Surgery for Atrial Fibrillation

AORN Journal,  July, 2007  by Patricia C. Seifert,  Jill Collins,  Niv Ad

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After the right atrial lesions are completed, the perfusionist institutes CPB. The surgeon cross-clamps the aorta and inserts an antegrade cardioplegia catheter into the aorta to arrest the heart with cardioplegia solution via an incision in the right lateral chest wall. The surgeon can infuse retrograde cardioplegia solution by inserting a catheter through the right atrial wall and positioning the catheter tip into the coronary sinus. The surgeon may institute additional myocardial protective measures, such as minimizing the risk of an air embolus from ambient room air trapped inside the heart by insufflating carbon dioxide (C[O.sub.2]) gas through a catheter into the pericardial well. The C[O.sub.2] gas not only displaces ambient air, but also dissolves approximately 25 times faster in the blood than room air and is less harmful to cardiac tissue. (34)

After the heart has been arrested, the surgeon creates the right and left atrial lesions in a manner similar to that described previously. After completing the ablative lesions, the perfusionist discontinues CPB. The surgeon repairs the femoral arterial and venous cannulation sites and closes the incisions.

CLOSING

After the lesion sets and any additional surgical procedures (eg, mitral valve repair) are completed, the perfusionist rewarms the patient by warming the blood with the heat exchanger in the CPB circuit. Additionally, the circulating nurse turns up the room temperature and the anesthesia care provider reactivates the warming device that was deactivated during the period of induced hypothermia. The surgeon inserts chest tubes and temporary pacing wires, and the perfusionist terminates CPB. The circulating nurse and scrub person perform initial closing counts, and the surgeon confirms that hemostasis has been achieved. The surgeon uses wire to close the sternum in patients who have undergone a sternotomy and uses heavy absorbable sutures to approximate the ribs in patients who have undergone a thoracotomy. The circulating nurse calls report to the nurse in the cardiovascular intensive care unit (CVICU) who will recover the patient.

When the incisions are closed and dressed and chest tube drainage is within acceptable range (ie, less than 200 mL of blood per hour), the patient is ready for transport. The circulating nurse brings the CVICU bed into the OR; using this bed avoids having to make an additional patient transfer from a gurney to a bed in the CVICU. The circulating nurse covers the patient with warm blankets. The scrub person ensures that the instruments and sterile field remain uncontaminated until the patient has left the room, in the event that the chest must be promptly reopened for bleeding or hemodynamic instability.

POSTOPERATIVE CARE PERIOD

The postoperative recovery time of each patient varies. It is important for patients undergoing a Maze procedure to understand that it may take up to three months for AF to convert to normal sinus rhythm. Patients usually will spend a minimum of three days in the hospital after the procedure. Participation in a physical therapy rehabilitation program is recommended for cardiac patients to promote cardiovascular health and an increased energy level. A follow-up appointment with the surgeon after discharge allows the patient to ask any questions or verbalize concerns.