Case history This is a 61-year-old male patient. He had paroxysmal atrial fibrillation (AF) for about 14 years, refractory to propafanone and amiodarone. AF had persisted for 2 years before Wolf Minimaze operation. The patient accepted a standard Wolf Minimaze operation, with bilateral pulmonary vein (PV) isolation and left atrial appendage exclusion through thoracic endoscopy, in October 2008. After Wolf minimaze operation, sinus rhythm only remained 21 days with oral amiodarone. With persistent AF, the patient's exercise tolerance decreased gradually (6 min walk less than 300 meter). Echocardiography showed that left ventricle end diastolic dimension (LVEDD) was 55 cm, left atrium (LA) long axis dimension was 47 cm, and left ventricle ejection fraction (EF) was 61%. 24 h ECG showed persistent AF, average heart rate was 72 bpm. This patient was referred to our centre in October 2010, and prepared for radiofrequency catheter ablation. After 4 weeks oral warfarin with INR 2–3, and no thrombi was confirmed by transesophageal echocardiography. Radiofrequency catheter ablation was performed under sedative. After transseptum and venogram, Lasso catheter was introduced into four PVs respectively, no residual PV potential could be recorded. So under the guidance of 3D Carto system, linear ablation was performed in left atrium, including roof line, septal line, mitral valve isthmus line, endocardial coronary sinus and tricuspid isthmus line in right atrium. AF still persisted and converted to sinus rhythm after a 200 joule direct current electrical cardioversion. After the patient's discharge from the hospital, warfarin and amiodarone were prescribed for 3 months, statin and angiotensin II receptor blocker were taken everyday until now. Every month, 24 h ECG was examined, showing stable sinus rhythm. After 7-month follow-up, 6 min walk is more than 500 meter. LVEDD is 51 cm. LA is 37 cm, EF is 71%.
Implication After standard Wolf minimaze operation, AF could recur with 4 PVs complete electrical isolation. Again, after more substrate in left and right was destroyed by endocardial linear ablation, sinus rhythm could remain without antiarrhythmic drug. The patient recovers to normal heart function with reversed heart remodelling.