Concomitant Atrial Fibrillation - allways Maze? -

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Concomitant Atrial Fibrillation - allways Maze?
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• Robert JM Klautzchief department Cardiothoracic
  Surgery

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Get Rhythm 2006
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Questions

• What do we want to achieve?
• SR
• reduce need for OAC / AAD
• freedom from palpitations
• freedom from TE / stroke
• improve LV function
• What is achieved by the primary procedure?
• Which patients benefit, what is the price?

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Concomitant AF

• definition
• AF in a patient undergoing cardiac surgery
• Type of Surgery
• Mitral valve surgery
• Aortic valve surgery
• CABG
• Type of AF
• paroxysmal
• persistent
• permanent

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Bleeding Risk with Warfarin

• Major Haemorrhage 4.6 /yr
• hospitalization, transfusion, or surgery

ICH risk 0.1 /yr no AC RR AC 0.5 disabilty
doubled
Chimowitz et al NEJM 2005
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Prevalence of Preoperative AF- likelyhood of
concomitant treatment -
STS database 2004-2006

Gammi et al Ann Thor Surg 2008
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AF in Mitral Valve Disease- prevalence -
AF in medically treated MV disease linearized
rate 5 per year !
Grigioni et al JACC 2002
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AF in Mitral Valve Disease- risk -

AF is an independent risk factor for death in MR
patients
Grigioni et al JACC 2002
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Survival after Mitral Valve Surgery-
pre-operative SR vs AF -
Ngaage et al Ann Thorac Surg 2004
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If AF is a risk factor for bad outcome in MV
disease and after MV surgery Can we modify it ?
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Combined MV AF Surgery
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
Wong et al Ann Thorac Surg 2006
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MV surgery and AF intervention

• RCT 6 mo AF
• 24 MV repair Biatrial modRF
• 25 MV repair intensive rhythm control

• 63 of pts with SR after AF-ablation had normal
  atrial function

von Oppell et al. Eur J CardioThor Surg 2009
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Combined MV AF Surgery- new energy sources -

• Radiofrequency
• Dry / Irrigated
• Unipolar / Bipolar
• Cryothermia
• High Frequency Ultrasound
• Microwave
• Laser

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Electrophysiological Goals in AF Surgery
What do we aim for?

Conduction block
Eliminate triggers/foci
Reduce substrate
PV isolation (complex or box)
LA
Connecting line roof LA Mitral isthmus line
RA
Intercaval? Free wall? Isthmus ?
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How to decide on an approach?

First STANDARDIZE Then INDIVIDUALIZE
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Lesion sets for AF Surgery
Paroxysmal AF pulmonary vein isolation (PVI)

Epicardially closed beating heart,
off-pump Energy source bipolar RF cryothermia A
ccess minimal access possible
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Lesion sets for AF Surgery
Persistent / permanent AF substrate reduction

Epicardially limited to box lesion only Energy
source HIFU (ultrasound) ( mitral
isthmus) cryothermia bipolar
RF Access minimal access possible
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Lesion sets for AF Surgery
Persistent / permanent AF substrate reduction

Endocardially Full CM III / derivative Energy
source bipolar RF cryothermia (cut and
sew) Access minimal access possible (CM IV)
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How 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

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How to standardize - Concomitant AF- extended
pulmonary vein isolation -

Benussi et al J Thorac Cardiovasc Surg 2005
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How to standardize - Concomitant AF- mitral
isthmus line -

Benussi et al J Thorac Cardiovasc Surg 2005
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How to standardize - Concomitant AF

• CONCOMITANT AF
• Trade off
• Quite invasive for aortic valve or CABG
  procedures
• Question
• - Right sided lesions ?

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How to standardize - Concomitant AF- right sided
lesions -

Barnett et al J Thorac Cardiovasc Surg 2006
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How to standardize - Concomitant AF- right sided
lesions -

PM implantation rate not studied
Barnett et al J Thorac Cardiovasc Surg 2006
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How to standardize - Concomitant AF- right sided
lesions -
"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"
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Combined MV AF Surgery- Left Atrial Appendage -
Garcia-Fernandez et al JACC 2003
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Combined MV AF Surgery- 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
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Combined MV AF Surgery- Left Atrial Appendage -
Kanderian et al JACC 2008
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Combined MV AF Surgery- Left Atrial Appendage -
Kanderian et al JACC 2008
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LAA Closure- Watchman Device -
Holmes et al Lancet 2009
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Surgery for Atrial Fibrillation- inherent risks -

• Atrioventricular Block PM implantation
• Collateral Damage
• Lesions related tachy-arrythmias

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ESC Guideline AF 2010
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Concomitant AF Surgery- the future -

• Patient-specific approach
• Assessment of conduction block
• Team up with EP cardiologist
• Trials
• CRAFT-CABG

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Allways Maze?

• Fewer lesions
• Patients with paroxysmal AF PVI
• LAA
• No ablation
• low chance of succes
• large atrium, (very) long standing
• high risk
• elderly patient