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1 Part 2 OR *3 pgs for this form Patient ID sticker here STS Registry- Atrial Fibrillation For Peds & Adult Cardiac Surgery Fill out questions 9-16 9. Left atrial size (diameter in cm) ____________cm volume _______________________ml/m2 Documentation from: Pre op echo / Intra op TEE circle one 10. Presence of a LA thrombus per TTE or TEE a. No b. Yes 11. Pulmonary Vein electrical isolation was confirmed a. No b. Yes 12. Surgical Arrhythmia Procedure (Check all that apply.) a. Pulmonary Vein Isolation b. Pulmonary Vein Isolation with Connecting Lesions c. Right Atrial Lesion Set (“non-Maze”/”modified Maze”) d. Right Atrial Full Maze Lesion Set e. Left Atrial Lesion Set (“non-Maze”/”modified Maze”) f. Left Atrial Full Maze Lesion Set 13. Left Atrial Appendage Obliteration a. No b. Yes If Yes, choose one: i. Excision ii. Exclusion 14. Autonomic ganglia ablation performed a. No b. Yes 15. Predominant technique used to create the lesion set (choose one) a. Epicardial Application of Energy Source b. Endocardial Application of Energy Source c. Incisions (surgical) “cut & sew” 16. Energy sources used a. Radiofrequency 1. No 2. Yes If Yes, answer i. and ii.) i. □Unipolar (Medtronic) □ Bipolar (Atricure, Medtronic, Estech) ii. □ Irrigated □ Non-Irrigated b. High Intensity Focused Ultrasound i. No ii. Yes If Yes, choose one a) St. Jude/Epicor c. Cryoablation i. No ii. Yes If Yes, choose one a) Nitrous Oxide Cryosurgery (Frigitronic) b) Argon Cryosurgery (Cryocath) d. Microwave i. No ii. Yes If Yes, choose one a) Guidant b) Boston Scientific e. Laser i. No ii. Yes f. “Cut and Sew” i. No ii. Yes Satou rev 9/08 OR Form date:___________________________________________ Name of person completing Form:___________________________ MD Signature:___________________________________________ Definition’s see below :Q12/ Q14/Q15 Identify specific lesions on diagram (see next page) Q 12. Surgical Arrhythmia Procedure a. Pulmonary Vein Isolation Box lesion isolating all four pulmonary veins. b. Pulmonary Vein Isolation with Connecting Lesions Lesion around the right pulmonary veins as a pair and left pulmonary veins as a pair with a connecting lesion between the two pairs. c. Right Atrial Lesion Set (“non-Maze”/”modified Maze”) Surgeon includes at a minimum the lesion below and does not perform the three lesions of a full Maze procedure. Right atrial isthmus lesion -Extending from tricuspid annulus to coronary sinus or IVC d. Right Atrial Full Maze Lesion Set Surgeon must perform all the following: Lesion from SVC to IVC Lesion from body of right atrium to tricuspid annulus Lesion from right atrial appendage to tricuspid annulus e. Left Atrial Lesion Set (“non-Maze”/”modified Maze”) Surgeon includes at a minimum the lesion below and does not perform the three lesions of a full Maze procedure. Isolation of left atrial pulmonary veins f. Left Atrial Full Maze Lesion Set Surgeon must perform all the following: Isolation of all 4 pulmonary veins with connections between right and left superior pulmonary veins and right and left inferior pulmonary veins Connecting lesion to mitral annulus Connecting lesion to left atrial appendage Q 14. Autonomic ganglia ablation Testing and ablation of autonomic ganglia Q 15. Predominant technique used to create the lesion set Epicardial application of energy source: All lesions are placed from the epicardial surface of the heart regardless of energy source (radiofrequency, laser, microwave, Cryoablation, ultrasound). No atriotomy is performed. Endocardial application of energy source: Some lesions are placed via atriotomy on the endocardial surface of the heart regardless of the type of energy used. This technique predominates, but may be used in combination with epicardial lesions. This technique may be left atrial or bi-atrial. Incisions (surgical) “cut & sew”: This technique may be left atrial or bi-atrial. Full thickness incisions are made and sutured in the atrium to create the ablation lines. This technique may include placement of cryolesions at the mitral valve annulus and the tricuspid valve annulus and the the coronary sinus. 2 See Lesion Diagram to complete this portion of the Data Collection Tool: Cryo type circle one: Argon or Nitric Lesion Confirmed Ablated Arrest Heart/Beat Heart Cryo MW Laser Block #1 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #2 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #3 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #4 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #5 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #6 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #8 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #9 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #10 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #11 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #12 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #13 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #15 □ □ AH □ BH □ Epi □ Endo □ C/S □ □ □ □ □ □ □ □ #7 #14 LAA Removed RAA Removed □ Yes □ No □ Yes □ No Choose one APPROACH Excluded Excluded Bipolar Unipolar Irrigated □ Yes □ No □ Yes □ No RIGHT APPENDAGE LEFT APPENDAGE SVC 14 7 15 1 8 12 11 HIFU Lesion Line Key 1. Pulmonary Vein Isolation 2. Box Lesion 3. Pulmonary Vein Connecting Lesion 4. Posterior Mitral Annular Line 5. Pulmonary Vein Connecting Lesion to Anterior Mitral Annulus 6. Mitral Valve Cryo Lesion 7. LAA Ligation/Removal 8. Pulmonary Vein to LAA 9. Intercaval Line to Tricuspid Annulus 10. Tricuspid Cryo Lesion 11. Intercaval Line 12. Tricuspid Annular Line to RAA 13. Tricuspid Cryo Lesion 14. RAA Ligation/Removal 15. Intercaval Line towards RAA 3 MITRAL ANNULUS 9 13 cryo lesion 6 cryo lesion CORONARY SINUS 4 to posterior annulus 2 10 TRICUSPID ANNULUS CORONARY ARTERY 7 5 IVC 3 8 Circle surgery type: off pump Circle Surgery type: Hybrid Satou rev 9/08 on pump Robotic combination Full Sternotomy Endoscopic 1 1 3 Ganglia Mapping: See Lesion Diagram to complete this portion of the data collection tool: Right Side: Left Side: PRE Pos Neg Pos POST Neg PRE Pos Neg POST Pos Neg R1 □ □ □ □ L1 □ □ □ □ R2 □ □ □ □ L2 □ □ □ □ R3 □ □ □ □ L3 □ □ □ □ R4 □ □ □ □ L4 □ □ □ □ R5 □ □ □ □ L5 □ □ □ □ R6 □ □ □ □ L6 □ □ □ □ R7 □ □ □ □ L7 □ □ □ □ R8 □ □ □ □ L8 □ □ □ □ R9 □ □ □ □ L9 □ □ □ □ R10 □ □ □ □ L10 □ □ □ □ R11 □ □ □ □ R12 □ □ □ □ R13 □ □ □ □ Satou rev 9/08