Surgical AF Ablation : Lesion Sets and Energy Sources. What are the data? Steven F Bolling, MD Cardiac Surgery University of Michigan

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1 Surgical AF Ablation : Lesion Sets and Energy Sources What are the data? Steven F Bolling, MD Cardiac Surgery University of Michigan

2 Disclosures Consultant/Advisory Board: Abbott, Edwards Lifesciences Ownership Interest: Millipede, Pipeline

3 Surgical AF Ablation : Lesion Sets and Energy Sources What are the recommendations?

4 2014 AHA/ACC/HRS Guidelines Surgical AF Ablation Recommendation An AF surgical ablation procedure is reasonable for selected patients with AF undergoing cardiac surgery for other indications COR LOE IIa C J Am Coll Cardiol. 2014;64(21):

5

6 2017 STS Clinical Practice Guidelines Mitral Valve Multiple populations studied: 11 RCTs, 4 Metaanalyses, Several Institutional experiences Recommendation: Surgical ablation for AF can be performed without additional risk of operative mortality or major morbidity, and is recommended at the time of concomitant mitral operations to restore sinus rhythm. (COR: I, LOE: A)

7 2017 STS Clinical Practice Guidelines CABG, AVR, AVR+CABG Limited populations studied: 2 RCTs, 2 Meta-analyses, limited Institutional experiences Recommendation: Surgical ablation for AF can be performed without additional risk operative of mortality or major morbidity, and is recommended at the time of concomitant isolated AVR, isolated CABG, and AVR+CABG operations to restore sinus rhythm. (COR: I, LOE: B-NR)

8 2017 AATS Expert Consensus Guidelines Stroke and Survival Recommendation: It is reasonable to choose to perform a concomitant surgical ablation procedure for patients with a history of AF over no treatment of AF because there is no increased risk of perioperative stroke/tia. (COR: IIA, LOE: A)

9 2017 AATS Expert Consensus Guidelines (COR: I, LOE: A)

10 Surgical AF Ablation : Lesion Sets and Energy Sources We should do something but do we?

11 US Rates of Surgical Ablation 50,000 Untreated Treated Number of Patients 40,000 30,000 20,000 NO! 24% 33% 10,000 52% 28% 0 (1) (1) Mitral Valve Aortic Valve Isolated CABG Total (Mitral + Aortic + Isolated CABG)

12 Cut and Sew MAZE Complex,Morbid and Scary! Never adopted!

13 CRYO and RF Ablation Thermal injury -60 o C Formation of intra and extracellular ice crystals. This disruptsthe cell membrane and cytoplasmic organelles

14 Trends in Surgical AF Ablation Badhwar et al, Surgical Ablation of Atrial Fibrillation in the United States: Trends and Propensity Matched Outcomes. Ann Thorac Surg 2017 Aug; 104(2)

15 Surgical AF Ablation Do something! but what? - What lesions? Bi-atrial? Left atrial only? PVI? - What energy source? RF, cryo, Us, micro, laser

16 Surgical Ablation - Modified Cox Maze IV

17 Cox : More lesions are better!

18 Bi - atrial lesions are better!

19 Bi - atrial lesions are not better!

20 Bi - atrial lesions are better for some!

21 The statistically significant predictors for SR after 1 year were left atrial diameter, AF duration, preoperative paroxysmal AF, postoperative SR, and biatrial ablation for persistent AF.

22 LA box vs. PVI (no box) Freedom from AF - box better! p = p = p = p = p = % 80% 93% 85% 88% 85% 87% 83% 83% 67% 78% 60% 40% 45% 20% 0% Time (Years) With Box Lesion Without Box Lesion Damiano RJ, et al. J Thorac Cardiovasc Surg Jan;141(1):

23 Surgical AF Ablation Do something! - What lesions: Bi-atrial - larger LA, longer and persistent AF Left atrial box > PVI paroxysmal AF

24 Europace 2015;17:38-47

25

26

27 SURGICAL ABLATION OF ATRIAL FIBRILLATION DURING MITRAL VALVE SURGERY THE CARDIOTHORACIC SURGICAL TRIALS NETWORK NEJM March 16, 2015

28 Surgical Ablation Options No Ablation PVI Biatrial Maze LAA closure performed in all patients

29 Operative Characteristics MVS Alone (N=127) MVS & Ablation (N=133) Mitral Valve Surgery Replacement 61 (48.4) 54 (40.6) Repair 65 (51.6) 79 (59.4) Concomitant Procedures Tricuspid Valve Surgery 48 (38.1) 50 (37.6) Aortic Valve Replacement 20 (15.9) 14 (10.5) CABG 25 (19.8) 27 (20.3) Cardiopulmonary Bypass Time (min)* Cross-Clamp Time (min) *P-Value for Cardiopulmonary Bypass Time = 0.03

30 Operative Characteristics MVS Alone (N=127) MVS & Ablation (N=133) Mitral Valve Surgery Replacement 61 (48.4) 54 (40.6) Repair 65 (51.6) 79 (59.4) Concomitant Procedures Tricuspid Valve Surgery 48 (38.1) 50 (37.6) Aortic Valve Replacement 20 (15.9) 14 (10.5) CABG 25 (19.8) 27 (20.3) Cardiopulmonary Bypass Time (min)* Cross-Clamp Time (min) *P-Value for Cardiopulmonary Bypass Time = 0.03

31 Primary Endpoint Freedom From AF (%) Risk Difference of Success 0.34 (95% CI, ), P< MVS Alone Randomization Group MVS + Ablation

32 Quality of Life MVS Alone (N=127) MVS & Ablation (N=133) P-Value SF-12 Physical Function 45.3 ± ± Mental Function 48.5 ± ± AF Severity Scale Daily AF no. (%) 42 (45.2) 20 (19.8) <0.001 Life Rating (1-10, median) NYHA Class III + IV no. (%) 8.0 (7,9) 8.0 (7,9) (2.9) 8 (7.0) 0.17

33 Freedom From AF (%) Biatrial Maze vs. PVI The absence of proof is Risk Difference of Success 0.05 (95% CI, ), P=0.60 not the proof of absence Biatrial Lesions Ablation Group PVI

34 Pacemaker Implantation Serious Adverse Events (Rate/100 Pt-Yrs) Incidence Rate Ratio 2.64 (95% CI, ), P< MVS Alone Randomization Group 21.5 MVS + Ablation

35 What Energy Source? RF vs Cryo

36

37 Catheter ablation - RF vs Cryo

38 STS Adult Cardiac Surgery Database July 1, 2011 June 30, ,668 Patients isolated MVRR Included: Patients with associated CABG, ASD closure, and tricuspid valve repair (TVr). Excluded: Previous MitraClip procedures, missing gender or age information, and/or right atrial SA only 88,765 Patients

39 Effects of AF Type, Energy Source, and Lesion Set In-Hospital Outcomes Operative Mortality Composite Major Morbidity Results Variable Risk Adjusted OR [95% CI] p-value Parox/Persist AF 1.02 [ ] Cryo vs. RF 0.71 [ ] RF+Cryo vs. RF 0.81 [ ] C&S vs. RF 0.81 [ ] LA vs. BA 0.85 [ ] Parox/Persist AF 0.98 [ ] Cryo vs. RF 1.06 [ ] RF+Cryo vs. RF 1.02 [ ] C&S vs. RF 0.83 [ ] LA vs. BA 0.92 [ ]

40 Surgical Ablation Procedures Performed by Operation Type Variable MVRR ±CABG (N=21,992) AVR± CABG (N=9,875) AVR +MVRR (N=2,304) Isolated CABG (N=14,334) Other Concomitant (N=10,252) Stand Alone (N=3,268) p-value LA only location Bi-atrial location Atrial Location Not Documented < Primarily Endocardial Primarily Epicardial < Ablation Location Not Documented RF only Cryo only CAS only < RF+Cryo LAA obliterated <0.0001

41 Surgical AF Ablation Do something! Lesions: Bi-atrial - larger LA, longer and persistent AF LA box > PVI - parox AF Energy : Cryo inside - MVr RF outside - AVR/ CABG Take the LAA!

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