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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Patrick M McCarthy MD FACCExecutive Director of the Bluhm Cardiovascular Institute
Chief of Cardiac Surgery DivisionHeller-Sacks Professor of Surgery in the Feinberg School of Medicine
Thursday October 5 20172017 Heart Valve Summit
Session VI Atrial Fibrillation in the Setting of Mitral RegurgitationChicago IL
Ablation Strategy Appendage Managementand How to Monitor Maze Success
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Disclosures
bull None
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF Management with Valve Surgery in lsquo17
bull Latest Guidelinesbull Why Whatrsquos the Evidencebull How Lesion sets Technologies LAAbull Outcomes How to Measure them
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Surgical ablation for atrial fibrillation (AF) can be performed without additional risk of operative mortality or major morbidity and is recommended at the time of concomitant mitral operations to restore sinus rhythm (Class I Level A)
Ann Thorac Surg 2017103-329-41
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why Such Strong Guidelines
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p =00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
Contemporary utilization of SA is increasing across all operative categories Performance of SA is accompanied by a 30-day reductionin mortality and stroke These findings further refine our understanding of the role of SA in the treatment of AF Ann Thorac Surg 2017104493-500
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched Treated PAF Untreated PAF and No history of AF
3797 3263 2724 2208 1748 1303423 365 313 250 206 131129 99 73 62 47 28
bullPlt 0001
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Disclosures
bull None
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF Management with Valve Surgery in lsquo17
bull Latest Guidelinesbull Why Whatrsquos the Evidencebull How Lesion sets Technologies LAAbull Outcomes How to Measure them
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Surgical ablation for atrial fibrillation (AF) can be performed without additional risk of operative mortality or major morbidity and is recommended at the time of concomitant mitral operations to restore sinus rhythm (Class I Level A)
Ann Thorac Surg 2017103-329-41
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why Such Strong Guidelines
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p =00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
Contemporary utilization of SA is increasing across all operative categories Performance of SA is accompanied by a 30-day reductionin mortality and stroke These findings further refine our understanding of the role of SA in the treatment of AF Ann Thorac Surg 2017104493-500
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched Treated PAF Untreated PAF and No history of AF
3797 3263 2724 2208 1748 1303423 365 313 250 206 131129 99 73 62 47 28
bullPlt 0001
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF Management with Valve Surgery in lsquo17
bull Latest Guidelinesbull Why Whatrsquos the Evidencebull How Lesion sets Technologies LAAbull Outcomes How to Measure them
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Surgical ablation for atrial fibrillation (AF) can be performed without additional risk of operative mortality or major morbidity and is recommended at the time of concomitant mitral operations to restore sinus rhythm (Class I Level A)
Ann Thorac Surg 2017103-329-41
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why Such Strong Guidelines
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p =00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
Contemporary utilization of SA is increasing across all operative categories Performance of SA is accompanied by a 30-day reductionin mortality and stroke These findings further refine our understanding of the role of SA in the treatment of AF Ann Thorac Surg 2017104493-500
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched Treated PAF Untreated PAF and No history of AF
3797 3263 2724 2208 1748 1303423 365 313 250 206 131129 99 73 62 47 28
bullPlt 0001
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Surgical ablation for atrial fibrillation (AF) can be performed without additional risk of operative mortality or major morbidity and is recommended at the time of concomitant mitral operations to restore sinus rhythm (Class I Level A)
Ann Thorac Surg 2017103-329-41
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why Such Strong Guidelines
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p =00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
Contemporary utilization of SA is increasing across all operative categories Performance of SA is accompanied by a 30-day reductionin mortality and stroke These findings further refine our understanding of the role of SA in the treatment of AF Ann Thorac Surg 2017104493-500
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched Treated PAF Untreated PAF and No history of AF
3797 3263 2724 2208 1748 1303423 365 313 250 206 131129 99 73 62 47 28
bullPlt 0001
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why Such Strong Guidelines
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p =00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
Contemporary utilization of SA is increasing across all operative categories Performance of SA is accompanied by a 30-day reductionin mortality and stroke These findings further refine our understanding of the role of SA in the treatment of AF Ann Thorac Surg 2017104493-500
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched Treated PAF Untreated PAF and No history of AF
3797 3263 2724 2208 1748 1303423 365 313 250 206 131129 99 73 62 47 28
bullPlt 0001
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why Such Strong Guidelines
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p =00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
Contemporary utilization of SA is increasing across all operative categories Performance of SA is accompanied by a 30-day reductionin mortality and stroke These findings further refine our understanding of the role of SA in the treatment of AF Ann Thorac Surg 2017104493-500
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched Treated PAF Untreated PAF and No history of AF
3797 3263 2724 2208 1748 1303423 365 313 250 206 131129 99 73 62 47 28
bullPlt 0001
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why Such Strong Guidelines
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p =00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
Contemporary utilization of SA is increasing across all operative categories Performance of SA is accompanied by a 30-day reductionin mortality and stroke These findings further refine our understanding of the role of SA in the treatment of AF Ann Thorac Surg 2017104493-500
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched Treated PAF Untreated PAF and No history of AF
3797 3263 2724 2208 1748 1303423 365 313 250 206 131129 99 73 62 47 28
bullPlt 0001
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p =00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
Contemporary utilization of SA is increasing across all operative categories Performance of SA is accompanied by a 30-day reductionin mortality and stroke These findings further refine our understanding of the role of SA in the treatment of AF Ann Thorac Surg 2017104493-500
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched Treated PAF Untreated PAF and No history of AF
3797 3263 2724 2208 1748 1303423 365 313 250 206 131129 99 73 62 47 28
bullPlt 0001
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
Contemporary utilization of SA is increasing across all operative categories Performance of SA is accompanied by a 30-day reductionin mortality and stroke These findings further refine our understanding of the role of SA in the treatment of AF Ann Thorac Surg 2017104493-500
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched Treated PAF Untreated PAF and No history of AF
3797 3263 2724 2208 1748 1303423 365 313 250 206 131129 99 73 62 47 28
bullPlt 0001
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched Treated PAF Untreated PAF and No history of AF
3797 3263 2724 2208 1748 1303423 365 313 250 206 131129 99 73 62 47 28
bullPlt 0001
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PS MatchedSurvival
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Does AF Treatment Change the Curve
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Maze Surgery is Complicated
Can It Be Effective and Efficient
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery
Trials YearNumber of Pts Technology
Control 12 Month
NSR
Treated 12 Month
NSRDeneke et al 2002
30 Unipolar Cooled RF
267 80 (p lt 001)
Schuetz et al 2003
43 Microwave 333 80 (p = 0036)
Akpinar et al 2003
67 Unipolar RF 94 936 (p = 00001)
Abreu Filho et al 2005
70 Unipolar Cooled RF
269 794 (p = 0001)
Doukas et al 2005
101 Unipolar RF 45 444 (p = 0001)
Blomstroumlm-Lunqvist 2007
69 Cryoablation 429 733(p=0013)
Chevalier2009
43 Unipolar RF 4 57 (p=0004)
Gillinov2015
260 Radiofrequency and cryo
294 632 (plt0001)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
bull Pulmonary Vein ldquoBoxrdquo Lesionbull MV Annulus to Box Lesionbull SVC-IVCbull TV Annulus flutter
lines X2bull Excision of LAA
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017Jun103(6)1858-1865
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation Not Just for Reops Anymore
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What About the Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The atrial appendage is the source of stroke in 91 of non-rheumatic AF and 57 in rheumatic AF
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 20161521075-80
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
European Journal of Cardio-Thoracic Surgery 45 (2014) 126ndash131
40 patients serial CT imaging over 3 year follow-up
CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100 effective safe and durable in the long term Closure of the LAA by epicardialclipping is applicable to all-comers regardless of LAA morphology Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation andor catheter closure Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What is ldquoSuccessrdquo Free From AF Off Antiarrthymics
ldquo 3 month blanking period hellipfreedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the
efficacy of AF ablationhelliprdquoHeart Rhythm 201710 in press
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitoring
ECG Thatrsquos Not EnoughHolter Most Common
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
PPM Most Accurate
Surgery
Cardioversion
Procedure Failure35 seconds of AF after 90 days
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions
bull Not Only Safe it May Reduce Peri-op Riskbull Effectivebull Surgery Can Be Efficient even with LA Only
Lesions (RA Ablation is Easy if Needed)bull 97 Use with MV bull Close or Excise Appendage
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What to Tell the Patient Before Surgery
bull Set Pre-op Expectations Early AF recurrence is NOT a failure
bull Meds Monitoring (ppm holter or zio) Frequency Intervention (CV or CA)
bull ldquoAF nurserdquo printed materials for patient AND the referring cardiologist
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelinesbull Phase I DC to 3 months (Blanking Period)
- Suppressive AAD and anticoagulation - Monitor for symptomatic arrhythmia and DCCV if
needed- Phone follow-up with patient by AF nurse
bull Phase II 3-6 months (Cards EP You)- HampP ECG extended cardiac monitoring- Consideration of discontinuing AAD at 3 months- Consideration of stopping anticoagulation
(CHADS2 or CHA2DS2VASc)- Phone follow-up by AF nurse
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Peri-op Meds
bull Amiodarone 90 at DC bull Second Choice The Prior AA bull Beta blocker rate control
bull 30 arenrsquot on these due to bradycardiaheart block
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Thorac Cardiovasc Surg 2016151798-803
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Monitor OptionsZio and Reveal LINQ
bullWater resistantbull14 days continuous recordingbullPhone app to log symptomsbullReceivereturn via mail
bullImplanted by injectionbull3 year batterybullRemote download of data
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
If You Donrsquot Detect AF is it Safe to Stop AC
Whatrsquos the Stroke Risk
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
CHA2DS2-VASc
Am J Medicine 2012125(6) 603
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
In press Ann Thorac Surg 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NM Freedom from Coumadin and Stroke
At last follow-up 496935 patients (53) off Coumadin
Stroke rate 08year in AF Ablation MV surgery patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 2017103329-41
After SA for AF full anticoagulation therapy is common and reasonable until durable rhythm restoration is established provided the patient otherwise meets criteria for the safe administration of systemic anticoagulant agents Anticoagulation therapy is commonly continued until a stable sinus rhythm is documented by at least a 24-hour Holtermonitor off all antiarrhythmic drugs often between 2 and 6 months postoperatively It is also common practice to obtain an echocardiogram before discontinuing anticoagulation to ensure adequate LA emptying by the absence of spontaneous LA echocardiography contrast
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
bull Phase III 1-2 years- At 6 months post-procedure and every 6 months for 2
years patients should have an ECG and a minimum of a Holter monitor
- Phone follow-up with AF nursebull Patients with Symptoms Suggestive of Arrhythmia
- Patient activated cardiac event monitor- Referral for DCCV or catheter ablation if AFAFL
bull Patients with Implanted Cardiac Devices- Pacemaker defibrillator implanted cardiac monitor- Program to detect and store AHR to substitute external
monitoring
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Post AF Surgery Guidelines
1 month 3 months 6 months 12 months 18 months 24 months
H amp P
ECG
Medication review
Antiarrhythmic STOP
Anticoagulation STOP
Extended Monitoring
Cardioversion 6-8 weeks
Catheter Ablation Consider
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Other
Left atrial
Biatrial
CM III
PVI
n=597 n=392
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Surgery (N=989)June lsquo06 to June lsquo16
0
10
20
30
40
50
60
Mitral Surgery All Others
PAF
Persistent
LSP
bull47
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH AF Ablation and Mitral SurgeryJune lsquo06 to June lsquo16
574 MV patients
405 (71) no intervention 169 (29) intervention
SR Fail CV CA Both303 (53) 102 (18) 119 20 30
SR114 (67)
73 success 20 ldquosalvagerdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summarybull AF in the early post-operative period does not
mean failurebull Cardioversion or referral to EP for ablation
can increase the success of procedurebull Monitoring is critical
- Prior symptoms may no longer exist- ldquoRegular pulserdquo may be controlled flutter
bull49
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
bull Repeated CV after 6 months not usually useful- Consider referral to EP for ablation- Consider re-initiation of suitable AAD
bull Some patients who fail AF surgery are not appropriate to send for intervention- Stop the AAD they were discharged on- Evaluate appropriate anticoagulation
bull50
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Team Follow-up After Surgical Treatment of Atrial Fibrillation
How do you make it happen
bull Develop care guidelines with all players- Cardiology electrophysiology cardiac surgery
and patient- Based on the Expert Consensus Statement
bull Communicate the planbull Follow-up to keep the plan on track
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoThis important manuscript considers many of the factors that are important in the decision making process for the surgical treatment of atrial fibrillation A clear treatment algorithm is offered which can help surgeons increase their success to the obvious potential benefit for patients ldquo
Patrick M McCarthy et al J Thorac Cardiovasc Surg Apr 01 2010 139 860-867
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Controversy About AF Ablation Lesion Set
bull Strong proponents of Cox Maze IV Biatriallesions1 2
bull Data Indicating Equal Efficacy of BA vs LA lesions 3 4
bull Increased Risk with Biatrial vs Left Atrial Only 45
1 Henn MC Lancaster TS Miller JR Sinn LA Schuessler RB Moon MR et al Late outcomes after the Cox maze IV procedure for atrial fibrillation J Thorac Cardiovasc Surg 2015150(5) 1168-78
2 Ad N Henry L Massimiano P Pritchard G Holmes SD The state of surgical ablation for atrial fibrillation in patients with mitral valve disease Current opinion in cardiology 201328(2)170-80
3 Gillinov AM Gelijns AC Parides MK DeRose JJ Jr Moskowitz AJ Voisine P et al Surgical ablation of atrial fibrillation during mitral-valve surgery N Engl J Med 2015372(15)1399-409
4 Phan K Xie A Tsai YC Kumar N La Meir M Yan TD Biatrial ablation vs left atrial concomitant surgical ablation for treatment of atrial fibrillation a meta-analysis Europace European pacing arrhythmias and cardiac electrophysiology journal of the working groups on cardiac pacing arrhythmiasand cardiac cellular electrophysiology of the European Society of Cardiology 201517(1)38-47
5 Soni LK Cedola SR Cogan J Jiang J Yang J Takayama H et al Right atrial lesions do not improve the efficacy of a complete left atrial lesion set in the surgical treatment of atrial fibrillation but they do increase procedural morbidity The Journal of thoracic and cardiovascular surgery 2013145(2)356-61
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Mechanism of AF in Our Surgical Patients is More Complicated than for
Most Lone AF Patients and Experimental Studies
And the Approach in ldquoSimplerdquo Patients Isnrsquot All That Clear
bull5
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular Institute
Northwestern Memorial Hospital
J Am Coll Cardiol 201769303-21
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
AF with MR is NOT The Same as Lone AF
bull Volume Overload Corrected by Surgerybull Pressure Overload Corrected by Surgerybull Atrial Fibrosismyopathyhypertrophy
Anatomically Scattered not at PVLA junctionbull Lessons from Basic Science and Lone AF
Patients are of Limited Use or Irrelevant
bull5
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
N Engl J Med 20153721399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Treating The Mitral Treats the AF
Adding Left Atrial Lesions (location of the Pathologic Change) Increases Success
For MR patients Do RA lesions Add Even More
Is There a Price for BA Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2017
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
2137 Mitral Surgery
838 (39) AF pre-op
724 (86) ablation
616 (79) BA or LA lesion sets with cryo andor bipolar RF available for analysis
359 (58) LA lesion
set
257 (42)BA lesion
set
Lesion set was at discretion of surgeon based on patient characteristics
MethodsNMH 4-rsquo04 thru 6-rsquo14
Mitral surgery +- other
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of Original Groups Variable Left Only
(N=359) Biatrial(N=257)
P-value
Age years 68 + 11 69 + 11 029
Ejection Fraction Median (Q1 Q3) 550 (500 610) 550 (450 600) 0027
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1230 (970 1540) 1310 (1100 1560) 001
Repeat Sternotomy 86 (24) 63 (25) 087
Tricuspid Valve Surgery No () 92(26) 158(61) lt001
Mitral Valve repair 218 (61) 145 (56) 028
Mitral Valve Replacement 141 (39) 112( 44) 028
Mechanical valve 10 (7) 4 (4 ) 028
AF duration years 10 (05 50) 40 (10 105) lt001
Left Atrial Size Median (Q1 Q3) 46 (41 52) 48 (42 53) 0039
Paroxysmal AF 223(62) 86(33) lt001
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 90) 80 (60 100) 0022
30-Day Mortality No () 7 (2) 7 (3) 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Characteristics of PS-Matched Groups Variable Left Only
(N=147) Biatrial(N=147)
P-value
Age years 68 + 12 69 + 12 081
Ejection Fraction Median (Q1 Q3) 550 (500 600) 550 (450 600) 075
Cardiopulmonary Bypass time (min) median (Q1 Q3) 1340 (1100 1620) 1320 (1100 1600) 083
Repeat Sternotomy 38 (26) 36 (24) 079
Tricuspid Valve Surgery No () 67(46) 69(47) 082
Mitral Valve repair 82 (56) 82 (56) 100
Mitral Valve Replacement 65 (44) 65( 44) 100
Mechanical valve 6 (9) 4 (6 ) 074
AF duration years 20 (05 90) 30 (10 80) 023
Left Atrial Size Median (Q1 Q3) 49 (43 54) 47 (42 52) 012
Paroxysmal AF 62(42) 63(43) 078
Post-Operative Length of Stay (Days) Median (Q1 Q3) 70 (60 100) 70 (50 100) 082
30-Day Mortality No () 4 (3) 4 (3) 100
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0
20
40
60
80
FFAF at last FU p=010
LA BA
70 89127
7998124
0
20
40
60
80
FFAF at last FU off AA p=09
LA BA
0
5
10
15
Pre-discharge PPM p=057
LA BA 0
002
004
006
008
Annualized Stroke rate per 10 personyear p=100
LA BA
6982119
7986109
00800712
1714710
14147
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Are There High Risk Subgroups Who May Benefit from BA More Extensive Lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
No Difference in Matched High Risk Subgroups FFAF off AA Last Fup
bull LSPPersistent 714 BA vs 662 LA p=051
bull Increasing LA Size OR=085 p=052
bull Increasing AF Duration OR=096 p=013
bull Also No differences in CVA Coumadin use PPM
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Failures Donrsquot Often Come from the RA and if so are quick and easy to treat as an outpatient
J Thorac Cardiovasc Surg 2010 139860-7
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Have Others Found Recently
bull6
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Conclusions PVI is associated with lower rhythm success than an extended left atrial lesion set The addition of a right atrial lesion to an extended left atrial lesion set does not improve efficacy but it does increase the rate of pacemaker placement for sinus dysfunction Adding an LAA lesion may confer additional efficacy when added to a lesion set that includes PVI + MV
(J Thorac Cardiovasc Surg 2013145356-63)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquohellipThere was no significant difference in the rate of freedom from atrial fibrillation between patients who underwent pulmonary-vein isolation and those who underwent the biatrialmaze procedure (610 and 660 respectively P=060)helliprdquo
N Eng J Med 2015372(15)1399-409
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
532 patients with Maze IV
44 pts with left only lesionsldquoThe success rates were reported for both the biatrialCMPIV and the left-sided CMPIV combined The left sided CMPIV lesion set was included in the analysis because the success rates were observed to be similar to that of the biatrial CMPIV However this group of patients was highly selected In our center a left-sided CMPIV was chosen for patients with paroxysmal AF left atrial sizelt50 cm and no evidence of right atrial enlargement In this selected group late efficacy was goodhelliprdquo
J Thorac Cardiovasc Surg 2015150(5)1168-76
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
LA-only ablation procedures included bilateral PVI (n = 82) with bipolar radiofrequency A PVI-only procedure is referred to as bilateral PVI (or bilateral antral PVI) whereas a more extensive lesion set is referred to as a box lesion in combination with connecting lines to the LA appendage and the mitral valve isthmus endocardially and epicardially over the coronary sinus PVI was accomplished with four to six repeated applications of bipolar radiofrequency
LA lesion set procedures (n = 28) were performed according to the Cox maze IIIIV lesion scheme only on the left atrium by using either a combination of bipolar radiofrequency and cryothermal energy or cryothermal energy only
Ann Thorac Surg 201710358-65
800 patients in study110 (14) LA only and 682 Cox Maze
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
LA-only (n= 93) Cox Maze (n=93) p valueSR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
Propensity score matched outcomesLA-only (n= 93) Cox Maze (n=93) p value
SR without AAD 6M 80 75 041SR without AAD 12M 85 83 074SR without AAD 24M 75 86 013Follow-up cardioversion 14 17 054Folllow-up catheter ablation 7 5 076Freedom from embolic stroke 951 989 021Freedom from TIA 901 930 053
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Europace (2015) 17 38-47
ldquoBiatrial and LA ablations produced comparable 30-day and late mortality but LA was associated with significantly reduced permanent pacemaker implantation rates Biatrial ablation appeared to be more efficacious than LA ablation in achieving SR at 1 year but this difference was not maintained beyond 1 yearrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Permanent Pacemaker Implant
173 in ablation group vs
55 in isolated Mitral Valve P=0003
75
24 in concomitant AVRvs
5 in stand alone Cox Maze IVP=0002
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Risk Factors for PPM Post-AF AblationNorthwestern All Surgery
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
ldquoIrsquod Rather Have a Pacemaker Than a Failed Ablationrdquo
Irsquod Rather Have a Late Right Side Ablation Than a Pacemaker the Rest
of My Life
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
A Series Needs a Comparison
You Canrsquot Say it only Works in Uncomplicated AF if you didnrsquot use it in more Complex Patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why This Study
bull Northwestern Has Extensive Experience with Both Lesion Sets
bull Hypothesis- In mitral valve surgery patients left atrial only (LA) and biatrial (BA) lesions result in similar outcomes
bull Objectives- Determine effectiveness of AF treatment with BA vs LA lesions
- Determine postoperative complication rate in different lesion set groups
- Determine possible subsets that may benefit
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2016
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Our study clearly demonstrates that early to intermediate success rates can be reasonably achieved with LA-only surgical ablation procedures in patients with no significant clinical predictors of failure However the results of the multivariate prediction models in this study should be evaluated with caution Although these modelsprovide initial evidence that ablation procedures confined to the LA may have reduced success in patients with traditional predictors of failure the small sample size and event rate limit the generalizability and reliability of these results
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Presented at The Society of Thoracic Surgeons 52nd
Annual Meeting January 25 2016 Phoenix AZ
Of 914 patients studied 115 had LA only lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
124 patients between 2004-2009 undergoing AVR +- CAB
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
A Series Needs a Comparison
You Canrsquot Say it only Works in Uncomplicated AF if you didnrsquot use it in more Complex Patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why This Study
bull Northwestern Has Extensive Experience with Both Lesion Sets
bull Hypothesis- In mitral valve surgery patients left atrial only (LA) and biatrial (BA) lesions result in similar outcomes
bull Objectives- Determine effectiveness of AF treatment with BA vs LA lesions
- Determine postoperative complication rate in different lesion set groups
- Determine possible subsets that may benefit
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2016
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Our study clearly demonstrates that early to intermediate success rates can be reasonably achieved with LA-only surgical ablation procedures in patients with no significant clinical predictors of failure However the results of the multivariate prediction models in this study should be evaluated with caution Although these modelsprovide initial evidence that ablation procedures confined to the LA may have reduced success in patients with traditional predictors of failure the small sample size and event rate limit the generalizability and reliability of these results
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Presented at The Society of Thoracic Surgeons 52nd
Annual Meeting January 25 2016 Phoenix AZ
Of 914 patients studied 115 had LA only lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
124 patients between 2004-2009 undergoing AVR +- CAB
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Summary
A Series Needs a Comparison
You Canrsquot Say it only Works in Uncomplicated AF if you didnrsquot use it in more Complex Patients
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why This Study
bull Northwestern Has Extensive Experience with Both Lesion Sets
bull Hypothesis- In mitral valve surgery patients left atrial only (LA) and biatrial (BA) lesions result in similar outcomes
bull Objectives- Determine effectiveness of AF treatment with BA vs LA lesions
- Determine postoperative complication rate in different lesion set groups
- Determine possible subsets that may benefit
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2016
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Our study clearly demonstrates that early to intermediate success rates can be reasonably achieved with LA-only surgical ablation procedures in patients with no significant clinical predictors of failure However the results of the multivariate prediction models in this study should be evaluated with caution Although these modelsprovide initial evidence that ablation procedures confined to the LA may have reduced success in patients with traditional predictors of failure the small sample size and event rate limit the generalizability and reliability of these results
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Presented at The Society of Thoracic Surgeons 52nd
Annual Meeting January 25 2016 Phoenix AZ
Of 914 patients studied 115 had LA only lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
124 patients between 2004-2009 undergoing AVR +- CAB
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why This Study
bull Northwestern Has Extensive Experience with Both Lesion Sets
bull Hypothesis- In mitral valve surgery patients left atrial only (LA) and biatrial (BA) lesions result in similar outcomes
bull Objectives- Determine effectiveness of AF treatment with BA vs LA lesions
- Determine postoperative complication rate in different lesion set groups
- Determine possible subsets that may benefit
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2016
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Our study clearly demonstrates that early to intermediate success rates can be reasonably achieved with LA-only surgical ablation procedures in patients with no significant clinical predictors of failure However the results of the multivariate prediction models in this study should be evaluated with caution Although these modelsprovide initial evidence that ablation procedures confined to the LA may have reduced success in patients with traditional predictors of failure the small sample size and event rate limit the generalizability and reliability of these results
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Presented at The Society of Thoracic Surgeons 52nd
Annual Meeting January 25 2016 Phoenix AZ
Of 914 patients studied 115 had LA only lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
124 patients between 2004-2009 undergoing AVR +- CAB
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg in press 2016
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Our study clearly demonstrates that early to intermediate success rates can be reasonably achieved with LA-only surgical ablation procedures in patients with no significant clinical predictors of failure However the results of the multivariate prediction models in this study should be evaluated with caution Although these modelsprovide initial evidence that ablation procedures confined to the LA may have reduced success in patients with traditional predictors of failure the small sample size and event rate limit the generalizability and reliability of these results
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Presented at The Society of Thoracic Surgeons 52nd
Annual Meeting January 25 2016 Phoenix AZ
Of 914 patients studied 115 had LA only lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
124 patients between 2004-2009 undergoing AVR +- CAB
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Our study clearly demonstrates that early to intermediate success rates can be reasonably achieved with LA-only surgical ablation procedures in patients with no significant clinical predictors of failure However the results of the multivariate prediction models in this study should be evaluated with caution Although these modelsprovide initial evidence that ablation procedures confined to the LA may have reduced success in patients with traditional predictors of failure the small sample size and event rate limit the generalizability and reliability of these results
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Presented at The Society of Thoracic Surgeons 52nd
Annual Meeting January 25 2016 Phoenix AZ
Of 914 patients studied 115 had LA only lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
124 patients between 2004-2009 undergoing AVR +- CAB
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Our study clearly demonstrates that early to intermediate success rates can be reasonably achieved with LA-only surgical ablation procedures in patients with no significant clinical predictors of failure However the results of the multivariate prediction models in this study should be evaluated with caution Although these modelsprovide initial evidence that ablation procedures confined to the LA may have reduced success in patients with traditional predictors of failure the small sample size and event rate limit the generalizability and reliability of these results
Ann Thorac Surg 201710358-65
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Presented at The Society of Thoracic Surgeons 52nd
Annual Meeting January 25 2016 Phoenix AZ
Of 914 patients studied 115 had LA only lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
124 patients between 2004-2009 undergoing AVR +- CAB
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Presented at The Society of Thoracic Surgeons 52nd
Annual Meeting January 25 2016 Phoenix AZ
Of 914 patients studied 115 had LA only lesions
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
124 patients between 2004-2009 undergoing AVR +- CAB
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
124 patients between 2004-2009 undergoing AVR +- CAB
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
J Heart Valve Dis 201221350-57
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Unmatched groups
0
5
10
15
Pre-discharge PMM p=0006
LA BA
0
20
40
60
80
FFAF at last FU off AA p=050
LA BA0
20
40
60
80
FFAF at last FU p=057
LA BA
000200400600801
012
Stroke Rate per 10 personyear p=091
LA BA
75231306
73159217
75210280
72143198
724359
1334257
011 011
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Long term survival of the original groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Perioperative complications in propensity matched groups p=032
10370
4430
No complications Complications
9565
5235
Biatrial
No complications Complications
Left only
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital bull9
Long term survival in propensity matched groups
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Heart Rhythm 201710 in press
Freedom from AF
ldquohellipstatement recommends a 3 month blanking period during which recurrences are not countedhelliprdquo
ldquohellipreaffirms the use of freedom from any atrial arrhythmia (eg AF AT AFL) greater than 30 seconds to be the gold standard for reporting the efficacy of AF ablationhellipstrict cutoff might underestimate the true benefit of ablationrdquo
