below the aorta in the transverse sinus, and, you know, you have to be really sure that these clips are applied correctly, because once the mammary is routed, the transverse sinus is very difficult to access for repair in case of bleeding. You see the bifurcation here? Superior epigastric and pericardial phrenic - so we are going to divide and actually leave this bifurcation patent and divide just above. Make sense? You see the bifurcation. We're going to keep this patent, so we're going to put the clip so that the pericardial phrenic and the superior epigastric wi - will still be in continuity.

So we’re going to move the attention to the rest of the course of the mammary. We’re keeping our field dry. We’re using this lap to have the lung nicely tucked away.

[Resident]: Do you think from being on the teaching side of things that this is more difficult to teach than pedicle?

Well, so requires… it’s graduate school for mammary harvest, so the progression that I teach follows this progression. I first teach the pedicle, of course. Usually in our rotation, you learn that from scrubbing with my partners who use the pedicle technique. Once the fellow is comfortable with the pedicle, meaning no injury, harvest-time less than half an hour, then I introduce the hemi-skeletonization. The hemi-Skeletonization is - is a version of this approach that allows you to have the same length afforded by skele - skeletonization but with a shortened time. However, the impact on the blood flow to the chest wall is same as pedicle so you would not use hemi-skeletonization technique in a bilateral mammary.

[Resident]: So it’s meant for teaching purposes?

So I progress it that way and once - once you learn the hemi-skeletonization, then you move to full skeletonization technique. So people like, like at your level - Kelly - would have an interest, they would, you know, start like a program where they maybe start taking half of this down, and then progress to do the full technique. So this is very reproducible, and then it takes perhaps 5-10 minutes longer than the pedicle. So a - a very expert harvester would take the pedicle down in 10-15 minutes. For this, you're probably adding between 5 to 10 minutes. That's - that's the little bit of a price to pay. So now we’re moving to the manubrium of the sternum. So far the harvest, I think, is doing well. I see another branch here. Clip please.

Some people use the harmonic scalpel for this harvest, and I have no experience with that technique, though some people swear by it. So you would not divide the branches the way I'm showing it. Clip please. I tried to use clips on even the small branches. I sleep better at night that way. So we're getting there. So we just transition the angle of Louis so we’re going toward second and first base. There you go, so here’s a mammary. Clip please. It could be intimidating the first time to look at this but - like - like many things, once you start doing it then, you realize that it is doable. This was a big - big branch. Hopefully, it will be a blow for freedom, as we complete the harvest here.

[Resident]: How proximal do you go?

I try to go as high as the first rib, above the first rib.

[Resident]: Do you think if you don't take the first branch that, that creates a potential Steal [Syndrome]?

That is a - a concern, yes. That has been shown, I try to go high. Another clip please. So as soon as we completed the harvest, we are going to systemically heparinize the patient. Our perfusionist has calculated the dose and the heparin will be given as a bolus by our anesthesia colleagues. And in order to start a heart-lung machine after we can cannulate will require an ACT, an activated clotting time, in excess of 400 seconds. We're getting there. Clip please. I think it’s very safe to go ahead and give the heparin.

[Resident]: So you think the take-home message is low heat and blunt dissection?

Yeah it’s gonna be a combination of blunt and sharp, yeah.

[Resident]: Bovie no more than 20?

Or 15 or 20, yeah.

[Anesthesiologist]: 15,000 heparin is in.

Thank you! So we start a timer, and in 3 minutes I will check the ACT (activated coagulation time) sample. So this is the first rib here. Very important here not too move to medially because there's a phrenic nerve, and I think it's safer to stay away from that area. So I moved from lateral to medial in my dissection, as you can see here, lateral to medial. I think we're pretty much done at this point. We have a, you know, very nice conduit here. So the heparin has been given, and we’ll divide this - this conduit right now. So use a medium clip. As I indicated, we would like to preserve the bifur - the bifurcation, so I'm going to leave these two vessels here. There's superior epigastric and pericardial phrenic in continuity. I'm going to put the clip that allows the two vessels to continue to be patent. We place two clips, and then we'll use a tenotomy. And we are observing nice flow from his mammary.

[Resident]: Yeah, excellent flow.

And my technique is, I put a bulldog at the very end. I let this mammary distend under its own pressure, and I apply topical papaverine. Bovie up to 50 please. So this is papaverine, and I'm using this 1mm Olive tip needle which allows me, if necessary, to do intraluminal dilatation. Today, I will not do that. I just apply papaverine topically, and then we're going to let the - this conduit dis - distend under it’s own pressure. So also I avoid bunching it up - up there. I keep it like this so it will - it will distend under its own pressure. So this concludes the skeletonization harvest. I take a quick look here - make sure the chest wall is dry. With this technique, also, there's much less potential for bleeding on chest wall. See - it looks good. Okay, so this concludes the mammary harvest.

CHAPTER 4

So we change gown here because I sat low. There’s potential for contamination, so… Any more vanco paste? Okay, I need a 2-0 Vicryl.

[Resident]: Okay, right here.

Put a rubber shod at the end - or a shod.

[Resident]: Yeah, from this guy.

So if there's air, in the area - just call us and so it's not perforation.

[Resident]: Exactly.

[Resident]: We had this the other day.

Okay thank you.

[Resident]: Let me do that for you.

[Resident]: I’ll get out of your way in a sec.

We're - We’re dividing the remnant of the thymus here, and we’re going to expose the pericardium. And then we’ll open the pericardium and ac - access the heart. So this is pericardium. And we’re opening pericardium now. Underneath that we’ll see the right ventricle.

[Resident]: Thanks.

[Resident]: You have another blue dog?

I’m losing the dog.

[Resident]: Well let's-we'll put a blue dog on that guy.

Oh this came off.

[Resident]: Oh nevermind - nevermind - we have it.

Can I get a Bovie? Bovie.

[Resident]: What’s the - what’s the Bovie on?

50.

[Resident]: You see the phrenic?

Phrenic visualized down there. Down there. Ok. 2-0 pop-off. So we have divided the pericardium. Now we're going to suspend the edges of the pericardium.

[Resident]: Oops, sorry.

Thank you, Jeff. We can see we’re at the right atrial appendage here, fibrillating. If you can see the chaotic motion of the atrium, that’s characteristic.

[Resident]: We need a - at the aortic.

Maybe just wait a little bit. I need-Bovie one more time, bovie set.

[Resident]: Short aorta huh?

I’ll take a 2-0 pop-off again.

[Resident]: Scis.

And one more 2-0 pop-off.

[Resident]: Do you wanna keep this long for your cannula?

Keep what?

[Resident]: You want to keep this one? Do you not want me to cut that? We’ll keep it for your cannula.

No, no, cut it. Actually just pull it through - no cut it off here. Pull through - one more please. And one more position. Okay, so let’s get the A-P aortic ultrasound probe. So this point we are going in preparation for cannulation of the aorta. We're going to perform an A-P aortic ultrasound using a handheld probe that’s passed and then kept sterile in the field, and this will allow us to examine the ascending aorta, which is a blind zone for the transvagial echo. If there is a severe intraluminal atheroma, we may have to find alternative cannulation. So we’ll provide a short axis view, just proximal to the take off for the innominate artery, and we observed that there is no protruding intraluminal atheroma. There’s normal thickness of the aorta. There's no mobile atheroma either. And then we’ll provide a long axis view going into the proximal arch and looks really good. I think it is a CAC zero score. Okay so we're done with this. Yes please. And the next step when we do Maze procedure for patients like this. If was a long-standing persistent atrial fibrillation, we always try to cardiovert, and - and if we can try it, have the patient in sinus rhythm. So can I have the paddles, and we’ll do synchronized cardioversion at 10 joules. We have confirmed with transvagial echo that there is no thrombus in the appendages. That's mandatory because -

[Resident]: Prevent stroke.

Of course. So this will be a step that we would skip if there was thrombus in the appendage.

[Resident]: Okay.

But there is no thrombus.

[Resident]: Why do we try to cardiovert before the Maze?

Well, first of all, because, we want to confirm the diagnosis of long-standing persistent - Is - are we capturing? Are we syncing? So, first reason is to confirm that is long-standing persistent. The second reason is - thank you. Syncing. Delivering. Okay recharge. So failed. Patient is still in AFib.

[Resident]: Okay, so the goal was not to car - cardiovert? The goal is to confirm?

It’s-cardiovert also. Okay, go up to 20. Failed twice at 10 joules, so we’ll try one more time. Sync and go up to 20 joules. Ready? Deliver. Okay so we failed the three - three cardioversions, so this confirms that this patient is in permanent or long-standing persistent atrial fibrillation. So that also will tell us that once we do pulmonary vein isolation, we will not be able to do exit block confirmation. Exit block requires we pace the pulmonary veins, and because the patient is in AFib, we will only be able to entry block. So the next step at this point is to... We’ll put purse strings in preparation. And.. So this is a the purse string for the aortic cannulation.

[Resident]: Can I have a DeBakey please?

I'm inclined to skip the GPs, what do you think?

[Resident]: Yeah, I think so.

This patient is advanced stage, so I think the contribution of the GP is going to be minimal. So we're not going to do GPs, Paul. Say again? Yeah, you can open a bipolar clamp, the lighted tip dissector as well. The wolf, okay, another stitch. No, I need to see the pledget, and you need to expose the pledget for me so I can go through.

[Resident]: Yep yep yep.

Is it twisted? So we’re dissecting around here. It's the right pulmonary artery right here. Right PA right there.

[Resident]: Yep. Blood pressure is okay? I'm just - I’m pulling a little bit on the aorta.

Okay. Purse string. So we cannulate directly the superior vena cava so we can perform a full Maze procedure. You take a pledget. You can let go of the tonsil.

[Resident]: And the other side...

So for the Maze procedure, we need to have a bi-cable venous cannulation in order to open the right atrium, and so we have to cannulate the superior and inferior vena cava sequentially. So now I need you to expose here for me a little bit.

[Resident]: Alright, I’m gonna push on the heart in a moment.

I'll take a stitch back in.

[Resident]: Pressure, ah okay. It's going to drop in a minute. Alright but here we go. Watch it.

Give it a breather as soon as I’m retrieving the needle. Okay, let go.

[Resident]: Alright.

Okay, let go.

[Resident]: Off the heart. Alright coming back.

Okay, you’re leading like a heart transplant, you know, very low. Let me see. That's a very good job you're doing, you know, giving him a chance to refill after each bite. Okay, one more. Okay. Okay.

[Resident]: Okay I'm off in a second.

Okay, stop - stop circulating. So we completed all the purse stringing. So let's divide the larynx tubing. Tubing scissor.

[Resident]: Alright we're clamped up here.

So, there are three components to the Maze procedure. The first component is the pulmonary vein isolation, left and right PV. That's the mainstay of the entire procedure. So that's one part. Second part, in order of us performing it, is the right atrial lesions and then the left atrial lesions. So 1, 2, 3. In addition we’ll manage the appendage. So these four components will constitute the full Maze.

CHAPTER 5

So in terms of the pulmonary vein isolation, we’ll start with the right pulmonary veins. There are two ways to do it. If possible, it’d be nice to do it before I go on pump, and that's not always possible. So what I like to do is we can try a little bit of dissection. However, in this case due to the severe atriomegaly, I have doubts we’re going to be successful. So we are actually going to go and cannulate first and then go on pump and perform that on the beating heart on pump. So I'll take a Metzenbaum. That's a choice that we make on a case-by-case basis. Yes.

[Resident]: So to do the pulmonary vein isolation only -

On pump - on pump beating heart versus off pump.

[Resident]: But I mean to that for pers - long-standing persistent AFib, that’s not enough to do the pulmonary vein isolation?

I just said that's one of the four components of the Maze.

[Resident]: Right, but to just do that part -

That will not suffice, of course, yes, you are correct. Okay, the pressure is good. 11 blade please. So we’re cannulating the aorta. Thank you for managing the pressure.

[Resident]: Um, can I use the pump sucker or no? Okay, where is it?

22 French arterial return cannula. So we have to turn it, as you remember. The blue line in this cannula is to look toward the head. Thank you, hold this please.

[Resident]: Yep yep.

Pick-up please. Try to orient it so the flow is aimed toward the middle of the arch, correct. Otherwise, our anesthesiologist will tell us that there is a bruit and then we'll have to reposition. The flow can go preferentially into the innominate. So we secure purse string. Tie on the passer, please. And then give me a little bit of room here, thank you. So this was truly a long-standing persistent AFib. See? Sometimes you know the diagnosis may or may not be confirmed. If the patient had converted to the sinus, stable sinus, it probably would have been a per - persistent case. I’ll take a clamp. Okay we’re in the process of connecting the aortic cannula to the arterial limb of the bypass machine. Let go. We’re checking to make sure there's no air. Hold this. 2-0 pop-off please.

[Resident]: Scissors please.

So we secure the cannula so it cannot be dislodged accidentally. And a towel - trying to put it here.

Okay I’ll take a long tonsil again. Next, we’re going to cannulate the superior vena cava. Thank you. And you have a forcep next also. Let me see.

[Resident]: Okay, pressure might change a little bit. Pulling on the aorta.

So Jamal, I will need your help. And - and… No, you need a forcep. Jamal has to hold the sucker. Okay, hold the sucker right here. I need an 11 blade. Yes.

[Resident]: Can you put the thumb sucker in a little more? Thank you.

Let go. Okay, now grab the cannula and hold it in place. So this is 24 French Pacifico type cannula that will drain the superior vena cava and will allow us to do total cardiopulmonary bypass and open the right atrium. Okay hold this. You can re - relieve this. Thank you, hold this up. Okay so far so good. Secure the cannula. Okay.

[Resident]: DeBakes.

Just a sec - down here. I help myself, you just need to suck. Yes. Yes.

[Resident]: Pushing on the heart.

[Resident]: Alright, we’re almost done, just hang tight.

Okay stop. I got to let go for a second. I need a tonsil.

[Resident]: Down a little.

Okay good. Advance it a little bit. Okay good. Okay. Okay. Okay, we’re good.

[Resident]: Okay, we're fine. I’ll hold it.

[Resident]: We’re off. Back on a little bit.

We’re going to go on in a sec. This is a big - big atrium, so definitely we could not have done it without going on pump. Okay good. Okay, thank you. Good job there. So this is a cannula in the inferior vena cava. This is a cannula in the superior vena cava, and we're going to be able to isolate the venous return once we open that right atrium. Can you remove the clamp? Saline. Let go. Okay Jeff, all yours. So you’re doing a wrap, directory at priming, displace that crystalloid and then go on pump.

CHAPTER 6

So the next step for us will be addressing the right pulmonary veins, and once we're on, we're going to have better exposure. The first thing we are going to do, we’re going to open the - into the oblique sinus of the pericardium and then pass the lighted tip dissector, which is this instrument here that has a light at the tip - with the light and it allows a smooth transition. So this instrument will go just flush inferior of the right inferior pulmonary vein, inside the oblique sinus of the pericardium, and then it will be turned on and will re-emerge on the roof of the left atrium. So the - this will allow us to go smoothly around both right pulmonary veins. Okay. So we will demonstrate this next, so if you expose for me, I’ll take a pi - pick-ups and use the Cell - Cell Saver.

[Resident]: Cell Saver please?

Is it ventilation off? Pick-up please. So over here you see the cannula of the inferior vena cava. We’re going to dissect a little bit of the pericardial reflection. Here you see the superior vena cava. Don’t pull on the cannula here, make su-stay away from the cannula. Stay away, wait wait, stay away. See it’s trying to come out so you have to stay away from there. Okay, so show me here, push. So I have to identify there the right inferior pulmonary vein, and then I'm going to divide the pericardial reflection here between the inferior vena cava and the pulmonary vein. That will lead me into the oblique sinus of the pericardium right there. See it right there? This led me into the - put the sucker inside - that is the oblique sinus of the pericardium, so this is posterior left atrium. So I’m going to extend this dissection until I see the pulmonary vein - the right inferior pulmonary vein. This will allow me to position the clamp - the bipolar clamp very well.

So this is the pulmonary vein here, you see? So we going to dissect this a little more toward inferior vena cava, and now let’s dissect here. So this is a right superior pulmonary vein, and we are going to dissect between the roof of the left atrium. Ok, suck here please. And the pulmonary artery. So this - this plane is where we’re going to retrieve our lighted tip dissector.

So the lighted tip detector has this plastic sleeve, so as indicated, we’ll introduce it flush with the right inferior pulmonary vein into the oblique sinus of the pericardium. Then we’re going to adjust the tip, and we are going to observe into the space that we have pre-dissected. For the - the lighted tip to - and you can see the light now - you can see the light there, you see? So that tells us we are free and we're clear of the sup - superior pulmonary vein and a little bit of more blunt dissection, and we're free.

The next two we're going to grab this with the Tonsil or forceps and I'm going to withdraw the dissector and pass this rubber across. So this now allows me to have a nice control of both right superior and right inferior pulmonary veins. So now we’re going to exchange - exchange - this is a bipolar radiofrequency clamp with gold plated electrodes on both jaws. And the energy will be contained between the two jaws, and so the tissue will be in between and by clamping, will allow us the circumferential ablation. So this will be the right pulmonary vein isolation will be done with this device. So this device we connect to the end of the rubber, this way. Okay and then we gently pull the rubber across, and we introduce it, following the path that the we have developed earlier until - use a suction here.

[Resident]: Suction please.

So, we are trying to visualize the - the jaw, right there, and see the jaw? And we advance, and we have to push the heel a little bit. So we try to - try to position this clamp nicely across, yeah. Okay now I'm going to remove the rubber, and now you can see that the jaw. Now I’m going to clamp. Clamp, this clamp will allow me to do a circumferential ablation. Where’s the stapler?

[Resident]: So you have to see it - see it come all the way across?

Take this. Okay, so we’re ablating currently, so you see the energy’s being deployed through the two anode and cathode of the jaws. And there is a conductance algorithm, and we do 5 of these RF applications. So the purpose here is to obtain a coagulation necrosis that is irreversible. So this device will alert us that more energy can be delivered. So we stopped the ablation, open the jaws, reposition slightly, you can see the char and reapply. So this is the second application of five.

[Resident]: So what, how did they determine there's five applications?

Well we did actually an experimental study in the porcine model in our - my lab and we saw that sometimes the thickness of the atrium is such that up - up to five or six applications are usually necessary.

[Resident]: And do you move it?

I re-open it and reapply.

[Resident]: But in the same area?

So at the end of this application, we are going to confirm entry block. In this case, patient is still in AFib so we cannot do exit block, but we will confirm entry block, provided that our sensing tool is operational.

[Resident]: How many seconds does that run?

We let it run until…..

[Resident]:Okay so you don’t set it.

There’s an algorithm that changes the sound and that’s how I know. So this is number three, you can see nice charring - that's what we want to see. We’re going to put another application, number four. So once this is completed, it will allow us to have a complete right pulmonary vein isolation, en bloc.

[Resident]: You're going in the same area, you’re not moving it from side to side?

No, no. But provided that, you know, I am across. See, like this - you have to go past...

[Resident]: It looks like it’s really burning it, it doesn’t - there’s no risk of it going through and through?

This is number five. So even if I don't have any confirmation from the sensing pen, five in my experience is sufficient. So you can see a little bit of char here on the device. This has to be cleaned, but I consider the right side completed. So the next step we going to be doing, open the right atrium, and in order to do that, we have to use umbilical tape and encircle the cava. So umbilical tape and curved clamp. So we’re going to go around here, see? Umbilical tape. So let's do this superior vena cava here, and we’re going to curve. Umbilical tape - no, no smaller - the other one. Easy easy easy easy easy, just pull the aorta. Yeah I pre-dissected so this should become pretty easy to do. Okay I'm coming down on this SVC. Let me know if you have issue with the venous return, Jeff.

[Jeff]: Nope so far so good.

And you want to make sure the head is not distended. How’s the anesthesia? I snared the SVC cannula, so make sure the head is decompressed.

[Resident]: That it’s not blowing up, right? Cause we just snared the SVC, so just make sure there is no head edema. Thank you.

And let's go down on this. I'm afraid this cannula is not in the right place. See, this cannula is not going in the right place.

[Resident]: Now is the time to readjust it.

Yeah we need to get adjust this, so I have to readjust the -

[Resident]: Do you have scissors, please?

15 blade.

[Resident]: Er yeah, 15, sorry.

No let me do it, this is a dangerous move. So Jeff, I have to reposition the IVC cannula because it’s not in the IVC, it was still in the atrium. So you may get some air, so leave a little bit in. So just release this, a little bit. It’s nice very tight, just control it with your hand. Let me see here, I need to see. Okay, that should be good, okay. Tighten. Empty the heart.

No, hold this cannula - no, not good enough - hold this, hold the cannula, hold this cannula in place, and show me here. Empty the heart. Pull this. Tie the passer.

[Resident]: Can I have scissors?

Pull this plastic thing up. Okay, that should be - that should do it. Let me see. Okay, Jeff, here I'm going down on the IVC as well. How's the venous return?

Same as it was. No problem.

I need the slinky. Tubing scissor. Okay I'll take a - so we’re doing now the right atrial lesions of the Maze, so hold this up. 11 blade. Yeah, open the cyro. Grab here. 11 blade. I’ll take a long scissor. Okay, so bipolar clamp, we can shoot, put this in. Yellow up. An atrial retractor. Atrial retractor. So we start on the right side by doing this incision with the scissor, which corresponds to the Cox-Maze counter incision, and then this will be the longitudinal incision toward the superior vena cava. It’s done with a jaw inside left atrium and a jaw outside towards the vena cava. So we going to apply this for three applications. Any luck with the sensing tool?

Where is the new one? Okay it’s on - it’s on atrial tissue. Okay this is, see the - the pen. Switch it. I want atrial tissue. I’m in the ventricle. Nothing working. Okay so this is the first application. We're going to do, we said three. I need to switch on bipolar RF right now. So this is second application of RF energy. And then we'll do a third one. So this is longitudinal incision of the Maze toward the superior vena cava. You can see the entire - inside of the right atrium. Okay we're going to clean this char. And you have a good venous return, we're looking good? Thank you. See what we needed is to reposition this cannula. This is the inferior lesion that is the continuation of this line, but instead of doing cut and sew, we’re using the radio frequency. Again, we going to do three application of RF energy, you good? Good?

[Resident]: So you would - you would open this and - and bicavally cannulate even if you're doing a CABG and a Maze?

Yes.

[Resident]: You would still open - open it this way?

If you choose to do it by - biatrial Maze, you may choose not to. So that's the surgeon's preference, and we'll do one more ablation. Okay, so we're done with this. Now we're going to do one more lesion toward the tip of the ri - right atrial appendage.

[Resident]: Also three?

Again, this is a lesion with one jaw inside the atrium, one jaw outside the atrium. Three provides a linear lesion. And next we’re going to use the cryo probe.

[Resident]: And the same lesions start with the cryo?

This - the cyro will be used for a lesion going toward tricuspid annulus.

[Resident]: Yes.

Y

ou see the nice tissue necrosis here? Very dense tissue so this thing takes about 10 seconds. So can you clean the jaws for me and now I need an atrial retractor.

[Resident]: So what if you applied cryo in these lesion sets, does it not have the same effect?

This is faster. So a radiofrequency takes 15 to 20 minutes and each cryo lesion takes 2 minutes, so it saves time.

[Resident]: But same effect?

So, yes.

[Resident]: But the difference is scarring?

So now you can visualize... Lift - lift up here. You can visualize the tricuspid valve. This is the septal leaflet of the tricuspid valve, and you can see the coronary sinus. And we have our suction device there. So this lesion will go from the cut end of the atriotomy toward 3 p.m. on a clock on the tricuspid valve and will overlap slightly with the tricuspid annulus.

[Resident]: So the tip goes to the annulus?

Okay grab this tissue here for me. So you want to make sure that it - it connects to - touches the - alright. Freeze. So the protocol is two minutes for this linear lesion. So as you can see, RF is much faster, but the reason why we’re using this if you can demonstrate is that it's safe here to use the cryo, even on the part of the valve leaflet. It would not be safe to use radio frequency on the leaflet. And the reason is because cryoablation provides ablation without damaging the collagen, and it does not result into scar while radio frequency provides irreversible coagulation necrosis but heals with a scar, so it will damage the leaflet tissue while the cryo will not. So this is sometimes referred to as part of the right isthmus lesion, and the right atrial lesions we’re doing as part of the Maze are primarily to prevent atrial flutter recurrences. Although some atrial fibrillation cases have also component of reentry in the right atrium. It's a little bit unpredictable.

[Resident]: So this - this step of operation is not completely necessary for AFib?

Yeah it is. It - The data show that by and large, the bi-atrial Maze is superior to left atrial Maze only. But it's somehow controversial, there are schools of thought and people who swear one way or the other.

Here’s the cryo probe, make sure it doesn't fly away. Take a 2-0 pop-off. 2-0 pop-off. So we have completed in the meantime the ablation, the lesion on the right atrium for the Maze procedure so that is done. Now we - we close the right atrium. I need a straight and then a 5-0 probe.

[Resident]: So we won’t go transseptal for the mitral?

No, no transseptal, just left atriotomy.

[Resident]: So this is the incision here, right? Never go this way?

Okay yeah, they have to reposition. Yeah, before it falls in the field. So, I’ll do the first stitch and then you sew it toward you.

[Resident]: Full thickness.

Squirt. So we're closing now the atriotomy, so you can see that the right atrial lesion - so the Maze in this case - was achieved using a combination of cut and sew. So, this atriotomy constitutes cut and sew, radiofrequency bipolar, and cryoablation. So we use basically - if you consider cut and sew an energy source - three different energies. And all of this is done on the beating heart. There's no ischemic arrest and that's done on purpose to minimize the myocardial ischemia.

Scissor, please. Okay, cut. Take this.

[Resident]: Yeah thanks.

Let’s do superficial and close together.

[Resident]: Superficial?

That’s not superficial. That’s not superficial. Take it, but the next one has to be superficial. Superficial. So we will try to do as much as possible on the beating heart before arresting the heart.

So this - so far we have completed 50% of the pulmonary vein isolation, which is one component of the Maze. We have to still do the left pulmonary vein isolation. However we have completed the right atrial lesions of the Maze. We - we still have to do half of the previous isolation on the left and the left atrium - left atrium lesions. And we will do those after we stop the heart and we open the left atrium.

[Resident]: Okay can you cut this? Please, thank you.

Okay I'll give you back the cava, so we don't - we don't need to have total cardiopulmonary bypass anymore, so I'm releasing the inferior and I'm releasing this superior. The next step shouldn’t need the cryo. I'm going to do part of the left isthmus lesion from the epicardial side. So let me see take a look here. So let me see. So I’ll take the cryo from -

Okay, so you can see here the corner, this is the POV, this is PDA, this is the posterolateral branch of the right coronary - this is the right dominant, and you can see the coronary sinus down there. Right there, the coronary sinus, the tip of the cryoprobe is coronary sinus and that's left atrium, so I'm going to perform the left isthmus lesion here from the epicardial surface. Freeze please. And this will catch the coronary sinus from the epicardial surface, you can see.

[Resident]: Okay I know, and I wanted to take a - I wanted to see where you are - where the tip is.

Okay it’s really important to study the coronary anatomy prior to doing this. Make sure cryoablation is not over a coronary artery because this will cause thrombosis. So this will be a two minutes lesion - so this is a left isthmus lesion - Peter, from the epicardial surface. We do it both endocardially and epicardially. It’s a cryoablation - a linear cryoprobe. This guarantees that we catch the coronary sinus. Yeah and this is - the protocol is 2 minutes. Yeah that is the reason why we added this lesion because the endocardial lesions were inconsistent and so this - this two combined provides a pretty solid left isthmus lesion which is critical. And again we're doing all this on the beating heart. There's no ischemia, so we're on pump with a beating heart.

Okay we're gonna try now to do the left pulmonary vein isolation on the beating heart. This sometimes is possible, sometimes it's not possible because the size of the heart. I believe that it will be very difficult to do today given the size of the heart. So at this point I'd rather move on to place the cardioplegia and cardioplegic arrest unless you want me to try the sensing tool one more time or we're giving up - giving up on that. Okay, pen one more time. We're going to curve to thirty-four. So, again this is the right atrium. It should have an electrogram if it works. I'm on left ventricle.

That's why I overkill in a sense - I do five ablations even if perhaps maybe two or three is enough because I don't take a chance, and I’ve had cases where I needed all five. Okay so I need a purse string for the anterior cardioplegia without a pledget - sorry with a pledget, I'm sorry. The pledget. And we have done needle cardioplegia today. Thank you. Okay, you want to flush the cardioplegia.

Cut, cut, cut and lighter please.

[Resident]: Jeff.

Flush cardio. Cut. Go straight. Cardioplegia needle.

[Resident]: Okay, off.

Hold this in place.

[Resident]: Yep, got it.

Okay, I’ll take a tie and a passer.

[Resident]: What?

It should go down to 32 please Jeff. Okay cut this.

[Resident]: Did we have scissors up here?

Take a tubing scissor. And root vent up. Okay, aortic clamp. Cardio is ready? Okay we're going to go proceed to stop the heart using cardioplegic arrest. And flow down please. The aorta is clamped. Flow back up. Start to integrate cardioplegia. Root clamp is off. We’ll do some topical hypothermia with ice slush. Pressure in the root is good. We confirm that the clamp is nicely across. We’ll take a deep breath now. Relax a bit. Ask a question, of course.

[Resident]: Are there any absolute contraindications to doing this Maze procedure?

It's - it's, well, let me think. I would not - would not do it in a redo operation honestly because you know the previous cardiac adhesions would make very difficult to - the access, although it is not impossible but you know, increase the risk. If you have to do five vessel CABG and double valve, I would not add a Maze. I would probably just exclude the left atrial appendage, so it's a judgment call. But as you know, it's - it - it's a Class 1 indication for mitral valve repair/ replacement to do this, because the data supports that there is no additional additional risk.

[Resident]: Yes, however only 60% of surgeons are doing it this way.

That's correct.

[Resident]: And the question is, why do you think that is?

Well it could be a combination of factors - one is training. Maze is not commonly taught in all training programs, so you need to seek education on your own after your training.

[Resident]: So how did you do that?

I did a Maze, yea, so, and there are courses-there's courses, of course, yea. But you had to really develop an interest and a - an understanding of the underlying - and develop, if possible, a relationship with the electrophysiologist, that's important. How much cardio in? At 750.

[Resident]: So - but there are no true absolute contraindications, just relative?

I think it was rel - relative, yeah.

[Person]: How effective is the Maze procedure is?

Oh the success rate, yeah, that’s an excellent question. So in the - in the - in the 90s when Cox described his results, he reported in excess of 95% success at 10 years, but the criteria were a little bit vague, not established, a little subjective, and since 2007, we have a consensus document with cardiology and surgeons the criteria for success is much more stringent. How much cardio is in?

[Person]: That is 1100 - we’re almost there.

Okay. Root vent up. Off. Okay. So for - for this procedure I would expect at six months of class 3 anti-arrhythmic, a success rate of about - between 70 - 70 and 75%.

[Person]: That’s pretty effective.

Yeah, well it's not 90 but it is...

[Resident]: I wonder if - how long they’ve had it pre-op, has correlated too?

Yeah it’s a risk factor, yeah - the larger the atrium, the lower the success.

[Resident]: So that goes back to the question about the size of the left atrium.

Okay, so let’s - let’s now...

[Resident]: Do you have a cut off for the size?

I don't. So let's now turn our attention to the left pulmonary veins, and this is a time where we want to isolate them.

[Resident]: Can you turn the table towards Dr. Zenati a little bit? Thank you.

Show me here, sometimes there is a ligament of Marshall - okay stop - that I try to divide, right here. This is the left superior pulmonary vein. This is left inferior pulmonary vein. So I'm going to develop this plane a little bit, get the appendage out of my way. And I need the lighted tip dissector and if you can move the sucker here. I'm going to go with a tip flush with the left inferior pulmonary vein and enter the oblique sinus superior cardium and I'm going to rotate the tip, and I'm going to look until the ti - the light appears - and see beautiful demonstration of this device.

[Resident]: Grab that guy?

We can use the Tonsil maybe.

[Resident]: Tonsil please.

So now we have encircled both pulmonary veins on the left side, and we’re going to withdraw the device and advance this plastic sleeve until we have the red rubber position across. And next we going to use our bipolar clamp. We're going to use to connect the jaw to one end and now Kelly. If you pull the plastic sleeve on your side gently, and I'm going to advance the device. Okay keep, keep pulling gently, keep pulling, keep pulling, keep pulling, gentle gentle gentle. Now we'll try - okay, now see, we're - we're across and now pull it hard. And it pops. Now if can expose for me, I'm going to demonstrate both tips are past - are past the vein, and I'm going to clamp across and we’re going to ablate.

[Resident]: Five times.

Five times. So once we're done with this, we’ve completed the bilateral pulmonary vein isolation. Make sense?

[Resident]: So you don’t have to - well we’re gonna open up the left atrium for the mitral valve but-

The lesions of the left atrium will be done last. This is just pulmonary vein isolation. First ablation.

[Resident]: So we’ll take the appendage?

That’s the next thing we’re going to do. There’s two ways to deal with the left tissue appendage. One will be to take a scissor and cut it off at the base and then over sew the stump. Another one is to place a clip so - Yeah, yeah. This is number three ablation. No you either do it inside or outside. We going to deal with the outside. You have to place it at the base - that's very important to do complete isolation. So this is number three, so this is number four ablation.

[Resident]: So doing this, pulmonary vein isolation, is not enough to complete a Maze?

No, we’ll have to open the atrium and do an additional lesion and you will demonstrate - and so it is not - the last lesion we’re going to do.

[Resident]: I think it’ll be helpful at the end, when - you know the picture you drew for me? To show that picture.

Okay so this is done. Okay, now if you take a Resano forceps, Kelly, and grab the tip of the appendage. So this is the - and then take a scissor. Grab a full thickness. We’re going to amputate the tip here, now put the sucker inside.

[Resident]: Pump sucker.

Give that to Jamal.

[Resident]: Yeah that’s the left atrial appendage.

Yeah keep it open here for a second. And I’ll - the additional lesion is done with a bipolar clamp with one jaw inside and one outside toward - overlapping toward the pulmonary vein isolation. You see this line goes from the stump of the appendage and overlaps with the pulmonary vein isolation. Is that clear? So lesion goes from stump of the appendage and overlaps with the ablation line that we created on the left pulmonary veins.

[Resident]: This must be done, this here.Is that clear? By putting one jaw inside and one outside, we create the transmural lesion.

[Resident]: And what about, cyro - just using cryo. Any difference?Yes, as we discussed, cryo takes 2 minutes per lesion, so I reserve it - I reserve it. You could do all this with cryo, but it will take you much longer. But it's - you know, it's not - you could do everything with bipolar radio frequency or with a cryo. I prefer the combination of energies because each energy modality has its own pros and cons, and the one against cryo is time. So this is done. Done three - three ablations, and you can see a nice line. Now I'm going to start the roofline of the appendage, and I’m going to put the jaw inside and another jaw outside, and the outside jaw is running in the transverse sinus of the pericardium, and you can see now below the aorta. And this will be half of the roof connecting line of the left atrium.

[Resident]: Where are you? Are you inside?

One jaw is inside. The other jaw is inside the transverse sinus of the pericardium. We were in the oblique sinus earlier - now we are in the transverse sinus.

[Resident]: Can I ask you, does this - does this qualify - this is like the following -

It’s half of the roof line. It’s half of the connecting roof line.

[Resident]: Is this considered the five-box Maze? Is that a term?

No. The five-box Maze is a procedure that is done exclusively epicardially using minimally invasive access. And there are only a few people doing it, and it's unclear whether - Because the energies are only applied epicardially, and as you see, the thickness of the tissues really is unpredictable.

[Resident]: Surgical Maze that’s epicardial even though that’s surgically - yeah.

It’s minimally invasive, so it’s done with a closed heart.

So we’ll do one more application, and then we're going to put the device on the at the base of the appendage. So we choose what the size is for the clip. And do we have the new clip? Okay, okay. So we're done with this. Now let's take a look here. Can you come up with the sucker please?

[Resident]: Can I have a DeBakey please?

Okay can you hold this heart for me? Can you hold the heart for me? Either 4 by 4. I’ll take a sizer.

[Resident]: Oh yeah, can I have a… I don't know, the heart was slipping, so I was gonna get a 4x4 from you.

I think a 40 will do, 40. 4-0.

[Resident]: Here, I'll take it from you. Sponge. Thanks.

And a Resono. 40. So this is a device that is placed at the base of the left atrial appendage, and we grab the appendage here, and then we place it inside this device. We make sure the entire appendage is caught. It's important to do a complete exclusion of the appendage. So this looks pretty good. I'm going to release it. I'm going to take a look here so I'm happy in this side. Let me see if I missed any, doesn't look like, so I think we're in good shape. What do you think? So 15 blade. Cut both. Strings. Pickup for a second. So this device will actually seal the base of the appendage. See we left it open in the tip here, and this will seal it, so there will be no blood going through. Okay, so this takes care of the left atrial appendage, which will prevent stroke in this patient. So let go. Now we’re going to do the - the coronary bypass, and then we’re going to do the mitral. Can you get the table back to the midline?

CHAPTER 7

[Resident]: Can I have a Gerald please?

I need a coronary forceps. This is our poor mammary. I need a wet lap. Wet lap. Flow is excellent as you can see. Bulldog. Okay so, Jacobson please. I need a 7-0 ready. You take two forceps and expose one.

[Resident]: Can I have another one please?

Okay, 7-0. Rubber shot. You can let got there. Okay, pick up. So this the left anterior descending coronary artery. Do you have a blue probe available?

[Resident]: Is your vent on or off?

Jacobsen. So we did an arteriotomy on the mam - on the coronary that’s about 1.7 mm in diameter. Probe. 1.5. Just wanna make sure I'm - I’m distal to the lesion. See that’s the lesion right there.

[Resident]: Check out beyond it right?

So this is the end-to-side anastomosis using a 7-0 probe. Can you go down to 32?

[Resident] Why do you do that?

Why? There’s air, so I brush air out.

[Resident]: Can I have a Ray-Tec for that?

I also make sure it's not twisted.

[Resident]: Last one? One more.

Okay.

[Resident]: Scissors please.

So the mammary to LAD anastomosis is completed. And we’re now going to turn our attention to the left atrium for the mitral valve and the remaining left atrial lesions, and we’ll access left atrium through a left atriotomy. Okay cut this. Thank you.

CHAPTER 8

Two needles back to you. Looks good. Okay, alright, so let’s now set up for the mitral. Okay, take the DeBakey, DeBakey, and then I cut this. going to cut this. Rotate the table away from me a little bit. These are too long. Want a regular short.

[Resident]: Can I have a DeBakey please? Long.

Okay, show me down there. Show me 4x4 end. Careful as you descend, you’re on this cannula, make sure you stay away from it - stay away from it. Suck. Suck. This is the Waterston’s groove, going to develop a little bit.

[Resident]: So where do you get your-you look for the-the pulmonary vein? And that's where you start?

See the veins? Yeah, I want to incise right here. It’s pretty deep. 11 blade. Okay, so this is a left atriotomy.

[Resident]: So right at the pulmonary vein. Pump sucker up all the way.

Yellow up. Lung scissor. Okay suck inside.

[Resident]: So you go up to the pulmonary vein.

Okay. Let go now and just get the Cosgrove stuff. So it goes like this.

[Resident]: It has to be loose.

I need to sit down, yeah, thank you. Ice, please. Do you have a sponge on a stick? Okay, let me see one of these guys.

[Resident]: Put that guy in there and there. First you should - well, try to put it in there, right?

Hold on to this. Hold on to this. 15 blade. You have to have the forceps and push the cannula in.

[Resident]: Forceps.

Pickup. You have to push that in as much as possible. Push, there you go, perfect, nice.

[Resident]: Is the air better?

[Anesthesiologist]: Yeah, that's better.

It's when I pull up you know so… Tie and a passer. Okay, pickup.

[Resident]: Scissors please.

I need the sucker. I need a Cell-Saver. Do you have a valve hook? This has to be deeper. Can you release it? Should - use a narrow one. Take this out. So this is an anterior leaflet, and there is some weird retraction here. So this is A2 - this is A2. See here, A2. And here's A3 that is kind of all sucked in. See it’s all retracted...

[Resident]: So it’s tethered.

Well, it’s a primary process. See, the height is very short. The height of the leaflet is very short there. So if there's a or - organic process, that - I really cannot augment this - see here A3, it's like a - it's like a healed -it's like a healed endocarditis or healed rheumatic process. This A3 is much shorter than - than here. This is commeasure here, commeasure, so this is A3. See, the quarter actually are - the A3 quarter, somehow, see how short it is?

[Resident]: Especially short.

So I don't think I can repair it, honestly. You have that Resano? See there is some process on the - on the anterior. So we’re going to replace the valve. Do you mind to hold it for me because I don't really have a good exposure here, I'm sorry. So just remove this - the other hand held retractor. Okay, remove this. Yeah, that’s better exposure. Hold it there. Hold it, like that. Okay I’ll take an 11 blade. So we’re going to leave the posterior, remove the anterior. Scissor, long.

[Resident]: You’re cutting the cords all the way down to papillary muscles?

Yeah for the anterior only. I’ll leave the posterior

[Resident]: Well, it’s thick as you were saying. It’s thick here.

I think there’s a ruptured chord - P2 also. Sizer for 27. Yeah, let me do this.

[Resident]: Okay this is specimen: anterior leaflet of the mitral valve.

Sizer for 27. Let me see. Like that. Have you drain your pan on the right side? There are... okay now - now it's better. Okay, 27. So you need stadium. Let me see if I - if I snare, it gets any better. Any better? Let me see.

[Resident]: See any air up here? Is it a lot of air, Jeff? Okay, it looks like it’s from the SVC, but...

Can you check your - your neck line - make sure there’s no three-way stopcock port open. We’re getting air from the SVC. Looks better here. Make sure that doesn’t fall. Make sure this doesn’t fault. Can - can you hold on here - towels.

Okay, I’ll need the... So let's do the rest of the ablation so that's done, we don't have to worry about it anymore. So I’ll need the cryo. Actually, let’s do the bipolar clamp first, so it’s faster. So we’re going to do a lower connecting lesion - one jaw in, one jaw out.

[Resident]: So where are you?

So this is lower connecting between the right inferior and left inferior pulmonary vein. See? Right inferior to left inferior pulmonary vein. Is that clear?

[Resident]: So it’s right to left.

Yeah, one jaw in, one jaw out. So full...

[Resident]: Three - three times?

Four - see, it’s pretty thick here. I'm - I’m losing the... where is it? Where is it? So in terms of the procedure now we're completing the left atrial lesion ablation. We have done both pulmonary vein isolation. So that's completed one part of the procedure. We have done the complete right atrial lesion, done - second part of procedure. And we're now completing the left atrial lesion sets of the Maze, and we’ve already done the appendage. So these two lesions left are the left isthmus and the roof will complete the full Maze. Then we'll have to do the mitral valve replacement.

Yeah 27, that’s fine. Can you make sure there's no three-way stopcock open?

[Resident]: So Jeff, no more air? Why? Because you have enough volume to get it out, or…?

Okay, so now I'm going to do half of the - half of the left isthmus lesion. So this lesion aimed toward P3 - aimed toward P3, and I'm going to do half with a cryo, with the RF, and the rest overlapping P3 with the cryo. This is half of the left isthmus lesion.

[Resident]: So where are you, are you at the right - superior pulmonary vein?

No, inferior. The right, right inferior, right? So at the atriotomy. And then this is going toward the mitral valve. This is the left isthmus lesion. So I need cryo, cryo. And I'm going to complete this lesion going toward the P3. So from where I left off to P3. And freeze. See? So this lesion goes from the atriotomy overlapping part of the lesion that I made and then into P3 so it connects with the fibrous skeleton of the heart at the mitral annulus. So this is done, saline. This, you know, allows me to take this off faster over here. So you get stuck to the tissue. Now we’re going to finish the roof lesion. Okay, freeze.

[Resident]: All and all, how many lesion sets are there?

There’s ten. Some are made in two bites. Some are made proximal part RF, distal part cryo. So I mean there's a lot of - lot of things to do. So we have to be able to move this case along. You have to take every chance you have to do things before you clamp the aorta. So you're right, ruptured chord on P2 and then some restriction of A3, and I didn't feel comfortable repairing so I'm replacing it. And we're done with the ablation. I think there was a cleft - so yes, there would have been a lot to repair, and I think in the end, the restriction of the A3 would have been the limiting factor. Okay, so, next I need the stadium and sutures. Expose this mitral valve. Yea, like that. Stitch, please.

[Resident]: Oh no, hold on. Nothing, I just can't have that be on my hands.

Pick them up. Like, what's the question? On the what? On the inferior? And what's the question? So the left isthmus lesion I did it - pull up - half with RF and the rest with cryo. This is not that short. That’s so deep.

[Resident]: Yeah.

Crazy. And now I’m - I’m proceeding, counter - counterclockwise. So if you could use this tool to somehow push this in like this, I can have better exposure. There you go, less less less less less less less push. Forehand.

4

[Resident]: Look at the top too. See what you're doing.

Less, less.

[Resident]: Less, less. Sponge there? Yeah.

So for the - this valve, the Magna, you need to know which stitch is at the level of the trigone because, you know, it’s an asymmetrical valve. So I think we're just passing the commissure here.

[Resident]: Near the posterior medial?

So that's - that’s the - no, anterolateral commissure. So this - the next stitch probably will be trigone. Now I'm going to be moving to become more anterior. See here is the anterior leaflet, which I've resected. This will be trigone. We need a marking pen. Let me see, if we can get this. Can I get another - another retractor - the other retractor? No the other handheld. Okay, that this off. And then - let go, like this. Like this. Next stitch. Do you have a green? This is fine actually. Backhand.

[Resident]: What? Yeah, yeah we’re good, thank you.

Let me see here, like that. So this is the right trigone. The time on cardio?

[Anesthesiologist]: We’re coming up on an hour.

Okay so we'll give - we’ll give a dose in a second. So marking pen here.

[Resident]: Do you always put your pledgets on the atrial side?

Yes, always. Forehand.

[Resident]: Almost there.

Yeah because when - you’ll see, when I put down the valve and I go to tie, I can see every pledget and by- by knowing the pledget is in my view, I know the valve is seated, as opposed to not - not seeing it and then I have to guess. So it helps in that regard as well. Okay I’ll take a - you can let go of the heart.

[Resident]: Alright.

There we go. What a relief.

[Resident]: Oh, you want me to come out all together?

Leave it there. Let’s give cardioplegia. Distension here. Release this tension. Okay, go, start. It's empty. There’s air everywhere. Keep going, keep your root vent up. Okay. It’s empty. Turn off the root vent. Okay, give cardio, push - push a little harder. There’s no pressure in the root. We have some pressure, increase the flow.

[Resident]: There’s some things in the well, so it’s going somewhere, because it’s - it’s - it’s in the well.

But the pressure in the root is very low.

[Resident]: It's going somewhere cuz it's...

I can’t get it so, I can’t release the tension on this suture. But then it's going to be difficult for me.

[Resident]: We’re making the valve incompetent.

Anyway, we're giving some because the heart is too cold.

[Resident]: It’s super soft.

Okay it’s fine. Alright stop. I’ll take a valve.

[Resident]: Get it in.

Okay here, just testing. So - so this tube will have to go into the LVOT. See? These are the two triangle sutures. You hold that. We have, 1, We have 1, 2, 3, 4, 5, 6, 7, 8, so 4 and 4, I need a holder, on the posterior.

[Resident]: Three more to go. Alright that’s three - it’s the last one. One more after this. One more. Okay, snap, snap. Okay, so you...

[Resident]: Just reset.

No, just pull up here.

[Resident]: Yep. Yep.

Okay, 15 blade. It’s important to do the ablation before you put the mitral down because after you put the mitral down, you won’t be able to see anymore. Exactly. I scored my hand, so Tonsil, long Tonsil. So, if you can expose for me there so I can confirm. We are indeed down, see there, the pledget, you see where the pledget is? That means the valve is all the way down. Squirt. Start rewarming.

[Resident]: So we just have to tie these down and then close the atrium...

And we're done.

[Resident]: We’re done.

Ah, quick procedure.

[Resident]: Yeah, right. Ten lesion sets. See?

Yeah but for instance, to do one, we did five applications of energy. So if you count every one that we did, there’s more than ten.

[Resident]: Where’s the reimbursement for that, huh? Right? What’s the cost benefit?

Yeah I think - I think there - I think there is a component of really not - not this procedure being compensated for the work that goes into it.

[Resident]: Also, but there is a mortality benefit, I mean, money aside.

Yes, the data - the data is pointing in that direction. I think the guidelines are possibly going to play a role in increasing the volume of the - the cases.

[Resident]: This thing just came out, this hunk.

See how nice it is to see the pledgets because sometimes this just has to be like that, like that, and this if you can just expose like this,, like this.

[

Resident]: So has this evolved? Your ten lesion set, as when we were doing it in Pittsburgh? Was it not like this?

Yes, the cryoablation from the epicardial surface for the left isthmus lesion, yeah that’s new. Because I was not satis -

[Resident]: Okay. you’ve added that?

You know, the literature, also you know, meetings, discussions. The procedure has evolved, yeah. I think that is a lesion that not everybody does - does, but...

[Resident]: The epicardial?

The epicardial, yes.

[Resident]: Forget it.

Squirt my hand.

[Resident]: I could tell.

So when you replace the mitral valve, you always tie the posterior first, because that's the weakest part of the annulus. And then you squeeze into the anterior, you force it in. Posterior first, tie it first always. It’s a good idea.

[Resident]: Where - where did you put your first bite?

Around there, around P3 here. And so now we go anterior.

[Resident]: So you find that that taking your bite there helps with exposure?

Well today, yes, the exposure was suboptimal, and not - not your fault at all, but just, I need to see here. Like this, can you push this thing? Careful of the mammary there and lift up this.

[Resident]: Do you see - I’m not on it, right? The mammary.

Tonsil. Tonsil. Leave it here, please.

[Resident]: So now even - okay so -

Yeah, give me a second, I need to visualize this, it’s a little hard. Score, please. Okay, getting there. So we’re going to close with that 4-0 Prolene. And rewarm all the way.

Okay. Tonsil. Those are tight already. Very good. Scissor. Okay. So the mitral is done. We’re going to just cut the sutures.. Remove that plastic component and pull.

[Resident]: Yeah.

Okay, 15 blade. Okay, let me see. Just a quick look, don't let go. Okay. Okay, I’ll take a suture. Okay, come out. 4-0 pledgeted, Prolene. Now just - yeah, use a 4x4 here.

[Resident]: Can I have a DeBakey?

And so, we’re going to close the left atriotomy and that will be the - the end of the procedure. I mean you're just muscling through there or you stopped? Yeah. I'm sorry, I don't know what else I could’ve done. Squirt my hand.

[Resident]: You don’t have a Bane retractor do you?Have you closed the left atriotomies? Yeah, sometimes it can be tricky.

[Resident]: Yeah, I don’t know this doesn’t look that big to me for some reason.

You were expecting a bigger one...

[Resident]: Yeah, I was, I was.

Okay, another stitch. Backhand, please. See there was a little bit of a hole here. Just take a big bite here. Squirt. He's a little older. Can I have a 5-0 Prolene?

[Resident]: What is that?

It’s the right atrium - it’s tearing a little bit. See this purse string here? Can I have a needle holder? Cut. Okay, head down.

CHAPTER 9

Leave some volume in the patient. Table up. 2-0 pop-off please. Okay, root vent up - Valsalva - root vent up! Valsalva, please. Okay, hold for a second, head down.

[Resident]: Head is down.

Okay, one more Valsalva, no no no, down the lungs - not with the...

[Resident]: The head - yeah, keep it down.

One more Valsalva. Okay, down with the Valsalva, empty the heart. Flow down, root vent up. Clamp is off. Flow back up.

[Resident]: The clamp is off and your mammary is open.

Okay. Another 2-0 pop-off What? Yeah yeah sure. Okay, can you adjust the table so it's not so much down.

[Resident]: Head back up a little bit.

Head up more. Okay 2-0 pop-off.

[Resident]: Yeah, so I can level the table a little more for us?

Yep, good, ventilate. Eh, it’s fine. Yes, please.

[Resident]: These are open, both of them, yeah. Scissors.

So you guys want to stay the whole thing? I mean right now we’re reperfusing the heart.

[Resident]: Why isn’t the right atrium filling up? Is it just taking time or what?

Say again?

[Resident]: It’s empty.

Yeah, because they’re drained. What do you mean?

[Resident]: I don’t know.

It’s supposed to.

[Resident]: Scissors. Is there no activity or… I mean I know he’s draining but -

Do you have the pacing wire? That’s the mammary. Nice. Pacing wire.

[Resident]: Scissors.

See his heart is restarting already. Cut this. A little more level, the bed. And down. So pacing cables out. I'm going to pace him at eighty. Do you have cables?

[Resident]: No. Do you have a set of cables for us? Please. Thanks. Okay here’s your - here’s a V wire for you.

Give me a sec. Okay. Scissor here. Cut this. Lower the bed a little more, please.

[Resident]: Take this needle, here you go.

Wait - wait a minute.

[Resident]: The ground - the ground is negative?

No, the ground is positive. Negative is always the one on the heart. This is ground positive. Pace at eighty please.

[Resident]: Okay where’s your ground? Here’s your ground. Ground is positive. Okay, giving them back to you. Try that. That’s just a V.

Okay, I’ll take another set of cables and 6-0 Prolene and another pacing wire. So HR is not doing anything, see? Which is good good. Yeah start us on inotropes. Okay.

[Resident]: So do you always put atrial wires no matter what?

Yeah, yeah.

[Resident]: Can I have a DeBakey please?

You have the lead with - without the needle? Why so short? Ah, it’s okay. We’ll make do.

[Resident]: Scissors. Metz.

Cut this. Can I get another empty needle holder? I’ll take - I’ll give you one needle. Okay. I'll have an 18 gauge needle. Cut this. Yes, sir. Okay I’ll take another ground wire.

[Resident]: Do we have the cables for the - for the A wires? Okay here's your A wire.

Okay at the - no no no. Of course. And 18 gauge if you have it. No, we’re not connected yet. Just leave it.

[Resident]: Do you have a stitch?

Lift some volume in. See there’s some here, see? See, look.

[Resident]: Oh yeah. Sometimes we like to put a syringe on and lift it up - lift it up and pull.

Put the sucker in there. Do you have the ground here? Okay, level the bed now. Level the bed and down all the way. Down. Okay, try again. Lower - raise it and lower it again. Okay. Okay, pace at atrial also - AV. You’re connected now. You’re connected now. So calcium in - okay - and half flow. I took a lot out.

That’s called the Pittsburgh squeeze.

[Resident]: Are you pacing your atrium? Okay, it doesn’t look like it.

But it’s not fibrillating, see? That’s good. So we're coming off cardiopulmonary bypass. We’re letting the heart take over the work of pumping. So the atrium is not fibrillating anymore and so that's encouraging. It’s being paced which is normal in this situation. A little too full here. Can you empty out? Yeah. Looks pretty good. Look see, capturing the atrium. So this by definition means we don’t have AFib. We’re able to capture the atrium, that means AFib is gone. You’re at two liters. Okay, go to one. So this is actually news. So AA - AAO is ideal in this case. Okay, once you come off, give me a hundred. Okay, turn it off. Nice!

[Resident]: Good job.

How's the mitral valve? Hundred.

[Resident]: What is the pacemaker rate after this? The pacemaker rate?

A permanent pacemaker? Oh that’s variable in the literature, you know. That’s one of the concerns. You know, a large series can go up 7, 8, 10%. Say again? Give a hundred. Yeah those - those generic statements here - they are not helpful. So you have to take into context everything. So is the preload - it’s not pumping well - is not helpful in this study. Well, so you have to discriminate between contractility issue or preload. Is it empty, as what Dr. Eliason was indicating, it's probably preload. But we're very sensitive for what you just said, because I give one example for teaching purpose. The circumflex runs right where the posterior annulus is, right? So a very deep bite there could compromise a SERT. So if you have regional wall motion abnormalities - lateral wall down - that’s bad. So I’m very sensitive to anything that you say. Anyway so the RV here looks great - look at this. So we’re pacing the atrium, so we’re very happy at this point overall. Look there's - there's no regional wall motion that I see. So I just need to know if the mitral valve is okay. Okay, well...

[Resident]: How much more volume do we have? Where’s your pressure? Can we give it some more volume?

Give a 100, yeah, sure. So let's get rid of this, 15 blade.

[Resident]: 15 and Debakey.

Nice. 15 blade please. You want to do something with that thing, right? You’re waiting for me.

[Resident]: Suction.

Okay so let’s -

[Resident]: DeBakey. Alright. I can pull it out.

I'm not going back for that, I'm sorry.

[Resident]: Maybe it’ll get better with the reversal, no? Okay. We’ll reassess that.

Yeah, I appreciate that.

[Resident]: Okay, you ready?

Go ahead and come out.

[Resident]: Your - your SVC is out.

Hold it, hold it.

[Resident]: Can we take it? Scis, please. Thanks. Do you have a squirt? Thank you. Let’s take a little look.

Hold on just a little-stop. 15 blade. 15. Lemme see.

[Resident]: Ready?

No, no, let me see. Let go of the pledget. Pull. Don’t pull the pacing wire, just pull the cannula.

[Resident]: Okay, it’s out. Okay, your IVC is out.

Whenever you're comfortable, start programming. Is something bleeding here? That’s atrium here. So let me see for a second. Let go - let go of the heart.

[Resident]: Are your pump - your pump suckers are off?

I’m gonna test on the live rhythm for a second. Okay that’s on his own. He’s in sinus rhythm. Look at that - look at that.

[Resident]: What? It’s off?

It’s off. It’s not pacing. I just disconnected here. Sinus rhythm - it's a beautiful thing. Mike knows what that means. No, but, we shocked him three times earlier and you know, so it's not just luck. Success, in one word, right? Look at his atrium, it’s kicking.

[Resident]: But what is the true definition of success?

No we're not at, early success though.The textbook success is 6 months off antiarrhythmic, but this is encouraging.

[Resident]: This is encouraging. Alright.

15.

[Resident]: Have you given the protamine yet?

Starting. 15 blade, yeah.

[Resident]: We’re getting ready to lose your vent.

Pickup.

[Resident]: Is there a pump sucker on? Okay. Ready. Okay, your vents out - your root vent. Yep. Scissors please.

So we demonstrated on the atrial electrogram that on the pulmonary vein side, on the right side, where we ablated, there was an electrical silence, and on the non-ablated side, there was sinus activity, so we documented that. Unfortunately, it was not working earlier.

[Resident]: The RV is looking sluggish.

15 blade. So we’ll have - have two curved: 32 and 36 straight. 15 blade.

[Resident]: It looked like he had the room, but... Do you have a stitch please?

Okay, scissor. Protamine, so restart protamine. Not working. Keep going.

[Resident]: Is your Cell-Saver on guys?

It’s working, it’s working.

[Resident]: Oh okay.

Just died. Ah, much better. See, Harvey.

[Resident]: That’s on Epi?

Lower the bed again - raise it and lower it. Still not working. Just level the - the head. Okay, keep going with the protamine. Yes. You’re going to spin the rest, okay? Hold this cannula - 15 blade. Find a right angle. Again, when you turn the knot, I don’t wanna see any tension in the aorta, it’s important. Really important. When you’re going to be independent, you’ll want your assistant to do that.

[Resident]: Don’t pull. Got it.Go ahead and go down. And now outside. Okay, cannula is out. Thank you.

[Resident]: Can you wipe my left hand please?

So it’s now decannulated. And now basically we just need to do hemostasis and closing the chest. And it stayed a nice sinus rhythm. We can actually see P-waves - that's really satisfying. So ideally - ideally, the pulmonary vein isolation has to be confirmed with an objective approach which is confirming that he has bi-directional block, okay. This patient - because he was in AFib when we could not convert, could not be a bidirectional block confirmation, only uni-directional, because the exit block, which is pacing across the test - that involves pacing across the ablation line could not be done because the patient was in AFib. So the only test left in order to confirm transmurality is the entry block test, which requires recording atrial electrograms and relies on this tool to work. However, I - my approach of doing - my approach of doing five lesions no matter what kind of, you know it's - it’s carpet bombing. It's like, you know, I overkill, so I almost never have to go back and do additional lesions. Generally, doing one or two lesions, you’re taking a chance. Then you should prove it. So my approach does not rely heavily on - on this system to work, but it's nice to have it, documenting it, giving it to the cardiologist, to the patient. So it's - it's a scientific approach.

CHAPTER 10.

How’s it look? Nice and dry.

[Resident]: Just wanna look over there, make sure there’s nothing on their side. Looks like they’re stuck in the well.

So cannulation here looks good. Good. Get those 37. I’m looking at the left atriotomy - looks pretty good. 37. Okay, scissor.

[Resident]: Alright I'm closed.

So 2-0 vicryl. So this was a difficult patient to, you know, get back in sinus because, you know... The fact that we - we cardioverted him three times, the size of the atrium - okay 2-0 vicryl.

[Resident]: He’s young so are you going to reapproximate the pericardium a little bit?

Yes.

[Resident]: Alright. Do you have Army-Navy, please? Thank you.

Tonsil, chest tube.

[Resident]: Can you put the - can the table go down? I think you’re just going to have to put the head down, and then put the table down. I - I think the back is up. I do think the back is up. So… yeah let’s do that. Yeah, see? See what I’m saying? Yeah. Thank you.

Knife for a second. 36 straight.

[Resident]: Suction.

Bovie on 50. All the papaverine is in? Not that I'm seeing a lot of clots really. I don't see much clots. You have any leftover vanco paste by any chance? Oh, okay. Look at P-wave, nice!

[Resident]: So proud. Definitely cool for me to see this, you know. Is that lap out of it? Hold on, suction. I don't like all that - I don't like all the blood. Trocar? Yeah, it was just this top guy here.

A type IV. There was perfusion - there was a perfusion. Yeah so a type IV - those are big cases. Wow. Oh man.

[Resident]: That’s insane. Thank you.

I mean a CABG, you know, is 3 hours skin to skin. An AVR is 2 hours. This is a big case, you know, we did CABG, Mitral, and Maze.

[Resident]: Can I have a wet and a dry, please?

Alright thanks everybody, I - I enjoyed the case. Bye, everybody. Good job. Thank you T. Thank you Jeff. Thank you Jim.

CHAPTER 11

The procedure was, I believe successful. We were I think overall very pleased with the outcome. The Maze procedure, which was full a biatrial Maze, resulted in normal sinus rhythm leaving the operating room, which is very rewarding and not always a guarantee, even with a very good quality procedure because patients who had long-standing persistent atrial fibrillation have sometimes what we call sinus node stunning. So the sinus node, not having worked for a period of time - sometimes years - requires a period of time to go back and function. So we were lucky that today the sinus node picked up right there with an excellent rate in the eighties. The left atrial appendage exclusion was also successful in the criteria we use is on the transvagial echo, a complete exclusion. There was no residual appendage that was left behind, so that also we're very pleased with that. The mitral valve had to be replaced, and we use a bioprosthetic valve. And the coronary bypass surgery was successful with a mitral - with a mammary to the LAD.