A Case of Intraoperative Epicardial Electrophysiolosic Mapping and Ganglionated Plexi Ablation for Concomitant Atrial Fibrillation with a Temporary Pacemaker

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A 64-year-old female was admitted to our institution with known atrial fibrillation (AF) and a 3-year history of worsening shortness of breath. Preoperative echocardiography revealed severe mitral regurgitation and dilated left atrium of 61 mm. Following optimization of heart failure therapy, ganglionated plexi (GP) ablation was performed in addition to MAZE IV procedure and mitral valve prosthetic ring annuloplasty (MVP). Autonomic GP was identified by rapid atrial pacing via a temporary pacemaker instead of a specific stimulator. A 27-point high-frequency stimulation (1000/minute, 18 V) was achieved by placing tweezers directly on the left atrial epicardium. Locations where stimulation resulted in ventricular slowing with doubling of the electrocardiographic R-R interval were identified as active GPs. In this case, only 2 points of the 27 in the inferior right area of the left atrium were active. The other 25 were inactive. The cardiac response to GP stimulation was eliminated with bipolar radiofrequency ablation. GP ablation was followed by MAZE IV procedure and MVP, these were successfully completed. The postoperative course was uneventful, and sinus rhythm was maintained upon discharge.