Should Paroxysmal Atrial Fibrillation be Treated During Cardiac Surgery?

Transcription

1 Should Paroxysmal Atrial Fibrillation be Treated During Cardiac Surgery? Patrick M. McCarthy MD, Adarsh Manjunath, BA, Jane Kruse, RN, BSN, Adin-Cristian Andrei, PhD, Zhi Li, MS, Edwin C. McGee, MD, S. Chris Malaisrie, MD, Richard Lee, MD Monday, May 6, 2013 Adult Cardiac Surgery Scientific Session AATS 93 rd Annual Meeting Minneapolis, MN

2 Should Paroxysmal Atrial Fibrillation be Treated During Cardiac Surgery? Patrick M. McCarthy MD, Adarsh Manjunath, BA, Jane Kruse, RN, BSN, Adin-Cristian Andrei, PhD, Zhi Li, MS, Edwin C. McGee, MD, S. Chris Malaisrie, MD, Richard Lee, MD Monday, May 6, 2013 Adult Cardiac Surgery Scientific Session AATS 93 rd Annual Meeting Minneapolis, MN

3 Disclosures Adin-Cristian Andrei, PhD: Consultant, AtriCure S. Chris Malaisrie, MD: Research, Medtronic Speaker: Edwards Lifesciences and Abiomed None for other authors

4 Prospective Randomized Trials of Permanent AF Ablation with Mitral Valve Surgery Number Control Treated Trials, Year of Pts Technology 12 Month * NSR 12 Month NSR Deneke et al., Unipolar Cooled RF 26.7% 80% (p < 0.01) Schuetz et al., 2003 Akpinar et al., Microwave 33.3% 80% (p = 0.036) 67 Unipolar RF 9.4% 93.6% (p = ) Abreu Filho et al., Unipolar Cooled RF 26.9% 79.4% (p = 0.001) Doukas et al., 2005 Blomström- Lunqvist 2007 Chevalier Unipolar RF 4.5% 44.4% (p = 0.001) 69 Cryoablation 42.9% 73.3%(p=0.013) 43 Unipolar RF 4% 57% (p=0.004)

5 7 RCT Permanent AF/MVR All p< in favor of NSR if AF treated No Peri-op AF Treatment Complications None powered or followed for late survival Heterogenous NSR rates (44-94%)

6 Little Known About PAF Risk CVA and thromboembolism Symptoms Medication effects

7 Survival Preop AF impacts other outcomes Years Increased Mortality Increased incidence of stroke and heart failure Increased Pacemakers Ngaage, DL, et al. Thorac and Cardiovasc Surg 2007;133 (1): Ngaage, DL et al. Ann Thorac Surg. 2007;84 (2): Banach, M, et al. Thorac Cardiov Surg 2008; 56:20-23 Quader MA, et al. Does preoperative atrial fibrillation reduce survival after coronary artery bypass grafting? Ann Thorac Surg. May 2004;77(5):

8 AF Treated vs. no AF Hx vs Untreated AF J Thorac Cardiovasc Surg 2012;143(6):

9 Investigate 1. Does AF Treatment Increase Risk? 2. Does AF Ablation Impact Survival? 3. FFAF outcomes?

10 Methods 4947 cardiac surgery pts (04/ /2012) 1150 pre-op AF (23%) 3797 no history of AF 552 pre-op PAF (48%) 423 Treated PAF (77%) 129 Untreated PAF (23%)

11 Decision Making Treatment or No Treatment: Dependent on Surgeon and concomitant operation Lesion Set: Which Concomitant Operation

12 Types of Ablation Surgery PAF ablated (N = 423) n % Left atrial only PVI Biatrial Classic Maze 20 5

13 Preoperative Unmatched p < Untreated PAF (N = 129) Treated PAF (N = 423) No AF (n=3797) Characteristics n % n % n % Age CHF NYHA Class III-IV Previous MI CAD Prior Pacemaker Reoperation Elective Ejection fraction Left atrial size

14 Intra/Post-op Unmatched all p <0.001 Untreated PAF (n=129) Treated PAF (n=423) No AF (n=3797) Variable n % n % n % Mitral Valve Aortic Valve CABG Euroscore CPB 117 [86, 160] 120 [94, 150] 106 [79, 142] XClamp 91 [73, 118] 89 [70, 115] 87 [66, 115] Complications PPM new day Mortality

15 PS Matched: Preoperative No AF (n = 879) Treated PAF (n =343) Characteristics n % n % p value Age CHF NYHA Class III-IV Previous MI CAD Prior Pacemaker <.001 Reoperation Elective Ejection fraction Left atrial size <.001

16 PS Matched: Preoperative No AF (n = 314) Untreated PAF (n =114) Characteristics n % n % p value Age CHF NYHA Class III-IV Previous MI CAD Prior Pacemaker Reoperation Elective Ejection fraction Left atrial size

17 PS Matched: Preoperative Untreated AF (n =80) Treated PAF (n =166) Characteristics n % n % p value Age CHF NYHA Class III-IV Previous MI CAD Prior Pacemaker Reoperation Elective Ejection fraction Left atrial size

18 FFAF: Unmatched 75% 85% 96%

19 PS Matched FFAF off AADs at Last Follow-up P= % 84% P= % 71% P= % 65%

20 Unmatched: Treated PAF, Untreated PAF and No history of AF P<

21 PS Matched Survival

22 Findings No increase in Periop Risk - Perhaps some decreased complications with TrAF - No increased PPM Improved FFAF Tr PAF vs. UnTrPAF - Decreased FFAF vs. No history of AF (reduced follow-up No AF Group) Survival TrPAF better than UnTrPAF and equal to No AF

23 Does AF Treatment Change the Curve?

24 Limitations/Implications Not a RCT Follow-up more intense in Tr PAF group Various Lesions sets for various operations. Selective use of AF ablation for PAF pts is safe and effective

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27 Conclusions Concomitant surgical ablation of PAF does not increase perioperative risk Treated PAF patients had higher late FFAF and survival compared to untreated PAF patients Consider AF ablation in select PAF patients at time of cardiac surgery

28 Does AF Treatment Change the Curve?

29 Prospective data collection Methods 1, 3, 6, 12 months after surgery, then annually Rhythm management Anti-arrhythmic (AA) drugs for 3 months Coumadin discontinued if SR regained at 3-6 months Cardioversion or ablation if AF persists Rhythm follow-up 12-lead EKG Mobile telemetry or Holter monitor at 3, 6 months Implanted device (ICD, Pacer, etc) interrogation Evaluation of success Freedom from AF, AA, and stroke

30 1 Percent of Patients with Diagnosis of AF treated at time of MV Surgery AF surgery was performed in 91% of isolated MV surgery patients with a previous history of AF compared to 53% nationally 100% Calendar Year % 60% 40% Northwestern Memorial Hospital Society of Thoracic Surgeons 20% 0%

31 HRS / STS Guidelines It is appropriate to consider all patients with symptomatic AF undergoing other cardiac surgery for AF ablation. Calkins H, et al. HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of AF. Heart Rhythm 2012; 9 (4):

32 PS Matched Survival

33 Original groups: LA only vs BA B Original groups: LA only vs BA

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35 Percent of Patients Freedom from Atrial Fibrillation at Last Rhythm 100 N= N=77 N=15 N=22 N= Classic BiAtrial Left HIFU PVI Maze Type J Thorac Cardiovasc Surg 2010; 139(4):860-7

36 McCarthy et al. JTCVS 2010: 140(4):885-9