Concomitant Atrial Fibrillation - allways Maze? - Robert JM Klautz chief department Cardiothoracic Surgery

Get Rhythm 2006

Questions 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 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 Warfarin Major Haemorrhage 4.6% /yrMajor Haemorrhage 4.6% /yr hospitalization, transfusion, or surgeryhospitalization, transfusion, or surgery Chimowitz et al NEJM 2005 ICH risk: 0.1% /yr no AC RR AC 0.5% disabilty doubled ICH risk: 0.1% /yr no AC RR AC 0.5% disabilty doubled

Prevalence of Preoperative AF - likelyhood of concomitant treatment - STS database Gammi et al Ann Thor Surg 2008

AF in Mitral Valve Disease - 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 Disease - risk - Grigioni et al JACC 2002 AF is an independent risk factor for death in MR patients

Survival after Mitral Valve Surgery - 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 AfibMCT + RCT ? 80 % at 5 years Superior freedom from Stroke / TEMCT (trend in RCT) No survival benefit (yet) But: obsolete Combined MV & AF Surgery Wong et al Ann Thorac Surg 2006

MV 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 % of pts with SR after AF-ablation had normal atrial function63% of pts with SR after AF-ablation had normal atrial function

RadiofrequencyRadiofrequency Dry / IrrigatedDry / Irrigated Unipolar / BipolarUnipolar / Bipolar CryothermiaCryothermia High Frequency UltrasoundHigh Frequency Ultrasound MicrowaveMicrowave LaserLaser Combined MV & AF Surgery - new energy sources -

Electrophysiological Goals in AF Surgery What do we aim for? Conduction block Eliminate triggers/foci PV isolation (complex or box) Reduce substrate Connecting line roof LA Mitral isthmus line Connecting line roof LA Mitral isthmus line LA RA Intercaval? Free wall? Isthmus ?

How to decide on an approach? First: STANDARDIZE Then: INDIVIDUALIZE First: STANDARDIZE Then: INDIVIDUALIZE

Lesion sets for AF Surgery Paroxysmal AF: pulmonary vein isolation (PVI) Epicardially closed beating heart, off-pump Energy sourcebipolar RF cryothermia Accessminimal access possible

Lesion sets for AF Surgery Persistent / permanent AF: substrate reduction Epicardiallylimited to box lesion only Energy sourceHIFU (ultrasound) (+ mitral isthmus) cryothermia bipolar RF Accessminimal access possible

Lesion sets for AF Surgery EndocardiallyFull CM III / “derivative” Energy sourcebipolar RF cryothermia (cut and sew) Accessminimal access possible (CM IV) Persistent / permanent AF: substrate reduction

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

How to standardize - Concomitant AF - extended pulmonary vein isolation - Benussi et al J Thorac Cardiovasc Surg 2005

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

How to standardize - Concomitant AF CONCOMITANT AF: Trade off: -Quite invasive for aortic valve or CABG procedures Question: -Right sided lesions ?

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

How to standardize - Concomitant AF - right sided lesions - PM implantation rate not studied Barnett et al J Thorac Cardiovasc Surg 2006

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"

Combined MV & AF Surgery - Left Atrial Appendage - Garcia-Fernandez et al JACC 2003

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

Combined MV & AF Surgery - Left Atrial Appendage - Kanderian et al JACC 2008

Combined MV & AF Surgery - Left Atrial Appendage - Kanderian et al JACC 2008

LAA Closure - Watchman Device - Holmes et al Lancet 2009

Atrioventricular Block – PM implantationAtrioventricular Block – PM implantation Collateral DamageCollateral Damage Lesions related tachy-arrythmiasLesions related tachy-arrythmias Surgery for Atrial Fibrillation - inherent risks -

ESC Guideline AF 2010

Concomitant AF Surgery - 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? 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