Surgical Ablation for Lone AF: What have we learned after 30 years? Ralph J. Damiano, Jr., MD Evarts A. Graham Professor of Surgery Chief of Cardiothoracic Surgery Vice Chairman, Department of Surgery Barnes-Jewish Hospital Washington University School of Medicine St. Louis, MO USA AATS/HRS STARS Meeting November 18, 2017
DISCLOSURE Speaker for AtriCure, Edwards Lifesciences, LivaNova Consultant for Medtronic Research and educational grants over the last 2 years: AtriCure Edwards
What do we know after 30 years of surgery for atrial fibrillation?
What do we know after 30 years of surgery for atrial fibrillation? The Cox-Maze procedure has excellent late results for all types of atrial fibrillation.
Late Recurrence of Symptomatic AF Stand-Alone Maze Only several hundred procedures were performed worldwide each year. Most of these occurred in a handful of specialized centers. Last year, over 40,000 ablations were performed! What happened? Prasad et al. JTCVS 2003;126:1822
Surgery for Atrial Fibrillation: Advances in the last decade Advent of ablation technology to replace the surgical incisions and decrease the invasiveness of the Cox-Maze procedure Development of less invasive surgical approaches
Bipolar Radiofrequency Ablation
Cryoablation Devices 2-3 cm long, reusable probes 10 cm long disposable probes Lee, et al Innovations 2010;5:281-286
Surgical Treatment of AF Lesion Set for Cox-Maze IV Bipolar RF and cryoablation used to simplify and facilitate the Cox-Maze procedure: Bilateral pulmonary vein isolation Connecting lesions between the PVs LAA PV lesion Right-sided lesions
Variables CPB time, median (IQR), min PERIOPERATIVE VARIABLES CMP III (n = 112) CMP IV (n = 100) p Value 163 (145-183) 129 (113-150) <0.001 CCT, mean (95% CI), min 90 (73.5-105) 39 (33.2-46.7) <0.001 30-d Mortality 2 (2) 1 (1) 0.625 Early ATAs 38 (34) 40 (40) 0.732 Pacemaker implantation 90 d 9 (8) 7 (7) 0.776 Major complication rate 11 (10) 1 (1) 0.003 Weimar T, et al Circ Arrhythm Electrophysiol 2012;5:8-14
Weimar T, et al Circ Arrhythm Electrophysiol 2012;5:8-14
Results: Paroxysmal vs. non-paroxysmal AF Freedom from ATAs ( n = 576) p = 0.104 p = 0.052 p = 0.554 p = 0.414 p = 0.949 100% 80% 96% 91% 93% 85% 89% 86% 85% 80% 78% 78% 60% 40% 20% 0% 1 2 3 4 5 Time (Years) Paroxysmal Non-paroxysmal Department of Surgery Division of Cardiothoracic Surgery
Late Outcomes After the Cox-Maze IV Procedure: What was not associated with late failure? Type of AF LA size Duration of AF < 10 years Age Previous catheter ablation Henn, M et al.: J Thorac Cardiovasc Surg 2015
Ad N, et al. Eur J Cardiothorac Surg 2015;47:52-58
What do we know after 30 years of surgery for atrial fibrillation? In patients with AF referred for cardiac surgery, performing surgical ablation improves early and late survival.
What is the current state of concomitant treatment? AF Trends and Matched Outcomes from the STS Database For propensity matched AF patients, concomitant treatment was associated with a reduction in relative risk (RR) of 30-day mortality [RR 0.92] and stroke [RR 0.84] offset by an increase in renal failure [RR 1.12] and pacemaker implantation [RR 1.33]. Data analyzed from STS database 1/2011-6/2014 From July 2011 to June 2014, 86,941 patients with AF, but without endocarditis, underwent primary Non-emergent cardiac operations in The Society of Thoracic Surgeons (STS) database. The risk of concomitant SA was analyzed by propensity matching 28,739 patient-pairs with and without SA by AF type, primary operation, and STS comorbid risk variables using greedy 1:1 matching algorithms. Ann Thorac Surg 2017;104:493 500
Concomitant Cox-Maze IV Procedure is Associated with Improved Long-Term Survival in Patients with a History of Atrial Fibrillation Undergoing Cardiac Surgery Farah N. Musharbash, Matthew R. Schill MD, Laurie A. Sinn RN, BSN, Richard B. Schuessler PhD, Hersh S. Maniar MD, Marc R. Moon MD, Spencer J. Melby MD, Ralph J. Damiano, Jr., MD Division of Cardiothoracic Surgery, Department of Surgery Washington University School of Medicine and Barnes-Jewish Hospital St. Louis, Missouri, USA
Methods: Propensity Score Matching Covariates = 22 variables, caliper width = 0.1, match ratio 1:1 No AF n = 8911 Match #1 CMPIV n = 438 Match #2 Untreated AF n = 1510 No AF n = 402 CMPIV n = 402 CMPIV n = 342 Untreated AF n = 342 Department of Surgery Division of Cardiothoracic Surgery
Survival Curve: Matched CMPIV and Untreated AF 62% 42% Adjusted hazard ratio: 0.58 (CI: 0.43-0.78), p <0.001 Department of Surgery Division of Cardiothoracic Surgery
What do we know after 30 years of surgery for atrial fibrillation Limited lesion sets, particularly PVI, do not work as well. GP ablation does not work at all!
Left Atrial Lesions of the Cox-Maze IV
Results: Box vs. no box lesion Freedom from ATAs off AADs (n=576) p < 0.001 p = 0.017 p = 0.024 p = 0.068 p = 0.017 100% 80% 60% 85% 56% 79% 79% 59% 53% 71% 50% 66% 40% 33% 20% 0% 1 2 3 4 5 Time (Years) With Box Lesion Without Box Lesion Damiano et al. J Thorac Cardiovasc Surg 2015
Zheng S, et al. PLoS ONE 2013; 8(11):e79755
Electroanatomic Mapping After Thoracoscopic Surgical Ablation Only 23% of patients had their entire posterior LA isolated!!! Bulava A, et al. Ann Thorac Surg 2017; in press
Primary Efficacy Endpoint at 12 mo Freedom from death, LA arrhthmia, and AAD 0.0 0.2 0.4 0.6 0.8 1.0 NNT 3.4, 95% CI of 2.3-8.7 Surgical Ablation Catheter Ablation p<0.01 N=63 63 63 62 60 56 53 30 30 30 26 26 23 Catheter Ablation N=61 60 60 60 59 58 54 42 41 40 40 40 40 Surgical Ablation 0 30 60 90 120 180 240 300 360 Days since index SA/CA
Driessen A. H. G., et al J Am Coll Cardiol 2016;68:1155-1165
What do we know after 30 years of surgery for atrial fibrillation? Hybrid ablation at experienced centers have had good mid-term results. It remains to be seen whether these will be widely reproducible in other centers.
Hybrid Atrial Fibrillation Procedures The goal of the hybrid procedure is to take advantage of combined endocardial and epicardial ablations to produce transmural lesions on the beating heart, resulting in high procedural success for in a single or staged minimally invasive procedure.
Coming at AF from Two Directions Advantages Transmural with ablation from both sides Straight lines minimize gaps LAA exclusion, LOM obliteration Avoids esophageal trauma EP testing of surgical lesions Disadvantages More invasive than standard catheter PVI Longer hospital stay (2-4 days) Risk of serious bleed, emergent bypass, single lung ventilation
78 consecutive patients No deaths, no conversions to CPB complication rate = 8% Pison et al. Ann Cardiothorac Surg. 2014 Jan;3(1):38-44.
Pison et al. Ann Cardiothorac Surg. 2014 Jan;3(1):38-44.
de Asmundis C, et al. Europace 2017; 19:58-65
Je HG, et al. Eur J Cardiothorac Surg 2015;8:531-541
Surgical Ablation for Lone AF: What have we learned after 30 years? The Cox-Maze procedure has had the best results and success rates are durable for all types of AF. Surgical PVI alone will have a very small role to play and has had poor results for the treatment of long-standing persisted AF. GP ablation is ineffective.
Surgical Ablation for Lone AF: What have we learned after 30 years? Hybrid AF ablation has had promising results in experienced centers. Multicenter, prospective trials will need to be performed to better define their role. Further advances in preoperative imaging and diagnostics (MRI, ECGI) and improved ablation devices for epicardial, beating heart applications are needed.
Thank you for your attention
Very poor late results for persistent and long-standing persistent AF Zheng S, et al. PLoS One. 2013 Nov 11;8(11):e79755.
Build a Better AF Procedure Transmural lesions Durable lesion set Maze success rates Ablation recovery times Physiology-based Physiology-tested Minimize risk Shorter procedure length LAA exclusion