Surgical Ablation: Which Lesion Set for Which Patient?

Transcription

1 Surgical Ablation: Which Lesion Set for Which Patient? Patrick M. McCarthy MD, FACC Director of the Bluhm Cardiovascular Institute Chief of Cardiac Surgery Division Heller-Sacks Professor of Surgery in the Feinberg School of Medicine May 2, 2010 AATS /STS Adult Cardiac Surgery Symposium Toronto, ON, Canada

2 Disclosures None

3 AF Ablation Surgery has become the Standard of Care Pre-op AF is Dangerous 11% of Cardiac Operations: STS Maze in 54.7% of MV operations AF Ablation surgery is safe and effective ( ~80%)

4 But, There is Variability in the Lesion Set and Technology Used for AF Ablation

5 Decision Points Which Operation? Primary vs. Reop Symptoms; tachy-med Cardiomyopathy Age Stroke history Recent Onset LA Size

6 Lesion sets Biatrial = LA Box and MV Annulus; RA set PVI = Bilateral antral isolation (RF Clamp) LA Only Classic (Cut and Sew)

7 Decision Making Do You Open LA Anyway? Add MV Annulus Do You Open RA Anyway? Biatrial AF Symptoms; CVA; Young; Long Duration? Biatrial AVR; CAB; Short Duration? PVI BUT if AVR; CAB: Pt has symptoms, CVA, Young, Long duration: Consider LA or Biatrial Classic: When you are operating for AF or want the best result

8 How To

9

10 Box Lesion

11 MV Annulus Lesion

12 What About Reop MV?

13 LA Dome Lesion

14 Inferior LA Lesion

15 MV Annulus Lesion

16 RA Lesions

17 C.S. TV Annulus Lesion

18 Bilateral PVI

19 NMH Registry Data 408 pts; 4 04 to 12 08; 1 surgeon 95% of pts with AF had Ablation 5 lesion sets - Classic Maze - Biatrial - LA only - PVI only - HIFU box lesion Prospective follow-up since Jan 2006 J Thorac Cardiovasc Surg 2010;139 (4):860-7

20 # of Procedures Maze Procedure Volume Biatrial Left-Only Year J Thorac Cardiovasc Surg 2010; 139 (4):860-7

21 NMH Data Mortality: 1.7% (0; stand-alone) CVA: 1.2% TIA: 0.7% LOS 6 days D/C Rhythm AF: 24%; 5.9% Classic Maze (p < 0.001) Follow-up: 16 % Antiarrhythmics 44% Warfarin J Thorac Cardiovasc Surg 2010;139 (4):860-7

22 Freedom from AF Freedom from AF and no Ablation

23 Percent of Patients Freedom from Atrial Fibrillation at Last Rhythm N=58 N=77 N=15 N=22 N= Classic BiAtrial Left HIFU PVI Maze Type J Thorac Cardiovasc Surg 2010; 139(4):860-7

24 Summary More Extensive Lesions, and Transmural, give best results Easy to add this for MV, TV: even in reop Biatrial Lesions for symptomatic, young pts, prior CVA Realistically may not be best for elderly pts with recent onset AF, needing AVR, CAB Classic when you need the BEST result

25

26 The Key Point Matching the Lesion to the Patient

27 Characteristics J Thorac Cardiovasc Surg 2010;139(4):860-7

28 J Thorac Cardiovasc Surg 2010 ; 13 9 (4):8 60-7

29 Classic Maze Low rate of Ablation: 4.4% (n = 3 ) Mitral Isthmus (n = 2) RU PVI (n = 1) 94% Free from AF

30 HIFU Group Higher rate of ablation: 37.5% 100% Incomplete Box Lesion 73% Free from AF

31 Left Ablation Only (LA + PVI) Low rate of Ablation: 3.4 % (n = 8/225) High Failure rate from RA: 75 % (n = 6/8) MV Isthmus: n = 2 Box Lesion (cryoablation): n = % Free from AF

32 Mitral Isthmus Ablation (LA; Biatrial; Classic) Low rate of Ablation: 4.8% (n = 16/134) MV Isthmus: 38 % (n = 6/16) Box Lesion or PV: 44 % (n = 7/16) 85.7% Free from AF

33 Conclusions AF Surgery Safe and Generally Effective HIFU: High Rate of Ablation and Failure of the Box Lesion LA lesions only: Risk of RA foci lead to failure MV Isthmus: A source for failure even when treated Classic Maze: Still the Gold Standard

34 Northwestern Strategy If a patient goes to cardiac surgery with a history of AF, that patient will receive an Intervention for AF.

35 Which Pts Should be Treated? Highly Symptomatic Patients Young, Low Risk Emboli, Failed Catheter Ablation

36 Which Pts To Avoid? 85 y/o, 6.5 cm LA, 15 yr history AF, 35 % EF, needs mini-avr Third time redo CAB Rheumatic redo triple valve Morbidly obese

37 Patient/Technique Selection MVR: PVI + MV lesion CAB, AVR, Aortic case, LV aneurysm: PVI +/- LA Appendage Closure On pump: Excise LAA (Classic Maze) or Close LAA (MVR); Ligate LAA at the base (CABG/AVR), oversewn or excised Off pump: Mini-Maze + Hybrid EP ablation

38 NMH Management Cut and Sew Mini-Maze / Hybrid EP Ablation 91% with AF History are Treated MVR: Bipolar RF and Cryo; Biatrial > 50% AVR, CAB, Aneurysm: PVI, bipolar RF, Close LAA More lesions if Symptomatic Redo MVR: Biatrial and Cryo

39 The More Extensive the Lesion Set the Better the Result Biatrial > LA Alone Classic Maze > Bipolar RF Within Reason

40 All must Create Transmural Lesions! No Collateral Damage No Char Ideally Off Pump

41 Extended (Biatrial) Lesions: If the LA is Open (MV) Or Permanent AF Or Symptomatic AF Or Right side surgery (TV repair)

42 PV Isolation: Wolf Procedure CAB, AVR, Aneurysm and PAF Elderly patients

43 Off Pump PVI + HIFU: Symptomatic AF patients preferring minimal-invasive approach

44 NMH Approach: Surgery and EP Monitoring Success AF Nurse Lockout EP 2 mo; Surgery: 3-6 mo Definition > 30 seconds Freedom from symptoms Interval 3 mo, 6 mo, 12 mo, annually

45 NMH Approach: Surgery and EP Monitoring Success Methods Pacemaker/ICD AF Express/Cardio Net Lifewatch 48 hour Holter monitor

46 Additional Procedures LA Appendage Closure Ganglionic Plexus Ablation LA isthmus lesion RA isthmus lesion

47

48 Patient Factors Left Atrial Size Age Etiology of MV Disease LV Function

49 Trying to Make Sense of A Bewildering Array of: Patient Factors AF Pathologies Lesions Technologies

50 Techniques: Briefly All Maze Operations are not the Same

51

52 Technologies Cut and Sew Cryoablation Unipolar RF Bipolar RF Microwave HIFU Laser

53 LA Appendage Stapling

54 Lesion Sets Classic Maze III Pulm Vein (Antrum) Isolation PVI with MV annular lesion Biatrial or Maze IV

55 Classic Maze Procedure Pulmonary Vein Box Lesion MV Annulus to Box Lesion SVC-IVC TV Annulus Flutter lines X2 Excision of LAA