Surgical Ablation of Atrial Fibrillation. Gregory D. Rushing, MD. Assistant Professor, Division of Cardiac Surgery

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1 Surgical Ablation of Atrial Fibrillation Gregory D. Rushing, MD Assistant Professor, Division of Cardiac Surgery Midwestern Conference on Optimizing Electrophysiology Patient Care and Procedural Success in the EP Lab Disclosures None 2 1

2 Atrial Fibrillation How big is the problem? Prevalence is expected to exceed 15 million patients by year Direct and indirect costs of approx. 15k per patient per year. Annual Mortality rate Paroxysmal 3% Permanent 8% 1 in 5 strokes in persons aged over 80 years Ontario Drug Benefit claims data in 125,195 patients >65 years old with AF who initiated warfarin therapy, found that almost one third (31.8%) discontinued warfarin within one year of initiation CCORT AF study: using prescription claims databases in Alberta, British Columbia and Ontario from 1997 to 2000, less than one half of AF patients filled a prescription for warfarin within 90 days of discharge for an AF hospitalization Miyaska et al. Circulation 2006; 114: Wu et al Curr Med Res Opin 2005; 21: Mozaffarian et al. Circulation 2015; 131 e Gomes et al. Arch Intern Med 2012; 172: Atrial Fibrillation Treating paroxysmal atrial fibrillation to prevent progression to longstanding persistent or permanent atrial fibrillation is a flawed philosophy. Keating et al. Am J Cardiol 2005; 96:

3 Atrial Fibrillation Catheter based treatment 5 year freedom from arrhythmia with single ablation reported as 29%, and up to 63% with multiple procedures in a paroxysmal patient population. Weerasooria et al. J Am Coll Cardiol. 2011;57: Surgical AF Ablation 6 3

4 Surgical AF Ablation 7 The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation Executive Summary of Recommendations With Strongest Evidence 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 (class I, level A). Surgical ablation for AF can be performed without additional operative risk of mortality or major morbidity and is recommended at the time of concomitant isolated aortic-valve replacement, isolated coronary artery bypass graft surgery, and aortic-valve replacement plus coronary artery bypass graft operations to restore sinus rhythm (class I, level B nonrandomized). Surgical ablation for symptomatic AF in the absence of structural heart disease that is refractory to class I/III antiarrhythmic drugs or catheterbased therapy or both is reasonable as a primary stand-alone procedure, to restore sinus rhythm (class IIA, level B randomized). 8 4

5 Concomitant Surgical Ablation The Annals of Thoracic Surgery , DOI: ( /j.athoracsur ) Copyright 2017 The Society of Thoracic Surgeons Terms and Conditions 9 Cox Maze Cut and Sew Gold Standard 1987 pioneered by John Cox at Washington University 10 year cure rate: 96% Freedom from stroke 99% MAZE I delayed atrial activation MAZE II bleeding MAZE III Successful long run, but not easily adoptable MAZE IV alternate energy sources rather than cut and sew 10 5

6 11 Lesion Sets 12 6

7 Convergent Procedure Multidisciplinary epi-endo approach that utilizes the best of cardiothoracic surgery, leveraging endoscopic and port access technologies Minimally invasive, using transdiaphragmatic, pericardial window access Abdominal incision with no chest incisions or ports Epicardial ablation performed under direct endoscopic visualization Can be performed in a single setting Comprehensive epicardial, posterior heart ablation 13 Convergent Procedure 14 7

8 Convergent Procedure

9 Convergent Procedure 17 Thrombus in the Left Atrial Appendage -70% of all strokes in patients with AF are cardio-embolic -90% of these arise from the LAA Blackshear et al. 1996,61:

10 Other reasons to hold anticoagulation 19 Total Thoracoscopic Left Atrial Appendage Ligation What s next for patients with contraindications: 20 10

11 Thank You! 21 11