Atrial Fibrillation:

1
Atrial Fibrillation

• A Surgical Opportunity
• Dr. Erik Beyer

2
Cardiac Surgeons Ablate Atrial Fibrillation
Because

• AF is common
• AF is dangerous
• Ablation is easy and successful

3
AF Is Common

• 2.2 Million in USA
• 160,000 new cases annually
• Prevalence increased in elderly

4
Prevalence of Atrial Fibrillation
30
50
Atrial Fibrillation
40
US Population
20
30
US Population x 1 million
Population with AF x 1000
20
10
10
0
0
lt 5
gt 95
5 - 9
75 - 79
70 - 74
90 - 94
85 - 89
60 - 64
40 - 44
35 - 39
30 - 34
15 - 19
10 - 14
80 - 84
65 - 69
55 - 59
50 - 54
45 - 49
25 - 29
20 - 24
From Feinberg et al. Arch Intern Med,
155469-73, 1995
5
AF Is Dangerous

• Stroke increased 3 to 5-fold
• Mortality increased 2-fold
• Antiarrhythmic medication side effects
• Cost 9300/year

6
A Leading Cause of Stroke
7
Ablation Easy and Successful

• Better understanding of AF
• Lesion sets
• PV isolation linear lesions
• Direct vision
• New ablation technologies

8
AF Two Patient Groups

• AF and concomitant heart surgery
• 100,000 patients per year
• Existing patients
• Existing technology
• AF is primary indication
• Larger number
• New patients
• New technology

9
AF Classification
10
Natural History of AF

• Paroxysmal ? Persistent ?
  Permanent

Self-terminating Sinus is predominant Lasts lt 1
week
Sinus can be restored (chemically,
electrically) Can last gt 1 week
AF is rhythm Rate control Anticoagulation
Paroxysmal
Continuous
Rate of Progression 1 / mo
Remodeling
11

• Rationale for Surgical Care

12

AF Management

• Rate control and anticoagulation
• Suppressive therapy (AAD)
• Device therapy
• Atrial pacing
• Implantable atrial defibrillator
• Ablation
• Catheter
• Surgical

13
Mortality and Morbidity in AFFIRM
30
25
Rhythm
20
Rate
15
Event ()
10
5
0
3
4
5
0
1
2
Time (Years)
Rate N
1889
1760
1264
722
208
2027
Rhythm N
2033
1895
1746
1259
719
231
14

• Surgeons Advantages

15
Surgeons Advantages

• Direct vision
• Operator independence
• Left atrial appendage excision
• Large number of candidates

16
Operator Independence

• Simple and effective technology
• Rapid learning curve
• Wide adoption
• Short procedure times
• Reproducible results

17
Excision of Left Atrial Appendage

• Easy
• Reduces risk of thromboembolism
• ? Eliminate need for coumadin

18

• Basis for Surgical Treatment

19

• Maze Concept Macro-Reentrant Circuits

20
Source Dr. James Cox
21
Source Dr. James Cox
22
New Operations

• Pulmonary Vein Triggers and Left Atrial
  Substrates

23
Pulmonary Vein TriggersParoxysmal AF
Right Atrium
Left Atrium
Septum
superior vena cava
31
fossa ovalis
17
pulmonary veins
inferior vena cava
11
6
coronary sinus
Haissaguerre NEJM 1998 339659-66
24
Atrial Fibrillation Anatomic Location

• Pulmonary veins critical to AF initiation
• LA substrate for AF maintenance
• Ablation therapies
• Directed to these sites
• Tailored to type of AF

25

• Surgical Options

26
Maze Procedure

• The Gold Standard

27
(No Transcript)
28
Cox-Maze III Procedure

• The single most effective curative treatment
  of AF

29
Hospital Mortality

• 0

30
Cox-Maze III Procedure

• The single most effective curative treatment
  of AF
• But it is rarely performed

31
Maze Procedure

• Efficacy
• Safety
• Low Morbidity
• Less Invasive

32

• Pulmonary Vein Isolation and New Operations for
  AF

33
AF OperationsTrends

• Reduce cut and sew
• PV/left atrium
• Alternate energy sources
• More rapid
• Less bleeding

34
AF Operations Energy Sources

• Radiofrequency
• Microwave
• Laser
• Ultrasound
• Cryothermy

35

• Radiofrequency

36
Bipolar Radiofrequency

• Transmural
• Linear
• Rapid
• No char
• No collateral damage

37
(No Transcript)
38
Surgical Animation
39
(No Transcript)
40
Ganglion
41
AG Stimulation
42
BP 2 Placement
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
LAA Resection
48
(No Transcript)
49
(No Transcript)
50
Bipolar RFPerioperative Management

• Perioperative AF
• Antiarrhythmic medication 8-12 wks
• Electrical cardioversion
• In-hospital
• 1-3 months postop
• Coumadin All patients
• 3 months
• INR 2-2.5

51
Bipolar RFConclusions

• Rapid and safe AF ablation
• Perioperative AF common
• More extensive lesion set for continuous AF
  (permanent and persistent)

52
(No Transcript)