Pr

1
SURGICAL TREATMENT OF ATRIAL FIBRILLATION
1/ Incidence of AF 5 of the population gt 60
years, - 600 000 candidates for AF surgery in
USA 2/ Etiologies among patients applying for a
life insurance 40 lone AF, 60 with
cardiopathy 3/ Restoration of sinus rhythm after
valve repair depends upon the duration of AF (gt
1year) and left atrium dimensions (gt60mm) 4/ The
presence of preoperative AF does not influence
the operative risk Specific surgical procedures
aiming at treating atrial fibrillation must add
minimal morbidity
Chua JTCS 1993 Obadia JTCS 1997
2
ATRIAL EXCLUSION LINES which tracing?
1/ Original Cox-Maze III procedure 2/ Hemicox
left maze procedure 3/ Exclusion of the pulmonary
veins ( left appendage exclusion)
3
CLASSICAL COX-MAZE III
left appendage
right appendage
sup. veina cava
septal incision
pulmonary veins
tricuspid
mitral
inf. veina cava
4
LEFT COX-MAZE PROCEDURE
left appendage
pulmonary veins
mitral
5
EXCLUSION OF THE PULMONARY VEINS
left appendage
pulmonary veins
6
COX-MAZE PROCEDUREassociated to mitral valve
surgery
N 40
Indications Chronic AF gt 6 months 35 Intermitt
ent AF (left maze) 5
AGE 15-71 YRS (4916 YRS) ETIOLOGIES OF
MITRAL VALVE DISEASE degenerative 20 rheu
matic 17 others 3
7
MITRAL VALVE PROCEDURE associated to the Cox-maze
MAZE DURATION complete 52 min left 23 min
8
RESULTScomplete maze left maze

• mortality 1 (2,5) (septic shock)
• reoperation for bleeding 3
• coronary bypass for circumflex stenosis 1
• pace maker (complete maze) 1
• fluid retention (complete maze) 4
• lower limbs edema 4
• pericardial effusion 2
• pleural effusion 2

9
POSTOPERATIVE EKGcomplete maze left maze
n 39
immediate
1 month
AT 1 MONTH, FREEDOM FROM AF 75
10
LATE EKG
18 pts with complete maze
1 month
1 year
AT ONE YEAR FREEDOM FROM AF 69
11
POSTOPERATIVE TREATMENT
anticoagulants
antiarhythmics
Transient stroke at 10 mths, sinus with AC 1
12
DOPPLER following COX-MAZE PROCEDURE evidence for
atrial transport
e
e
a
a
tricuspid flow
mitral flow
13
ATRIAL WALL in chronic atrial fibrillation
muscular hypertrophy
fat transformation
C. Guiraudon in La fibrillation auriculaire JY
Le Heuzey 1997 p51
14
COX-MAZE PROCEDURE INDICATIONS
AF indication N intermit. /
chronic lone AF other
Cox World Heart Foundation Schaff 221 20
80 25 75 Mayo Clinic Mc Carthy 100
22 78 23 77 Cleveland
Clinic Izumoto 104 0 100 0
100 Iwate, Japon
308 58 42 56 44
15
COX-MAZE OPERATION RESULTS
CPB mortality fluid ret. pace
maker
Cox - 2,9 6 15 World Heart
Foundation Schaff 122 mn 1,4 - 3,2 Mayo
Clinic Mc Carthy 120 mn 1 yes 6 Cleveland
Clinic Izumoto 177 mn 2 - 6 Iwate, Japon
16
COX-MAZE OPERATION RESULTS

free from AF free from AF
postop. intermittent AF late
99 38 99 World Heart
Foundation Schaff 90 38 70
3 yrs Mayo Clinic Mc Carthy -
33 90 3yrs Cleveland Clinic Izumoto
72 - 65 5yrs Iwate, Japon
17
COX-MAZE OPERATION RECENT ADVANCES
1/ Results of patients with rheumatic vs
degenerative MV disease are identical Lee,
Annals 20037557-61 2/ Right sided maze does not
arrythmogenic substrate of lone AF and may not be
necessary Jessurun, Europace 2003539-46 3/ The
maze operation does not influence atrial volumes
in patients with lone AF / mitral surgery reduces
LA volume Jessurun, Annals 20037551-6 4/ The
left maze can be performed through a minimally
invasive approach Akpinar, Eur J Card Surg
200324223-30
18
ENERGY SOURCES which ablation technique?
1/ Surgical cut and sew GOLD STANDARD 2/
Radiofrequency 3/ Cryogenic injury TRANSMURALITY
? 4/ Microvawe
19
RADIOFREQUENCY ABLATION technical approach
endocardial
epicardial
20
RADIOFREQUENCY ABLATION
epicardial endocardial probes
histology showing transmural lesion
21
RADIOFREQUENCY PROCEDURE INDICATIONS
22
RADIOFREQUENCY PROCEDURE RESULTS
23
RADIOFREQUENCY ABLATION RECENT CONCEPTS
1/ No transmurality when atrial wall thickness gt
4 mm 2/ The epicardial is less efficient than
the endocardial approach (epicardial fat
circulating blood) Thomas, Annals
200375543-8 3/ Atrioesophageal fistula is a
potential complication cachectic patient, LA
ectasia, TEE probe Mohr, J Thorac CVS
2002123919-27 4/ Circumflex coronary stenosis
is a potential complication Fayad, Annals
2003761291-3 5/ Age at surgery and postop
arrhytmias are predictive factors of a negative
outcome Benussi, Eur J Card Surg 200317524-9
24
CONCLUSIONS
1/ The Cox-Maze operation is very efficient in
restoring normal sinus rhythm in chronic or
intermittentAF and remains the gold standard 2/
The left maze seems to be as efficient as the
complete maze in pts with mitral valve
disease 3/ Radiofrequency ablation could be an
important adjunct in pts with lone/non-mitral
related AF 4/ Antiarrhythmics are often necessary
to maintain a good long term results 5/ The TE
risk is decreased but not eliminated