Hybrid Ablation of AF in the Operating Room: Is There a Need? MAZE III Procedure. Spectrum of Atrial Fibrillation

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Hybrid Ablation of AF in the Operating Room: Is There a Need? MAZE III Procedure Paul J. Wang, MD Amin Al-Ahmad, MD Gan Dunnington, MD Stanford University Cox J, et al. Ann Thorac Surg.

Treatment Algorithms for AF: 2011 Update Amiodarone Dofetilide No (or minimal) heart disease Dronedarone Flecainide Propafenone Sotalol ablation Amiodarone Dofetilide MAINTENANCE OF SINUS RHYTHM No

1 Hybrid Ablation of AF in the Operating Room: Is There a Need? MAZE III Procedure Paul J. Wang, MD Amin Al-Ahmad, MD Gan Dunnington, MD Stanford University Cox J, et al. Ann Thorac Surg. 1993;55: Treatment Algorithms for AF: 2011 Update Amiodarone Dofetilide No (or minimal) heart disease Dronedarone Flecainide Propafenone Sotalol ablation Amiodarone Dofetilide MAINTENANCE OF SINUS RHYTHM No Dronedarone Flecainide Propafenone Sotalol Hypertension Substantial LVH ablation Yes Amiodarone ablation Coronary artery disease Amiodarone Dofetilide Dronedarone Sotalol ablation Heart failure Amiodarone Dofetilide ablation Spectrum of Atrial Fibrillation Least Most Paroxysmal, LA <5.0 cm Persistent, LA < 5.0 cm Paroxysmal, LA >5.0cm Persistent, LA >5.0cm (>1 year) LA < 5.0 cm (>1 year), LA >5.0cm ACCF/AHA/HRS Focused Update on Management of Patients with Atrial Fibrillation (Updating the 2006 Guideline) J Am Coll Cardiol 2011; 57: Differences from 2006 Highlighted by P Wang compared to Fuster V et al. J Am Coll Cardiol. 2006;48:e

2 Spectrum of Atrial Fibrillation Spectrum of Atrial Fibrillation Least Most Paroxysmal, LA <5.0 cm Persistent, LA < 5.0 cm Paroxysmal, LA >5.0cm Persistent, LA >5.0cm (>1 year) LA < 5.0 cm (>1 year), LA >5.0cm Ablation Least Most Paroxysmal, LA <5.0 cm Persistent, LA < 5.0 cm Paroxysmal, LA >5.0cm Persistent, LA >5.0cm (>1 year) LA < 5.0 cm (>1 year), LA >5.0cm What is your estimate of freedom from AF at 1 year of 1 catheter ablation procedure with LA 6.0 cm and AF persistently for 5 years? Which single (not repeat) procedure has the highest success for achieving freedom from AF? A % B. 50% 86% A. ablation B. Thoracoscopic Maze 67% C. 70% D. 90% C. Thoracoscopic Maze plus ablation 29% 5% % 5 0 % 10% 7 0 % 3% 9 0 % 0% C a t h e t e r a b l a t... T h o r a c o s c o p i c... T h o r a c o s c o p i c... 2

Rationale for a Hybrid AF Procedure Does any catheter ablation procedure have a single procedure success of 50%, 80% or more in these patients at 1yr, 2yr, 5yr?

3 Rationale for a Hybrid AF Procedure Does any catheter ablation procedure have a single procedure success of 50%, 80% or more in these patients at 1yr, 2yr, 5yr? For example, patient with AF 5 years and LA 6.0 cm Long-standing persistent AF Large atria Highest single procedure success Rapid procedural recovery Reasonable risk Procedure Methodology Hybrid Approach 12 Hybrid Epicardial Ablation Procedure Lesion Set Lesions consist of: -Pulmonary Vein Isolation -Roof and inferior connecting lesions -Lesion from the left superior pulmonary vein to the left atrial appendage -LA isthmus lesion from LI PV to AV groove Patient is intubated with double lumen endotracheal tube Patient is prepped in usual manner Small incisions are made for 5mm or 10mm diameter access ports Access ports are inserted in the right chest 3

Epicardial Surgical Ablation- Right Side Right Side GP Testing and Ablation Right Antral Ablation Start Right Roof line through Transverse Sinus using Ablation Pen (approximately half of the line to

4 Epicardial Surgical Ablation- Right Side Right Side GP Testing and Ablation Right Antral Ablation Start Right Roof line through Transverse Sinus using Ablation Pen (approximately half of the line to be completed from the right side) Start Right sided inferior line using Ablation (approximately half of the line to be completed from the right side) Optional: SVC to IVC linear line with Ablation Pen or Transpolar Pen (discontinue line at junction of IVC at area of no recorded electrograms) Optional: Encircling SVC lesion using the bipolar clamp and/or Ablation Pen Epicardial Surgical Ablation- Left Side Left Side GP Testing and Ablation Obliterate Ligament of Marshall Left Antral Isolation Finish ablation of the Roof Line and extend from LSPV to left atrial appendage using Ablation Pen Finish ablation of the Inferior Line using Ablation Pen Epicardial Surgical Ablation Lines Setup A line from the inferior (caudad) box lesion towards the mitral annulus using the Ablation Pen Ablation will stop 1-2 cm before reaching the atrioventricular groove, to avoid injury to the left circumflex coronary artery. 4

5 Marking Port Breaking Through Skin to Make Port Maneuvering Devices Maneuvering Scope 5

6 Right PV Dissection. Aorta svc Head of Patient Pulm Artery La ap La dome svc Right superior PV pa Post la dome rspv Waterston s Groove Grabber holds end of the Lighted Dissection tape and will advance behind the PV SVC SVC Waterson s groove RPA and below SVC Waterstone;s groove PA RSPV PA RS PV RIPV Lighted dissection under RIPV comes in transverse sinus 6

Pinching tool pulls off the Lighted Dissection tape from the

where pv enter lung Lung Endocardial Ablation LA AP common

CS for standard EP mapping and ablation techniques Place multi

CS cannulation and transseptal puncture Create Right

7 Pinching tool pulls off the Lighted Dissection tape from the lighted articulated dissection tool pericardium Hilum of lung where pv enter lung Lung Endocardial Ablation LA AP common trunk LIPV LSPV Insert multipolar Coronary Sinus catheter into CS for standard EP mapping and ablation techniques Place multi electrode diagnostic HIS catheters in position for guidance of CS cannulation and transseptal puncture Create Right Cavotricuspid Isthmus Lesion Check for bidirectional Right Cavotricuspid Isthmus block 7

8 Endocardial Ablation Perform Transseptal puncture Assess the LAA surgical lesion for presence of bidirectional block. If incomplete block exists, complete the ablation lesion using an endocardial approach. Endocardial Ablation Complete ablation to the Mitral Valve Isthmus Lesion Test for bidirectional Mitral Valve block Check for both Right and Left entrance and exit block PVIs Check Posterior Box for isolation Endocardial Ablation Re-Check bidirectional block for Right Cavotricuspid Isthmus Lesion Check Encircling SVC Lesion for entrance and exit block Hybrid Endocardial Ablation Procedure Endocardial Right Atrial Isthmus Lesion: - RA Isthmus lesion will be completed by the EP 8

9 Right Superior Pulmonary Vein Post-Epicardial Ablation Right Inferior Pulmonary Vein Post-Epicardial Ablation Left Superior Pulmonary Vein Post-Epicardial Ablation Left Inferior Pulmonary Vein Post-Epicardial Ablation 9

N=47 Courtesy of Mark La Meir: Netherlands/Belgium and Univ Virginia Courtesy of Mark La Meir: Netherlands/Belgium and Univ Virginia What is the Contribution of Endocardial catheter ablation stage?

8 days 10 persistent; 17 long-standing persistent Iso: 13 patients had 1 atrial flutter All patients had antral and SVC isolation 28 gaps in 17 patients Roof near LSPV 10/27 (37%); floor near RIPV

10 N=47 Courtesy of Mark La Meir: Netherlands/Belgium and Univ Virginia Courtesy of Mark La Meir: Netherlands/Belgium and Univ Virginia What is the Contribution of Endocardial catheter ablation stage? 27 patients; EP study within 4 days: days 10 persistent; 17 long-standing persistent Iso: 13 patients had 1 atrial flutter All patients had antral and SVC isolation 28 gaps in 17 patients Roof near LSPV 10/27 (37%); floor near RIPV 4/27 (15%); mitral line 10/12 (83%) Mahapatra S et al Heart Rhythm Journa 2011:S315 What is the Contribution of Endocardial catheter ablation stage? All gaps were ablated months 23 patients free of AF and off AAD (85%) 3 free off AF with AAD (11%) 1 patient had AF despite AAD(4%) No atrial flutter requiring repeat ablation Mahapatra S et al Heart Rhythm Journa 2011:S315 10

Which single (not repeat) procedure has the highest success for achieving freedom from AF? A. ablation B. Thoracoscopic Maze C. Thoracoscopic Maze plus ablation C a t h e t e r a b l a t.

11 Which single (not repeat) procedure has the highest success for achieving freedom from AF? A. ablation B. Thoracoscopic Maze C. Thoracoscopic Maze plus ablation C a t h e t e r a b l a t... 12% T h o r a c o s c o p i c... 4% 84% T h o r a c o s c o p i c... Take Home Messages Success of single procedure is low in patients with large atria and long-standing persistent AF Hybrid approach appears to result in a low AF recurrence rate with low likelihood of atrial flutters Further studies are needed to examine this approach in a larger patient population Thank You Paul.J.Wang@stanford.edu 11

Stand alone maze: when and how?

Stand alone maze: when and how? Dong Seop Jeong Department of Thoracic and Cardiovascular Surgery, HVSI Samsung Medical Center Type of atrial fibrillation First diagnose AF Paroxysmal AF: self-terminating