1. 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

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

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

5. 30-40% of MV patients need treatment for AF
Atrial Fibrillation The Cox Maze Procedure
30-40% of MV patients need treatment for AF

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

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

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

9. 9

11. The brand name 11

12. my maze
Different energy
Different lesion set 12

13. 13

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

15. New ablation device
Do you know your
ablation device?

16. 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

17. 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

18. 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

19. 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).

20. 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

21. 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

22. 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

23. Single surgeon results5
With N’s noted
With N’s noted
Off AA Medications
With N’s noted

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

25. Is the CHADS Score applicable

26. Stroke/TIA
Events
Bleeding

27. HRQL Norm Based for All Groups

28. 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