Slayt 1 - RM Solutions

The Surgical Treatment of
Atrial Fibrillation.An
Overview of Ten Years.
February 8-12 2010 Riyad
SHA
Prof. Dr.Belhhan Akpinar
Istanbul Bilim Universitesi
Florence Nightingale Hastanesi
Istanbul
Flörence Nightingale Hospital
Surgery for AF
(1985-1993)
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
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1 . Corridor operation (Dr Guiradone)
2. M aze procedure (Dr Cox )
M aze I I ,I I I ,I V
Alternative Methods(MAZE)
First Step Towards A Less Invasive Approach
Cryoablation
 Microwave
 Bi-polar Cautery
 Radiofrequency
 Irrigated Radiofrequency
 Irrigated BP Radiofrequency
 Ultrasound
 Laser

CUT & SEW /ALTERNATIVE
SOURCES,PUBMED-MEDLINE
SCANNING RESULTS (1995- 2005)


Ablation w ith alternative
sources w as safe and effective
to treat AF.
K hargi. Eur J Cardiothorac Surg 2005
Heart Rhythm Society 20062008(EHRA,ECAS,ACC,AHA & STS)
Indications for surgical ablation

1.Sym ptom atic AF patients undergoing
cardiac surgery
2.Selected asym ptom atic AF patients
undergoing cardiac surgery in w hom
ablation can be perform ed w ith
m inim al risk
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3. Stand-alone surgery should be considered
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for sym ptom atic patients w ho prefer a
surgical approach,
- have failed one or m ore attem pts at
catheter ablation
- or are not candidates for catheter
ablation.
IRF Maze,Florence Nightingale
Feb 2000- November2009
N= 592 patients
 Follow-up: 6 - 77 months


Bipolar: 208 patients
Florence Nightingale Hospital
Florence Nightingale Hospital
Florence Nightingale Hospital
Ablation lesion pattern for bipolar
devices
Concomitant Procedures

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

MVR
MVP
MVR + TP
MVP + TP
MVR + AVR
CABG
CABG + MP
AVR
292
96
33
36
34
59
16
27
RESULTS

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Mortality
10(1.94%)
Reoperation for bleeding 7
Infection
6
LCO
9
IABP
3
Pace maker
10
Florence Nightingale Hospital
RHYTHM STATUS
100
90
80
70
60
50
40
30
20
10
0
PO
S
S
S
4-12 weeks 12 months 24 mo
36mo(95)
48mo(45)
60mo (18)
Gr A
Gr B
RF Ablation,Results at one year
 Melo et al
 Williams et al
 Alfieri et al
 Mohr et al
 Khargi et al
 Sie et al
74 - 97 %
Why are Results Different ?
I. Patient Selection
II. Ablation Pattern
III. Ablation Device
LA Size and Results
LA Diameter:
< 70 mm
> 70 mm
94 %
56 %
Ann Thorac Surg 2001
LA Diameter:
LA diameter < 65 mm
LA diameter > 65 mm
90%
52%
FNH Experience
Atrial Fibrillation
Lone AF:
 LA diameter is generally normal


AF + Mitral Valve Disease
Large LA with remodeling
with less likelyhood for cure
Kosaka Y,Advances in cardiac surgery,2000
Arrhythmia After RF Maze

Micro-re-entries that cause atrial
arrhythmia,increase in atrial automaticity

Tissue edema and scar formation in the atria

10-15% AF rate after open heart surgery
Mechanism of AF
The maze procedure prevents
Large macroeentry perfectly.
The maze procedure cannot
prevent small macroeentry
Which is ready to stop.
The maze procedure cannot
prevent small microeentry
Which continues endlessly.
Modes of failure
f-wave is nearly 0 mV
 LA diameter > 70mm
 CT ratio >80%


curative rate of AF falls below 50%

Wang et al Eur J Cardithorac Surg 2009;35 116-122
Von Oppel et al,Eur J Cardithorac Surg 2009 35 641-50
Lee et al,Eur J Cardiothorac Surg 2009,36,36 272-279


General Risks Concerning RF Ablation
Esophagus injury
 Coronary artery injury
 Bleeding
 Pace maker (1-3%)

RF Maze
Are lesions transmural?
Tissue thickness (2 - 4mm)
 Level of energy
 Irrigation
 Time

Average Lesion Depth vs. Ablation Time*
*95% confidence
8
-
Average Depth (mm)
7
30 watts 5cc/min
6
-
5
--- 20 watts 5cc/min
--
25 watts 5cc/min
4
3
2
1
0
0
5
10
15
20
25
Time (sec)
(over 1cm area)
30
35
40
Left or Bi -Atrial Maze

Left Sided Maze:
127
Bi atrial Maze:
51
History of Atrial Flutter
Tricuspid valve pathology

No Difference in SR R estoration
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Akpinar et al:Biatrial versus left atrial M aze P rocedure:Cardiac
Electrophysiology Review ,Oct 2003
K hargi et al:Left versus Biatrial M aze. Cardiac Electrophysiology Review ,2002
Left or Biatrial M aze
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A meta analysis of the literature
suggests that there may be a
difference in favour of the bi-atrial
appropach.
Barnett S. J Thorac Cardiovasc Surg 2006
Left or Biatrial M aze
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Prospective randomized comparison of
left atrial and biatrial RF ablation in
the treatment of AF.
Both treatment modalities were
equally effective.
Wang et al,European Journal of Cardiothoracic
surgery 2009
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To assess the clinical and survival benefit of atrial
fibrillation surgery in patients submitted to valve
surgery.
1773 patients with a follow up of more than one
year were divided into three groups.
Stable sinus
Stable AF
Other rhythm
Adverse cardiac event incidence and predictors of
long term outcome were compared between three
groups.

Thromboembolic events were
found to be associated with
the absence of stable sinus
rhythm.
Melo et al, The Journal of Cardiothoracic And Cardiovascular Surgery April 2008
Conclusion

The achievment of stable
sinus rhythm is a predictor of
better survival and lower
incidence of thromboembolic
events.
Conclusion

The achievment of stable
sinus rhythm is a predictor of
better survival and lower
incidence of thromboembolic
events.
Predictors of stable sinus
rhythm
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sm aller dim ensions of left
atrium
biatrial approach
absence of preoperative
permanent AF
duration of AF
absence of concomittant CABG
surgery
Surgery for Acquired CVD
Melo et al, The Journal of Cardiothoracic And Cardiovascular Surgery April 2008
To ablate or not?

Mitral valve surgery plus concomittant
atrial fibrillation ablation is superior to
mitral valve surgery alone with an
intensive rhythm control strategy.
75 % -- 39%

Von Oppel et al. Eur J Cardiothorac Surg 2009

Unipolar versus Bipolar M aze
Manual of Surgical treatment of AF, Sie et al 2008
Full Lesion Set Required to Optimize
Efficacy of Treatment
Sources:
Hocini 2004 JCE, Wazni 2005 JAMA, Feld 2004 JAC,
Pappone 2005 Ital. Heart J, Karch 2005 Circulation,
Weerasooriya 2005 Heart Rhythm
Lesion
Parox.
Pers.
Perm.
PVI
75%
65%
55%
LPV->
RPV
85%
MV
85%
LPV->
LAA
85%
AG
?
75%
75%
75%
?
65%
70%
75%
?
= required lesions
Trigger
Substrate Paroxismal
Persistent
Permanent
P.V.
İsolation
Maze
Late
Early
Time
Evaluation of Rhythm
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There is an unstable period for 3
months. Evaluating rhythm during this
period may be misleading.
First evaluation should be at 3 months,
followed by 6 months and at 12
months. Yearly follow up is
recommended afterwards/
Postoperative Treatment
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1. Amiodarone,loading dose in the OR,
continuing the loading dose in the ICU
with iv perfusion, and then 200mg
daily for 3 months.
2. B blockers (Metoprolol or Sotalol)
daily for 3 months
Contraindications
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Sick Sinus Syndrome
Reoperations with severe adhesions
LA calcific wall
Endocarditis
Tips for success
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PATIENT SELECTION
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Duration of AF
Long standing chronic AF
Left atrial size
Concomittant pathology
Overall survival
P ostoperative freedom from stroke
rates betw een concom ittant m aze and
control groups in four random izedcontrolled trials
Postoperative sinus rhythm conversion
rates betw een four random ized
controlled studies 4
P ostoperative long term survival rates
in the four random ized controlled
studies
Conclusion 1
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Long lasting AF rarely converts to sinus
rhythm after m itral valve surgery.
I n such patients elim ination of AF is
desirable to prevent anti arrhythm ic
treatm ent and continuing LA
enlargem ent if this can be achieved w ith
low risk.
P rophylactic ablation during m itral valve
surgery in patients w ith SR is not
recom m ended at this point.
Conclusion 2
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Question
Facts
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Freedom From AF
++++
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Freedom from throm boem bolic
Com plications
+++
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Long Term Survival Advantage
++
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Quality of life

?
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Thank you