What is Minimally Invasive Surgical Ablation?
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1 What is Minimally Invasive Surgical Ablation? ( and who might be suitable for it?) HRC October 2011 Mr. Jonathan Hyde Consultant Cardiac Surgeon Royal Sussex County Hospital, Brighton
2 Introduction Atrial fibrillation (AF) affects millions Treatments include: Cardioversion Drug therapy Ablation Ablation: Lab-based (catheter) Surgical
3 What Happens in AF? Several sites send extra (abnormal) electrical waves, interfering with the heart s normal pacemaker The atria quiver, or fibrillate, causing the heart to beat too fast This is very inefficient as the Ventricles (pumping chambers) have less time to fill with blood so the heart pumps less around the body Not all blood is pumped some pools, which can cause a blood clot
4 Classification of AF Paroxysmal AF is recurrent AF that terminates spontaneously within seven days. Persistent AF is sustained beyond seven days or may have occurred less than seven days but requires chemical or electrical cardioversion. Longstanding persistent AF is AF lasting longer than one year. Permanent AF is discouraged in the context of treatment options. Source : HRS/EHRA/ECAS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation: Recommendations for Personnel, Policy, Procedures and Follow-Up
5 Concomitant vs. Stand-alone Surgical Ablation CONCOMITANT: Standard ablation performed at the same time as another heart surgery operation (eg bypass or valve). STAND-ALONE: Ablation performed as a procedure on its own. Stand-alone ablation can be performed through: Median sternotomy (open-chest) Mini-thoracotomy (minimally invasive approach) Thoracoscopically (True keyhole surgery)
6 Concomitant Surgical Ablation Usually done with other heart surgery e.g. bypass surgery or mitral valve repair/replacement Open-chest surgery, with a heart-lung bypass. It takes only a few extra minutes to create the scars (ablations) that can block the abnormal electrical impulses causing AF. Can eliminate AF in up around 90% of patients.
7 Stand-alone Surgical Ablation Performed as an isolated procedure for patients with AF but no other cardiac problems suitable for surgery Performed under anaesthetic, and on the normal beating heart (not needing the heart-lung machine). Exactly the same lesion sets can be performed as in concomitant ablation The left ATRIAL APPENDAGE can also be removed
8 Surgical Technique Overview The Cox-Maze IV lesion set (exit block) Ganglionic plexi (GP) Ablation Exclusion of left atrial appendage
9 Endoscopic (minimally-invasive) Ablation Right Side 5 mm 10 mm 5 mm
10 Endoscopic (minimally-invasive) Ablation Left Side 5 mm 5 mm 10 mm
11 Totally Thoracoscopic Ablation Opportunity Truly minimally invasive, single patient prep Considerations Positioning single or bilateral Lesions PVI, GP, LA dome, floor
12 3-4 ports with insufflation Two x 5mm One x 10-12mm Port placement
13 Totally Thoracoscopic Ablation
14 Conduction Block
15 GP Ablation Right side
16 GP Ablation Left Side
17 Right Side Preparation
18 Right Side Clamp Ablation
19 Left Side Preparation
20 Left Side Clamp Ablation
21 Left Side LAA Exclusion
22 Left Side LAA Exclusion (Stapler)
23 Surgical details 2 to 3 hours. Alternate lung ventilation 3 small pen-sized holes each side Local anaesthetic to port-sites. Single stitches or steristrips only
24 Post-operatively 2 drains (removed after 1 hour) Woken up within an hour (or in theatre) Eating and drinking within hours Home the next day
25 Who will benefit? Symptomatic PAF patients AF patients who want to come off Warfarin. Some persistent AF patients Contraindications
26 Outcomes Minimal morbidity. USA/Europe 91% cure in PAF & 60-70% for persistent AF RSCH (UK) similar to these results. 35 pure VATS cases so far. Medium/long-term results and studies
27 The RSCH Programme 2 Consultants (JH and ML) Both went to USA and Netherlands to learn procedure 1 st cases in st unit for VATS RF Need increased awareness (GP and cardiology) Accept referrals from all over the UK (only 2 centres perform this)
28
29 Contact details Mr Jonathan Hyde Consultant Cardiac Surgeon Royal Sussex County Hospital, Brighton Sec: Debbie Long ext 7296
30
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