Richard Harvey, M.D.

• Interventional Cardiologist at GMC/Gwinnett Medical Group

• Board Certified as a Surgeon• Specialty: Congenital Cardiac

Surgery (Thoracic Surgery)• Diplomat of the American Board

of Thoracic Surgery, as well as a member of the American College of Surgeons, the Society of Thoracic Surgeons and the Alpha Omega Alpha honor medical society

Residency-CardiacUniversity of Mississippi

Residency- SurgeryMercer University School

of Medicine

Medical School:University of Mississippi School of

Medicine

Richard L. Harvey, MD

Gwinnett Medical Group

HYBRID APPROACH TO AFIB

QUESTION # 1 - 3

• Where was the first successful corrective therapy for a cardiac arryhthmia performed?

• Who performed this procedure?

• Where is this person from?

FATHER OF ARRHYTHMIA SURGERY

WILL C. SEALY, MD

• Chairman of Cardiothoracic Surgery at Duke University

• WPW Syndrome

• Ivan Brown, PhD

• May 2, 1968

• On Cardio-pulmonary Bypass

• Cut and Sew Lesion

• Off-pump efforts had failed at Mayo earlier

• Spent the last 10 years of career at Mercer

QUESTION # 4 - 6

• Where was the first successful corrective therapy for Afib performed?

• Who performed this procedure?

• What was it called?

INTRODUCED THE MAZE PROCEDURE

JAMES L. COX, MD

• Followed Dr. Sealy at Duke

• Multiple failed efforts with mapping

• Developed MAZE due to ineffective mapping

• Performed fully open with CPB

• Cut and Sew Technique

• Poorly Adopted due to Complexity

MOVEMENT AWAY FROM SURGERY

• Procedures were to complex/invasive

• Catheter Skills/Technology continued to improve

• Large Office-Based Component to Patient Care

• Electrophysiology developed as a discipline of Cardiology

SURGERY AND THE MITRAL VALVE• Late 1990s and MV Surgery

• Symptoms and strong association with Afib

• Open techniques returned

• Multiple devices were introduced—simplicity

• Cryo

• Radiofrequency

• Monopolar

• Bipolar

• Ultrasound

• Cut and Sew MAZE was still considered too much

REMAINED SEPERATE FROM EP

• No Multi-disciplined approach

• Academic Centers resurgence in research

• Ongoing Debate about Efficacy

• Very poor Trust in Data

THE UNIVERSITY OF MISSISSIPPI MEDICAL CENTER

June 11,1963

Martin L. Dalton, MD

James D. Hardy, MD

Norman E. Shumway, MD

Medgar Evers

NEW TECHNOLOGY HAS CREATED CHANGE

• Muliple new Therapies has changed approach

• Require multi-disciplinary Team Approach

• Require medical specialties and surgical specialties to work together as a team

• Places that cannot do this fail

• TAVR

• Destination LVAD

ARRHYTHMIA CENTERS AT ACADEMIC INSTITUTIONS

• Complexity of Disease

• Minimally invasive techniques Improved

• Recognition of Limitations of Catheter Therapies

• Surgical Patients

• Persistent Afib

• Long-Standing Persistent Afib

• Failed Catheter Paroxysmal Patients

• Enlarged Left Atrium

• Cleveland Clinic

• Northwestern University

• Vanderbilt University

• Washington University

DEVICE COMPANIES

• Responded to the Increased Interest

• Less Invasive Methods

• Mimic MAZE Procedure

• Deal with the Left Atrial Appendage• Concomitant FDA Approval

University of Mississippi

AFIB: THE HYBRID APPROACH• Surgeons and EP working together

• Can’t speak for EP

• Sugeons:

• Not Electrophysiologists, we are Anatomists

• Are not equipped to treat medically

• Not Office-based

• Not Medicine pushers

• Can get to anatomical areas of the heart that are difficult with a catheter

• Without Back-up

AFIB: THE HYBRID APPROACH• Simultaneous or Sequential Procedures

• Part done by the Surgeon

• Part done by an Electrophysiologist

• Patient Selection = Algorithm/Symptomatic

• Persistent Afib

• Large Left Atrium

• Thrombus in LAA

• Failed Catheter Ablations

QUESTIONS # 7 – 9

• A patient in Afib for 10 years undergoes Cardiac Surgery requiring CPB, what will his/her rhythm be when seperating from CPB?

• On POD #3, patient goes into Afib who has never had this prior to surgery, what is the cause?

• A Patient undergoes a MAZE procedure with a Mitral Valve Repair, what are their chances of going back into afib post-op? When is the ablation considered a failure?

University of Mississippi School of Medicine

SURGICAL DEVICES: PROS & CONS

ESTECH COBRA

ESTECH COBRA

• Unilateral Thoracoscopy

• Doesn’t Require CPB

• Creates only Box Lesion

• Mostly used with Concomitant AVR

• Requires:

• No history of Thoracotomy

• Adequate Lung Function

• Usually Staged Procedures

ATRICURE

ATRICURE

• Most closely mimics MAZE

• Allows closure of LAA

• Allows Immediate testing for block

• Requires Bilateral Thoracoscopy

• No history of Thoracotomy

• Adequate Lung Function

• Only device with FDA Approval for Afib

NCONTACT

NCONTACT

• Called Convergent Procedure

• Requires both Surgical and EP Procedure

• Transabdominal via Diaphragm

• Simplest of the Surgical Side of the Options

• Previous Upper Abdominal Surgery is a Contraindication

• Does not address the LAA

ANY QUESTIONS?