Mitral Repair/AF Ablation Sternotomy Approach

Transcription

1 Mitral Repair/AF Ablation Sternotomy Approach Patrick M. McCarthy MD, FACC Executive Director of the Bluhm Cardiovascular Institute Chief of Cardiac Surgery Division Heller-Sacks Professor of Surgery in the Feinberg School of Medicine November 17, 2017 Session IV: Concomitant Ablation How I Do it and Why Nobu Eden Roc Hotel Miami Beach, Florida

2 Disclosures None

3 MVR/AF Ablation Issues to Consider MV: TV/RA Involvement; Reop; Mechanical? AF: Type; Duration; Stroke Hx; Symptoms Decision: Technology and Lesion Set

4 What Technology and Lesion Set?

5 Cox Maze Procedure Pulmonary Vein Box Lesion MV Annulus to Box Lesion SVC-IVC TV Annulus flutter lines X2 Excision of LAA

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8 What I Don t Like about Bi Polar Clamps Multiple applications (7-10) Awkward (Left atrium); esp w small incision Thin tissue next to thick tissue; e.g. svc Need a second device (cost and footprint)

9 Last 3 Years Almost Exclusively Cryo

10 MV Repair; LA Maze; Atriclip

11 Reoperations: MV Annulus Lesion

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13 Tips/Pitfalls of Cryo Mind the Gap unfold the tissue push from outside 2 min freeze LA, 1 min RA and Epicardial CS Release the retractor blade Don t poke anything (like your mv repair!) Don t freeze the coronaries

14 Lesion Set: Left vs. Biatrial Not PVI; Do the MV and CS

15 Cox Maze Procedure Pulmonary Vein Box Lesion MV Annulus to Box Lesion SVC-IVC TV Annulus flutter lines X2 Excision of LAA

16 Ann Thorac Surg, 103(6):

17 Box Lesion Across LAA Freeze Endo and Epicardial to C.S.

18 Propensity matched groups FFAF at last FU, p=0.10 FFAF at last FU off AA, p=.09 80% 80% 60% 40% 20% 70% 89/127 79% 98/124 60% 40% 20% 69% 82/119 79% 86/109 0% LA BA 0% LA BA Pre-discharge PPM, p=0.57 Annualized Stroke rate per 10 person/year, p= % 10% 5% 0% 10% 14/147 LA 12% 17/147 BA LA 0.08 BA

19 Patient Population and Late Outcomes Impact Success

20 NMH: DMR % of AF Treated 97% of Valves Repaired Variable Age ± 12.7 Gender (female) % NYHA Class I / II % NYHA Class III / IV % Repeat Sternotomy % N

21 Operative Characteristics Entire Cohort Class I Class II Class III / IV P- Variable (N=892) (N=390) (N=370) (N=132) value Perfusion 89(74, 111) 84(71, 103) 92(77, 113) 96(73, 126) <.001 Cross Clamp 74(62, 92) 72(60, 87) 78(66, 96) 75(62, 97) <.001 Elective Surgery 875 (98%) 388 (99%) 363 (98%) 124 (94%) <.001 CABG 133 (15%) 47 (12%) 58 (16%) 28 (21%) Aortic Valve 42 (5%) 15 (4%) 17 (5%) 10 (8%) 0.21 Tricuspid Valve 99 (11%) 38 (10%) 34 (9%) 27 (20%) AF Ablation 217 (24%) 76 (19%) 100 (27%) 41 (31%) Mitral Surgery <.001. Repair 865 (97%) 382 (98%) 363 (98%) 120 (91%). Replacement 27 (3%) 8 (2%) 7 (2%) 12 (9%) MV Leaflet Anterior 49 (6%) 20 (5%) 22 (6%) 7 (6%). Posterior 659 (79%) 306 (83%) 268 (77%) 85 (77%). Bileaflet 121 (15%) 42 (11%) 60 (17%) 19 (17%)

22 Freedom from MV Reoperation for DMR NMH Freedom from MR 3+ (No 4+ MR) Year1 Year2 Year4 Year6 Year8 Year10 Follow-up (Years) MV Repair 99.8% 99.4% 98.3% 97.3% 96.5% 96.5% 3.4±2.8 MV Replacement 100% 100% 100% 100% 100% 100% 3.7±3.1

23 Pacemaker Thoughts (Not Party Line)

24 NMH Incidence of PPM by AF Lesion Type

25 Pacemaker Retractor on SA Node SA Node Artery Divided SSS Occurs without AF Surgery

26 MV/Maze Opinions Cryo is Easier; Faster; Cheaper; More Flexible than RF Early in The Course of The Mitral Disease Little RA Involvement: LA Only Always Do LA and Isthmus Lesions Pacemakers are from SA Node Trauma, not SSS, not from the Maze

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28 Freedom from MV Reoperation for DMR NMH 04-15; Single Surgeon Year1 Year2 Year4 Year6 Year8 Year % 99.6% 99.6% 99.6% 99.6% 99.6%

29 Freedom from MR 3+ (No 4+ MR) by MV Surgery Type Year1 Year2 Year4 Year6 Year8 Year10 Follow-up (Years) MV Repair 99.8% 99.4% 98.3% 97.3% 96.5% 96.5% 3.4±2.8 MV Replacement 100% 100% 100% 100% 100% 100% 3.7±3.1

30 Need new HRS quotes 10 minutes of video 5 min discussion

31 MV Annulus Lesion

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33 Key points Have to do mitral ring or replace before mitral annular line Cut SA node; retractor on SA node; we see SSS in non-maze surgery I don t use a separate LAA line. Excision or cryo goes to LAA

34 Why LA only bring slides from the 900+ DMR 84% FC I or II Only % had mod or more TR Combined free from 3-4+ MR and free from reop.so no recurrence leading to late AF 97% of AF is treated (some maybe others wouldn t because too advanced, others only 1 or 2 episodes

35 Valve Inspection 24 seconds

36 Valve Measurements 21 seconds

37 Mitral Repair 4 minutes

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39 Cryoablation: Not Just for Reops Anymore

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41 For next slide need to animate with some red arrows to TV surgery and AF ablation Box around Class I N=390 Do we have data on type and duration of AF?