Is There a Need to Address AF in patients Undergoing Valve Surgery? Niv Ad, MD Chief, Cardiac Surgery Inova Heart and Vascular Institute Washington DC Metropolitan Area

DISCLOSURES ATS Medical AFM Atricure Inc. Consultant Speaker SAB Co-Owner Atricure Inc. Past consultant (<2yrs)

Is There a Need to Address AF in patients Undergoing Valve Surgery? YES!!

30-40% of MV patients need treatment for AF Atrial Fibrillation The Cox Maze Procedure 30-40% of MV patients need treatment for AF

Maze procedure: Long term results 97% Intermittent AF in 58 % (n=276) 92% Prasad SM et al. JTCVS 2003;126:1822-8 6

Do we (you) believe the results? Analysis Do we (you) believe the results?

The most common introduction in the literature: The Maze procedure The most common introduction in the literature: The gold standard Complex Complications Results?

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The brand name 11

my maze Different energy Different lesion set 12

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Barnett S. and Ad N.; JTCVS May 2006 Meta-Analysis: Bi-atrial vs. Left atrial only n~6000, 1991-2005, 69 studies Barnett S. and Ad N.; JTCVS May 2006 14

New ablation device Do you know your ablation device?

The IHVI AF surgery program Since 2005 n=450 25% stand alone procedures About 25% minimally invasive Over 90% of the stand alone performed using MI techniques

Energy source Argon based cryothermal energy Combination of bipolar RF and cryo NEVER used unipolar RF, microwave or laser Very careful with epicardial beating heart procedures

IHVI surgical AF ablation with mitral valve N=177 Groups Minimally Invasive (MI) Median Sternotomy (MS) Total Repair 16 83 99(56%) Replacement 3 74 77(43%) Repair/replace 1 1(1%) 19 (11%) 158 (89%) 177

Pre-operative characteristics All N(%) Mean (SD) N= 177 MI N= 19 MS N=158 Age >75yrs 27(15%) 1(5%) 26(16%) Long Standing Persistent/Permanent Afib 79(45%) 6(32%) 73(46%) Months Duration 73.1(72.4) 33.9(24.5) 76.6(74.3) Persistent Afib 80(45%) 10(53%) 70(44%) 4.5(9.4) 14.5(23.2) 3.0(3.5) Paraxsymal 8(5%) 7(4%) 21.0(43.9) 127.8(-) 5.7(8.7) No History of Afib/Unk/Other 10(5%) 2(10%) 8(6%) Thromboembolic Event LA Size >5.5 cm2 53(30%) 8(42%) 45(28%) EF <35% 9(5%) CHADS Score 1.6(1.1) 1.5(0.9) Hemorrhagic Score** 1.9(1.3) 1.1(1.0) 2.0(1.3) ** calculation= [1.6*age > 60 (0,1)] + [1.3* female (0,1)] + [2.2* history of malignancy (0,1)] (Higher score indicates an increased risk for bleeding/ maximum score would be 5.1).

Selected complications All N=177 MI N=19 MS N=158 Months Post Operative 33.2(17.5) 21.3(13.5) 34.6(17.3) Days of Hospital Stay (op to DC) 10.5(13.3) 5.3(2.0) 11.2(13.9) Length of Stay>10 days 47(27%) 47(30%) Infection-Sternum Deep 1(0.6%) Infection-Sternum Superficial Permanent Stroke Transient Stroke Operative Death 6(3%) 6(4%) Prolonged Ventilator 19(11%) 19(12%) Re-admit to ICU 3(2%) Renal Failure 11(6%) 11(7%) Dialysis Required 9(5%) 9(6%) Reop-bleeding 7(4%) 1(5%) Reop-Valve Dysfunction Rewire Sternum 2(1%) Readmit to Hosp <30 days 17(10%) 2(11%) 15(9%) *Complications are during operative stay

Post discharge complications (mean follow-up 33.2±17.5 mo) # Pts with Episodes of: All MI MS Major Bleeding 10 Stroke-embolic 2 Stroke-bleed 1 TIA *Post discharge after blanking period

All surgeons results Regardless of AA Medications Off AA Medications 114 100 74 109 98 74 With N’s noted 101 91 69 13 9 5 9 5 89 96 69 13 With N’s noted With N’s noted Regardless of AA Medications Off AA Medications

Single surgeon results 5 With N’s noted With N’s noted Off AA Medications With N’s noted

Figure 1: Survival of Patients Undergoing Surgical Ablation for Atrial Fibrillation Compared to those who did not Undergo Surgical Ablation for Atrial Fibrillation

Is the CHADS Score applicable

Stroke/TIA Events Bleeding

HRQL Norm Based for All Groups

Conclusions The maze procedure is safe and effective Should be considered in all patients High risk patients may benefit from restoring SR Surgeons should specialized Programs should designate surgeons CHADS score unreliable Be careful with the energy source