Recently, novel techniques for control and cure of atrial fibrillation have been developed since the advent of the original Maze procedure. These have included a variety of minimally invasive approaches, energy sources, as well as lesion sets. In this video we present our surgical approach to bi-atrial ablation using cryogenic frost through a minimally invasive incision.

Femoral venous and arterial access is obtained for cannulation followed by a 4cm mini-thoracotomy in the 4^th right intercostal space. The pericardium is opened and cardiopulmonary bypass is instituted, followed by cardioplegic arrest. After left atriotomy, the CryoCath SurgiFrost 10 ablation device (CryoCath Technologies Inc., Montreal, Quebec, Canada) is used to create an encircling lesion around the pulmonary veins connecting with the incision of the atriotomy. Next, a connecting lesion from the pulmonary "box" to the mitral annulus near P3 is created. An epicardial lesion from the cut edge of the atrium down to and across the coronary sinus is then created, followed by an endocardial purse-string closure of the atrial appendage. After closure of the atriotomy and with the patient on beating heart bypass, a lesion is placed along the intercaval line, followed by a separate lesion crossing the intercaval lesion and continuing down to the transverse sinus, crossing the closed atriotomy. Finally, a tricuspid valve lesion is created by directing the probe endocardially through a right atriotomy.

Minimally invasive cryo-ablation can be successfully performed through a small right thoracotomy. Our results to date are encouraging with close to 90% freedom from atrial fibrillation at six months with further results to follow.