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Dubrava University HospitalZagreb, Croatiawww.kbd.hr
DEPARTMENT OF CARDIAC SURGERY
RF Ablation of Atrial RF Ablation of Atrial Fibrillation in Valvular Fibrillation in Valvular
Heart Surgery PatientsHeart Surgery Patients
Željko Sutlić
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
IntroductionIntroduction
The incidence of chronic atrial fibrilation (AF) is age dependent:
1% of the general population
4% in pts > 60 years
7% in pts > 70 years
60-80 % in pts with significant mitral valve disease
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
AF - TYPESAF - TYPES
paroxsismal AF
persistant AF
permanent AF
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Criteria for SuccessCriteria for Success
Sinus Rhythm
Absence of intermittent AF
Absence of atrial flutter
Atrial transport function
Restricted antiarrhythmic medication
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
CriteriaCriteria
Indication for mitral valve repair/replacement or coronary artery disease
Chronic atrial fibrillation (>6 months)
Electrocardiographical confirmation of diagnosed chronic atrial fibrillation by 24 hour holter monitoring
EF > 30 %
Age: 18 – 80 years
Informed consent
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Atrial fibrillation in Patients Atrial fibrillation in Patients Undergoing Mitral Valve Surgery: Undergoing Mitral Valve Surgery: Why AF Surgery?Why AF Surgery?
Incidence of AF varies between 30 – 50%
Curative AF surgery can eliminate the need for anticoagulation by restoring sinus rhythm, particulary important in patients having valve repair
Rate of anticoagulation-related bleeding after mechanical valve surgery is between 0,3 to 4,9 events/ patient year
Bleeding rates with mitral bioprosthesesare less but stillsignificant (0,6 – 2,1 episodes/patient year) in part due to the need for anticoagulation for AF
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Atrial Fibrillation: Surgical TherapyAtrial Fibrillation: Surgical Therapy
Cox developed the Maze Procedure – first performed in 1987 at Barnes Jewish Hospital
High rate of surgical cure for atrial fibrillation (>90%) without antiarrhythmic therapy
Indications:Drug refractory AF
Arrhythmia intolerance
Recurrent thromboembolism
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Atrial fibrillation and Mitral Valve Atrial fibrillation and Mitral Valve DiseaseDisease
Should all patients with atrial fibrillation who are referred for mitral valve surgery undergo a concomitant Cox-Maze procedure?
Let's look at our long term surgical results in these patients!
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Cox-Maze III ProcedureCox-Maze III Procedure
Cox-Maze III first performed in 1988
Maze-like surgical incisions
Based on theory of multiple macro-reentrant circuits
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
The Cox Maze Procedure:The Cox Maze Procedure:Evolution of the Surgical ApproachEvolution of the Surgical Approach
The Cox Maze I was abandoned because of a high incidence of chronotropic incompetence and pacemaker implantation
The Cox Maze II was replaced because of its' technical difficulty
The Cox Maze III has remained the gold standard since 1988 and has extraordinary long term efficacy
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
The Cox-Maze Procedure:The Cox-Maze Procedure:Surgical ObjectivesSurgical Objectives
Cure of atrial fibrillation
Restoration of A-V synchrony
Preservation of atrial function
Discontinuation of anticoagulation and anti-arrhythmic drugs
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Cox-Maze III ProcedureCox-Maze III ProcedurePatient PopulationsPatient Populations
Lone atrial fibrillation
Atrial fibrillation in association with organic heart disease:
valvular heart disease
ischemic heart disease
Freedom form AF Freedom form AF All PatientsAll Patients
Cox JL. Surg Treat of AF, San Francisco, June 2003Cox JL. Surg Treat of AF, San Francisco, June 2003
Freedom from AF Freedom from AF LM versus CMLM versus CM
Cox JL. Surg Treat of AF, San Francisco, June 2003Cox JL. Surg Treat of AF, San Francisco, June 2003
Efficacy of Surgical Maze Procedure for Efficacy of Surgical Maze Procedure for Atrial FibrillationAtrial Fibrillation
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Cox-Maze III Procedure with Mitral Surgery: Cox-Maze III Procedure with Mitral Surgery: Washington University ExperienceWashington University Experience
65 consecutive patients between January 1988 – May 2003; mean follow-up = 3.6 years
Avarage duration AF: 5.2 years (0,5–28 years)
Paroxysmal AF: 41%
Operative mortality : 1/65 ( 1.5% )
Freedom from AF at 10 years: 97%
No late strokes!
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Advantages of the COX-MAZE III Advantages of the COX-MAZE III ProcedureProcedure
High cure rate (>90%)Proven long-term efficacyApplicable to both persistent and paroxysmal AFEliminates the late risk of stroke in a high risk populationRequires no additional devices except for a cryoprobe
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Shortcomings of the COX-MAZE III Shortcomings of the COX-MAZE III ProcedureProcedure
Requires cardiopulmonary bypass and an arrested heart
Adds to cross-clamp time
Few surgeons perform the operation due to its' complexity
Significant morbiditypacemaker requirement and left atrial dysfunction
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Cox-Maze III Procedure for AF Cox-Maze III Procedure for AF Postoperative ManagementPostoperative Management
DiureticsLasixSpironolactone
Coumadin3 monthsDiscontinue if in NSR
Anti-arrhythmic drugs2 monthsDiscontinue if in NSR
Postoperative sinus node dysfunction10 – 15 % of patientsWait 7-10 days before implanting pacemaker
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
The Cox Maze Procedure:The Cox Maze Procedure:Goals of a Less Invasive ApproachGoals of a Less Invasive Approach
Preserve the high success rates of the Cox-Maze III procedure while decreasing its' morbiditySimplify and/or decrease the number of atrial incisions to shorten the procedure and increase its' adoption rate among surgeonsReplace surgical incisions with linear lines of ablation using various energy sources:
CryosurgeryRadiofrequencyMicrowaveLaserUltrasound
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Radiofrequency energyRadiofrequency energy
similar to electrocautery
very fast AC current
no depolarisation of the heart
monopolar or bipolar
irrigated or not irrigated (early)
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Dry vs- Irrigated Electrode Tissue Dry vs- Irrigated Electrode Tissue Heat DistributionHeat Distribution
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Complications of RF Ablation for Complications of RF Ablation for Atrial FibrillationAtrial Fibrillation
CVA
TIA
Tamponade
Aortic tear
Pulmonary vein stenosis
Damage to MV apparatus
Phrenic nerve injury
Coronary artery injury
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Surgical procedure (began on april Surgical procedure (began on april 2003)2003)
MVR and TVP 6 patients
MVR and CABG 1 patient
average aortic clamp time 94 ± 42 min
average pump time 124 ± 25 min
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Table 1. Clinical characteristics (n=7)Table 1. Clinical characteristics (n=7)Age (years) 58 (45-72)Male/femalePower p wave 25 W
< 3 years 53-6 years 1> 6 years 1
amjoderon 4atenolol 1
verapamil 1metildigoxin 1
DM (n) 1Arterial hypertension (n) 1Reoperation (n) 1Death (n) 1
AF duration
Antiarrhythmic drug tested
3/4
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Table 2. Echocardiographic variablesTable 2. Echocardiographic variablespreoperative
valuespostoperative
valuesanteroposterior LA diameter (mm)
49 (45-59) 47 (42-51)
mediolateral LA diameter (mm)
50 (50-52) 49 (48-55)
superinferior LA diameter (mm)
61 (60-69) 62(60-67)
anteroposterior RA diameter (mm)
40 (39-45) 38 (31-43)
mediolateral RA diameter (mm)
45 (42-56) 39 (31-45)
superinferior RA diameter (mm)
56 (52-60) 47 (45-52)
LVED (mm) 57 (50-64) 53 (48-64)
LVES (mm) 43 (38-47) 42 (37-48)
EF (%) 47 (45-51) 48 (41-56)
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Table 3. Single case (male, 58 years old, MVR + TVP)Table 3. Single case (male, 58 years old, MVR + TVP)
preoperative postoperative3 month
postoperativeanteroposterior LA diameter (mm)
45 47 45
mediolateral LA diameter (mm)
52 48 46
superinferior LA diameter (mm)
61 67 48
anteroposterior RA diameter (mm)
39 31 31
mediolateral RA diameter (mm)
45 45 34
superinferior RA diameter (mm)
56 52 48
LVED (mm) 64 52 55
LVES (mm) 47 39 35
EF (%) 51 49 65
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Surgery for Atrial Fibrillation:Surgery for Atrial Fibrillation:Established Facts and Surgical Established Facts and Surgical ApproachApproach
We have very effective, though invasive, operation with high success ratesPatients who are candidates for Cox Maze procedure should not be deprived of a curative, known procedure for a theoretical lesion set performed with unproven technologyNew procedures and technology should be subject to rigorous prospective clinical trialsNew lesion sets should be based on known mechanisms of atrial fibrillation
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Will There Be a Role for Surgery in Will There Be a Role for Surgery in the Future?the Future?
Yes, for the symptomatic patient:Who requires other concomitant cardiac surgical procedures
Coronary artery disease
Valvular heart disease
Congenital disease
With prior thromboembolic complications
For persistent and "permanent" atrial fibrillation
PossiblyWith paroxysmal atrial fibrillation if performed via minimally invasive techniques
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Catheter Ablation Techniques for Atrial Catheter Ablation Techniques for Atrial Fibrillation: ConclusionsFibrillation: Conclusions
Effective (60-80%) for drug refractory paroxysmal AF with pulmonary vein triggersTargets PV-LA junction, with linear line to MVA, possible linear lesion across Bachman's bundleProlonged procedures, requires transseptal access to the LALesions constrained by biophysical properties of tissueComplications approach 5%
TIA/CVAPulmonary vein stenosis Cardiac tamponadeAortic tear, coronary injury
One of multiple tools available
Dubrava University HospitalZagreb, Croatia
www.kbd.hr/kardkir
Department of Cardiac Surgery
Everything should be made Everything should be made as simple as possible. But as simple as possible. But
not simpler.not simpler.
Albert Einstein