Atrial Fibrillation Surgery The Blackpool Experience

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1 Atrial Fibrillation Surgery The Blackpool Experience Augustine Tang BMedSc(Hon) DM FRCS(C Th) FETCS Consultant Cardiothoracic Surgeon

AF Pathophysiology Structural heart disease BP, CCF Autoimmune: anti MHC Genetic lamin AC gene RAAS, MMP, disintegrin Conduction system Sick sinus syndrome Henry WL, Morganroth J,

Relation of left atrial pathology to atrial fibrillation in mitral valvular disease. Ann Intern Med. 1968;69:13-20. Davies MJ, Pomerance A. Pathology of atrial fibrillation in man.

2 AF Pathophysiology Structural heart disease BP, CCF Autoimmune: anti MHC Genetic lamin AC gene RAAS, MMP, disintegrin Conduction system Sick sinus syndrome Henry WL, Morganroth J, Pearlman AS, et al. Relation between echocardiographically determined left atrial size and atrial fibrillation. Circulation. 1976;53: Bailey GWH, Braniff BA, Hancock EW, Cohn KE. Relation of left atrial pathology to atrial fibrillation in mitral valvular disease. Ann Intern Med. 1968;69: Davies MJ, Pomerance A. Pathology of atrial fibrillation in man. Br Heart J. 1972;34: Sanfilippo AJ, Abascal VM, Sheehan M, et al. Atrial enlargement as a consequence of atrial fibrillation. A prospective echocardiographic study. Circulation. 1990;82:792-7.

3 AF Surgery Why do it? Restoration of sinus rhythm would Improve quality of life, reduce symptoms & increase exercise tolerance Offer freedom from long term anti arrhythmic drugs Offer freedom from long term anticoagulation Reduce thromboembolism & stroke? Reduce long term mortality? Removal of left atrial appendage would Minimize thromboembolic stroke Offer freedom from long term anticoagulation

4 AF Surgery Basis Macro reentry circuits in atrial walls Ectopic triggers sited in Pulmonary veins Substrate remodelling Perceived invasiveness: CPB duration & technical demands Postoperative morbidities: bleeding, arrhythmias & LA function

5 AF Surgery Evolution Cox Maze procedures Version III 1988 Modified CM III/CM IV (Cryothermy 2000; Bipolar RF 2003)

6 AF Surgery Muddy Waters Gold Standard CM III Freedom from AF 96.6% at 6yr FU 95% at 10yr FU 93% at 14yr FU Emerging fore runner CM IV (n=282) 89% free from AF at 1yr 78% free from AF & drugs (Damiano, RJ et. al. J Thorac Cardiovasc Surg 2011;141: ) But what about... Patient factors? Paroxysmal v. Persistent AF duration Lone v. Concomitant Preop atrial size Technical factors? Lesion pattern Energy source & design Exit block test for PVI Concomitant procedures

7 Atrial Fibrillation Left atrial size Atrial fibrillation

AF & Atrial size Very large left atria provide the substrate for atrial fibrillation [Kopecky S, Gersh B, McGoon M, Whisnant JP, Holmes Jr DR, Ilstrup DM, Frye RL.

8 AF & Atrial size Very large left atria provide the substrate for atrial fibrillation [Kopecky S, Gersh B, McGoon M, Whisnant JP, Holmes Jr DR, Ilstrup DM, Frye RL. The natural history of lone atrial fibrillation: A population based study over three decades. N Engl J Med 1987;317:669 74] LA with diameter >60 mm is a substrate for development and maintenance of AF [Henry W, Morganroth J, Pearlman A, Clark CE, Redwood DR, Itscoitz SB, Epstein SE. Relation between echocardiographically determined LA size and AF. Circulation 1976;53:273 9] Ravelli F, Allessie M. Effects of atrial fibrillation on refractory period and vulnerability to atrial fibrillation the isolated Langendorff perfused rabbit heart. Circulation 1997;96: acute dilatation of the atria by volume load in isolated perfused rabbit hearts measured the right and left effective refractory periods, as well as the generation of atrial fibrillation by simple premature stimuli a decrease in threshold and an increase in the ability to induce AF from 0% to 100% (drastic shortening of atrial effective refractory period) the induced atrial fibrillation in a dilated left atrium contributes to further atrial dilatation

9 RF Catheter AF ablation & LA Jeevanantham V, Ntim W, Navaneethan SD, Shah S, Johnson AC, Hall B, Shah A, Hundley WG, Daubert JP, Fitzgerald D. Metaanalysis of the effect of radiofrequency catheter ablation on left atrial size, volumes and function in patients with atrial fibrillation. Am J Cardiol May 1;105(9): Systematically review relevant studies through April 2009 for the effects of RFCA on LA size, volumes, and function in patients with AF Weighted mean differences for changes in LA diameter, LA max volume, LA min volume, LA ejection fraction, and LA active emptying fraction were estimated using fixed and random effects meta analyses Seventeen (869 patients) among 192 studies were analyzed Compared to baseline, overall LA diameter and volume significantly after ablation LA ejection fraction & active emptying fraction remain unchanged after ablation These changes were not observed in those with recurrent AF after ablation Successful RFCA in patients with AF significantly decreases LA size and volume and does not seem to adversely affect LA function

Effect of AF surgery on LA size It has been reported that atrial size remained unchanged after an isolated maze procedure Jessurun ER, van Hemel NM, Kelder JC, et al.

10 Effect of AF surgery on LA size It has been reported that atrial size remained unchanged after an isolated maze procedure Jessurun ER, van Hemel NM, Kelder JC, et al. The effect of maze operations on atrial volume. Ann Thorac Surg 2003;75:51 6 Choo et al. compared GLA patients to those with LA diameter <65 mm who underwent the maze procedure. LA size was reduced in both groups early postoperatively, but no further reduction was observed for the next 2 years follow up Choo S, Park N, Lee S, Kim JW, Song JK, Song H, Song MG, Lee JW. Excellent results for atrial fibrillation surgery in the presence of giant left atrium and mitral valve disease. Eur J Cardiothorac Surg 2004;26: Among 30 GLA patients, LA diameter significantly from 69.0±8.5 mm to 53.7±9.1 mm shortly after surgery and maintained at 5 years of follow up Hagihara H, Kitamura S, Kawachi K, Morita R, Taniguchi S, Fukutomi M, Kawata T, Hasegawa J, Yoshida Y. Left atrial plication combined with mitral valve surgery in patients with a giant left atrium. Surg Today 1995;25:338 42

11 Cox maze for AF & Atrial size DOES SIZE MATTER?

12 Cox maze & atrial morphology Multiple transmural lesions to interrupt macro reentry circuits Excision/exclusion of left atrial appendage Left atriotomy Right atriotomy RA appendage access incision

$Cox maze in Giant atria The ability of the left atrium to fibrillate is determined by the relation between the effective refractory period of the atrial myocardium and the atrial area available for$

13 Cox maze in Giant atria The ability of the left atrium to fibrillate is determined by the relation between the effective refractory period of the atrial myocardium and the atrial area available for the macroreentrant circuit. This fact that a critical area of atrial tissue is needed to support or sustain atrial fibrillation would therefore suggest the importance of reducing the size of the atrium to eliminate AF. Furthermore, by Laplace s law, decreasing the size of the atrium will ultimately decrease the wall stress of the chamber and may reduce a primary stimulus for fibrillation Matthew A. Romano, David S. Bach, Francis D. Pagani, Richard L. Prager, G. Michael Deeb and Steven F. Bolling. Atrial reduction plasty Cox maze procedure: extended indications for atrial fibrillation surgery Ann Thorac Surg 2004;77: The maze itself depends on placing the incisions close enough to preclude the development of macro re entrant circuits in the atrium. A maze can be performed absolutely perfectly in a huge atrium, but if the resultant lesions are far enough away from one another that macro re entrant circuits can form between them, then the operation will fail and the atrial fibrillation will persist. James L Cox STS 2004

14 Recurrent AF after Cox maze Mean LA size 5.8cm preop (N=263) Larger LA diameter the prevalence of AF in both the late & constant time phases At 5 yr FU, the predicted prevalence of AF was 5% with a 4 cm LA but 15% with a 6 cm left atrium There is no clear cut off value beyond which restoration of sinus rhythm is impossible Earlier operation and left atrial size reduction should be considered Gillinov AM, Sirak J, Blackstone EH, McCarthy PM, Rajeswaran J, Pettersson G, et al. The Cox Maze procedure in mitral valve disease: predictors of recurrent atrial fibrillation. J Thorac Cardiovasc Surg 2005;130:

15 LA reduction in Cox maze Concomitant LA reduction: facilitate SR restoration (85% v. 68% p<0.05) improve LA mechanics & function ( Booster pump & reservoir function) promote LA reverse remodelling

LA reduction in Cox maze In the present study, patients who did not undergo LA volume

recovery, most likely because prolonged atrial overload before the surgery may have

stress of the enlarged left atrium compared with the reduced left atrium might prevent

16 LA reduction in Cox maze In the present study, patients who did not undergo LA volume reduction surgery did not have reduced LA volume despite successful sinus rhythm recovery, most likely because prolonged atrial overload before the surgery may have caused irreversible structural damage to the LA myocardium, or because the higher wall stress of the enlarged left atrium compared with the reduced left atrium might prevent the reverse remodeling. BUT non randomized with only 1 yr FU and limitations of MRI gating in AF

17 Isolated LA reduction for AF Impact of Left Atrial Size Reduction on Chronic Atrial Fibrillation in Mitral Valve Surgery Mirela Scherer MD, Omer Dzemali MD, Tayfun Aybek MD, Gerhard Wimmer Greinecker MD, Anton Moritz MD Department of Thoracic and Cardiovascular Surgery, J. W. Goethe University, Frankfurt am Main, Germany The Journal of Heart Valve Disease 2003;12: Background and aim of the study: Left atrial enlargement is a risk factor for the development of atrial fibrillation (AF). Large atrial size increases thromboembolic risk and reduces the success rate of cardioversion. The study aim was to evaluate if left atrial size reduction affects cardiac rhythm in patients with chronic AF undergoing mitral valve surgery. Methods: Twenty seven patients were analyzed prospectively. The left atrial incision was extended to the left inferior pulmonary vein. Left atrial size reduction was achieved by closure of the left atrial appendage from inside with a double running suture. The same suture plicated the left lateral atrial wall to the roof of the left pulmonary vein inflow and the inferior atrial wall. The atrial septum was plicated by placing stitches of the closing suture line across the fossa ovalis. Rhythm, neurological complications, cardioversion, anticoagulation and anti arrhythmic medication were evaluated at one year postoperatively and at recent follow up (mean 40 ±15 months). Results: At discharge, five patients (19%) were in sinus rhythm (SR). At one year postoperatively, SR was restored in 17 patients (63%), but five (19%) reported episodes of arrhythmia and AF persisted in 10 (37%). At recent follow up, four patients had died and three were lost to follow up. Among 20 patients examined, 13 (65%) had SR but six reported episodes of arrhythmia and AF persisted in seven (35%). LA diameter was significantly reduced, from 60.2 ±9.8 mm preoperatively to 44.5 ±7.0 mm at one year after surgery. Conclusion: The addition of left atrial size reduction to mitral valve surgery is technically simple, and was effective in 63% of patients with chronic AF, restoring predominant SR. In order to influence pathogenetic factors other than size, additional ablative steps may further increase the SR conversion rate. Size reduction may also improve the outcome of other ablative approaches.

18 Isolated LA reduction for AF Hornero F, Rodriguez I, Buendía J, Bueno M, Dalmau MJ, Canovas S, Gil O, Garcia R, Montero JA. Atrial remodeling after mitral valve surgery in patients with permanent atrial fibrillation. J Card Surg Sep Oct;19(5): PRCT (N=50) Permanent AF & LA Randomized to isolated MVS or concomitant LA reduction LAR group has SR (46% v. 18%), LA volume & LA remodeling (p<0.05 for both)

19 LA reduction Surgical technique

20 LA reduction Surgical technique

21 LA reduction Surgical technique

22 LA reduction Surgical technique

23 LA reduction Surgical technique

24 LA reduction Surgical technique

25 LA reduction Surgical technique Partial auto transplantation Pros: Significant atrial reduction; good access to mitral/tricuspid valves; excellent PV isolation Cons: Prolonged ischaemic time; involvement of non affected structures (PA, aorta, SVC, IVC); complication from a complex approach

26 LA reduction + Cox maze = Holy Grail? Clinical series show sustained SR at 12 months 75 85% Sick atrial substrate with LA diameter/volume as a surrogate marker? Long term anti arrhythmic agents postoperatively? Subgroup too late to respond?

27 Cox maze IV Blackpool Experience Concomitant vs stand alone AF surgery Referred for surgery with structural heart disease/ischaemic heart disease/aortic disease surgical OP assessment Arrhythmias MDT meeting Screened for eligibility for the AMAZE trial Surgery with EP input: confirm PVI exit block EP follow up after surgical OP discharge

28 Cox maze IV Blackpool Experience Total in series = 27 1 in in in in Jan 2012 (?>30) 22 valve +/ CABG surgery, 5 CABG; 1 redo, 1 ASD Full hybrid lesion set in 24, left atrial lesions for flutter in 3, atrial reduction since 2011

29 Cox maze IV Blackpool Experience M:F = 16:11 Mean age = 72 (range 57 86) 1 in hospital death, 1 ischaemic stroke, 1 PPM 1 late death Freedom from AF at latest FU = 24/25 (96%) Freedom from AF at 12m FU = 7/8 (88%) Symptomatic improvement = 24/25 (96%) Warfarin withdrawal CHAD VASC score

30 Cox maze IV Blackpool Experience THANK YOU! ANY QUESTIONS PLEASE?

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