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Concomitant Atrial FibrillationConcomitant Atrial Fibrillation
- allways Maze? -- allways Maze? -
Robert JM KlautzRobert JM Klautzchief department Cardiothoracic Surgerychief department Cardiothoracic Surgery
QuestionsQuestions
• What do we want to achieve?What do we want to achieve?
• SRSR
• reduce need for OAC / AADreduce need for OAC / AAD
• freedom from palpitationsfreedom from palpitations
• freedom from TE / strokefreedom from TE / stroke
• improve LV functionimprove LV function
• What is achieved by the primary procedure?What is achieved by the primary procedure?
• Which patients benefit, what is the price?Which patients benefit, what is the price?
Concomitant AFConcomitant AF
• definitiondefinition• AF in a patient undergoing cardiac surgeryAF in a patient undergoing cardiac surgery
• Type of SurgeryType of Surgery• Mitral valve surgeryMitral valve surgery• Aortic valve surgeryAortic valve surgery• CABGCABG
• Type of AFType of AF• paroxysmalparoxysmal• persistentpersistent• permanentpermanent
Bleeding Risk with WarfarinBleeding Risk with Warfarin
• Major HaemorrhageMajor Haemorrhage
4.6% /yr4.6% /yr
• hospitalization, transfusion, or surgeryhospitalization, transfusion, or surgery
Chimowitz et al NEJM 2005
ICH risk:0.1% /yr no ACRR AC 0.5%disabilty doubled
ICH risk:0.1% /yr no ACRR AC 0.5%disabilty doubled
Prevalence of Preoperative AFPrevalence of Preoperative AF- likelyhood of concomitant treatment -- likelyhood of concomitant treatment -
STS database 2004-2006STS database 2004-2006
Gammi et al Ann Thor Surg 2008
AF in Mitral Valve DiseaseAF in Mitral Valve Disease- prevalence -- prevalence -
AF in medically treated MV disease:linearized rate 5% per year !
AF in medically treated MV disease:linearized rate 5% per year !
Grigioni et al JACC 2002
AF in Mitral Valve DiseaseAF in Mitral Valve Disease- risk -- risk -
Grigioni et al JACC 2002
AF is an independent risk factor for death in MR patientsAF is an independent risk factor for death in MR patients
Survival after Mitral Valve SurgerySurvival after Mitral Valve Surgery- pre-operative SR vs AF -- pre-operative SR vs AF -
Ngaage et al Ann Thorac Surg 2004
If AF is a risk factor for bad outcome
in MV disease
and after MV surgery
Can we modify it ?
If AF is a risk factor for bad outcome
in MV disease
and after MV surgery
Can we modify it ?
Cox Maze III + MV surgery
Remains gold standard regarding lesion set
Superior freedom from Afib MCT + RCT
? 80 % at 5 years
Superior freedom from Stroke / TE MCT (trend in RCT)
No survival benefit (yet)
But: obsolete
Combined MV & AF SurgeryCombined MV & AF Surgery
Wong et al Ann Thorac Surg 2006
MV surgery and AF interventionMV surgery and AF intervention
• RCT 6 mo AFRCT 6 mo AF
• 24 MV repair + Biatrial modRF24 MV repair + Biatrial modRF
• 25 MV repair + intensive rhythm control25 MV repair + intensive rhythm control
von Oppell et al. Eur J CardioThor Surg 2009
• 63% of pts with SR after 63% of pts with SR after
AF-ablation had normal AF-ablation had normal
atrial function atrial function
• RadiofrequencyRadiofrequency
• Dry / IrrigatedDry / Irrigated
• Unipolar / BipolarUnipolar / Bipolar
• CryothermiaCryothermia
• High Frequency UltrasoundHigh Frequency Ultrasound
• MicrowaveMicrowave
• LaserLaser
Combined MV & AF SurgeryCombined MV & AF Surgery- new energy sources -- new energy sources -
Electrophysiological Goals in AF SurgeryElectrophysiological Goals in AF Surgery
What do we aim for?Conduction block
Eliminate triggers/fociEliminate triggers/foci
PV isolation (complex or box)PV isolation (complex or box)
Reduce substrateReduce substrate
Connecting line roof LAMitral isthmus lineConnecting line roof LAMitral isthmus line
LALA
RARA Intercaval? Free wall? Isthmus ?Intercaval? Free wall? Isthmus ?
How to decide on an approach?How to decide on an approach?
First: STANDARDIZE
Then: INDIVIDUALIZE
First: STANDARDIZE
Then: INDIVIDUALIZE
Lesion sets for AF SurgeryLesion sets for AF Surgery
Paroxysmal AF: pulmonary vein isolation (PVI)Paroxysmal AF: pulmonary vein isolation (PVI)
Epicardially closed beating heart, off-pump
Energy source bipolar RF
cryothermia
Access minimal access possible
Lesion sets for AF SurgeryLesion sets for AF Surgery
Persistent / permanent AF: substrate reductionPersistent / permanent AF: substrate reduction
Epicardially limited to box lesion only
Energy source HIFU (ultrasound) (+ mitral isthmus)
cryothermia
bipolar RF
Access minimal access possible
Lesion sets for AF SurgeryLesion sets for AF Surgery
Endocardially Full CM III / “derivative”
Energy source bipolar RF
cryothermia
(cut and sew)
Access minimal access possible (CM IV)
Persistent / permanent AF: substrate reductionPersistent / permanent AF: substrate reduction
How to standardize - Concomitant AFHow to standardize - Concomitant AF
CONCOMITANT AF:
sternotomy in general, minimal access in selected cases
paroxysmal cases: PVI only (off-pump)
persistent cases: more extensive lesions – epi-endocardial
How to standardize - Concomitant AFHow to standardize - Concomitant AF- extended pulmonary vein isolation -- extended pulmonary vein isolation -
Benussi et al J Thorac Cardiovasc Surg 2005
How to standardize - Concomitant AFHow to standardize - Concomitant AF- mitral isthmus line -- mitral isthmus line -
Benussi et al J Thorac Cardiovasc Surg 2005
How to standardize - Concomitant AFHow to standardize - Concomitant AF
CONCOMITANT AF:
Trade off:- Quite invasive for aortic valve or CABG procedures
Question:- Right sided lesions ?
How to standardize - Concomitant AFHow to standardize - Concomitant AF- right sided lesions -- right sided lesions -
Barnett et al J Thorac Cardiovasc Surg 2006
How to standardize - Concomitant AFHow to standardize - Concomitant AF- right sided lesions -- right sided lesions -
PM implantation rate not studied
Barnett et al J Thorac Cardiovasc Surg 2006
How to standardize - Concomitant AFHow to standardize - Concomitant AF- right sided lesions -- right sided lesions -
"Addition of right atrial lesions conferred no additional benefit in these patients"
"Addition of right atrial lesions conferred no additional benefit in these patients"
"…both the left atrial combined with cavotricuspid isthmus ablation and biatrial procedures had similar outcomes despite
significant shorter CPB times in the LA group"
"…both the left atrial combined with cavotricuspid isthmus ablation and biatrial procedures had similar outcomes despite
significant shorter CPB times in the LA group"
Combined MV & AF SurgeryCombined MV & AF Surgery- Left Atrial Appendage -- Left Atrial Appendage -
Garcia-Fernandez et al JACC 2003
Combined MV & AF SurgeryCombined MV & AF Surgery- Left Atrial Appendage -- Left Atrial Appendage -
Retrospective analysis of 205 MV replacement pts
14 % SR
58 ligation LAA (6 incomplete)
69 months: 27 TE events
Absence of LAA ligation vs TE: OR 6.7
Including incomplete LAA ligation: OR 11.9
Garcia-Fernandez et al JACC 2003
Combined MV & AF SurgeryCombined MV & AF Surgery- Left Atrial Appendage -- Left Atrial Appendage -
Kanderian et al JACC 2008
Combined MV & AF SurgeryCombined MV & AF Surgery- Left Atrial Appendage -- Left Atrial Appendage -
Kanderian et al JACC 2008
• Atrioventricular Block – PM implantationAtrioventricular Block – PM implantation
• Collateral DamageCollateral Damage
• Lesions related tachy-arrythmiasLesions related tachy-arrythmias
Surgery for Atrial FibrillationSurgery for Atrial Fibrillation- inherent risks -- inherent risks -
Concomitant AF SurgeryConcomitant AF Surgery- the future -- the future -
• Patient-specific approachPatient-specific approach
• Assessment of conduction blockAssessment of conduction block
• Team up with EP cardiologistTeam up with EP cardiologist
• TrialsTrials
• CRAFT-CABGCRAFT-CABG
Allways Maze?Allways Maze?
• Fewer lesionsFewer lesions
• Patients with paroxysmal AF: PVIPatients with paroxysmal AF: PVI
• LAALAA
• No ablationNo ablation
• low chance of succeslow chance of succes• large atrium, (very) long standinglarge atrium, (very) long standing
• high riskhigh risk• elderly patientelderly patient