Minimally Invasive Stand Alone Cox-Maze Procedure For Patients With Non-Paroxysmal Atrial Fibrillation Niv Ad, MD Chief, Cardiac Surgery Inova Heart and Vascular Institute
Disclosures Niv Ad: Medtronic Inc. Atricure Inc. Estech Inc.
Q10. What is your experience with surgical ablation for stand alone AF? a. No experience b. 0-10 cases c. 10-25 cases d. 25-50 cases e. >50 cases
Introduction Percutaneous Catheter ablation for AF or surgical ablation performed off pump demonstrated limited success Several on bypass MI approaches have been developed applying the full Cox- Maze (CM) procedure lesion set. Concerns regarding increased morbidity eliminating the effect of the improved success rate.
Introduction From 2005 through 2010, a total of 91,801 surgical ablations were performed of which 4893 (5.3%) were stand-alone procedures Significant increase in the stand alone procedures from 552 in 2005 to 1014 in 2010, with 80% being performed off-cpb
Surgical Ablation for Stand Alone AF- Matched Group Variable^ Overall N=1708 On Pump N=854 Off Pump N=854 P-value + Operative Mortality 1.23 1.52 0.94 0.2752 Stroke 1.00 1.29 0.70 0.2253 Dialysis-Newly Acquired 0.76 1.05 0.47 0.1655 New Pacemaker 1.29 0.82 1.76 0.0881 Perioperative Atrial Fibrillation 2.46 3.04 1.87 0.1228 Gastro-Intestinal Complications 0.88 1.05 0.70 0.4386 Prolonged Ventilator (>24hrs) 5.27 6.56 3.98 0.0139 Reop for Bleeding/Tamponade 1.29 2.22 0.35 0.0003 Disharge Meds-Warafin 74.53 73.89 75.18 0.5367 Median Total Length of Stay (Days) 5 [4-8] 6 [5-9] 4 [3-6] <0.0001 + P-values are based on McNemar tests for categorical outcomes and Wilcoxon signed rank tests for continuous outcomes. ^ Data presented as mean [interquartile range] or percent unless otherwise noted.
Minimally invasive off bypass surgical ablation for AF In hospital major complications from 0-39% 3 operative deaths 11 cerebrovascular accidents 12 conversion to sternotomy 25 bleeding and port related complications Freedom from AF: Variable and limited consistency with regard to the duration and the methods of the follow-up La Meir et al, minimally Invasive surgery for atrial fibrillation and updated review. Europace, July 2012
Baseline characteristics MI Stand Alone Maze N=110 Age (years) 55.9 9.0 Female 9 Type of AF Long Standing Persistent 81 Persistent 23 Mean AF Duration (months) 69.1±70.4 Median [IQR] AF Duration (months) 49.9 [22.7-92.6] Left Atrial Diameter (cm;range) 5.0±1.1 (2.6-9.9) Left Atrial Size > 6cm 13 Previous Ablation 46 AF, atrial fibrillation; IQR, interquartile range.
Patients outcome MI Stand Alone Maze N=110 Perioperative Renal Failure Stroke 0 0 TIA 1 Reoperation for Bleeding 1 Intraoperative Blood Given 3 Postoperative Blood Given 4 Operative Mortality 0 Readmissions <30 Days 13 Perioperative PM for SN Dysfunction 1 Median [IQR] Length of Stay (Days) 4 [3-5] Median [IQR] ICU Stay (Hours) 22.9 [8.2-33.3] Mean Follow-up (Months) 44.9±26.3 Late Embolic Stroke 1 Warfarin at 12 Months 21/86 (24%) Clinically Indicated warfarin 14/21 (67%) Warfarin at 24 Months 9/53 (20%) Clinically Indicated warfarin 8/9 (89%) Cumulative 4-year Survival 97.1% TIA, transient ischemic attack; PM, pacemaker; SN, sinus node; IQR, interquartile range; ICU, intensive care unit.
Return to sinus rhythm
PERCENT OF PATIENTS Return to sinus rhythm 100 80 94% 87% 94% 87% 92% 79% 92% 80% 60 40 20 0 6 12 24 36 MONTHS OF FOLLOW-UP All Off AAD LTM
PERCENT OF PATIENTS Return to sinus rhythm 100 80 94% 87% 93% 94% 87% 92% 79% 100% 92% 80% 60 40 20 0 6 12 24 36 MONTHS OF FOLLOW-UP All Off AAD LTM
Arrhythmia-Free Survival
Conclusions On pump MI Cox-Maze procedure can be performed with comparable morbidity to catheter ablation and off pump surgical ablation with acceptable success rate in a challenging subgroup of patients with AF. The long term success rate is promising with 81% freedom from atrial arrhythmia at 5 years Our experience suggests the development of educational strategies to overcome the initial learning curve is needed.
Thank You
Q11. Should surgical ablation for stand alone AF using cardiopulmonary bypass be considered less safe compared to surgical ablation using off pump techniques? a. Yes b. No
Q12. Should cardiac surgeons training in surgical ablation for AF include all aspects of surgical ablation options? a. No - It is sufficient to be trained on limited left atrial lesions using closed heart techniques b. Yes Atrial fibrillation should be approached in a way that surgeons will be equipped with the knowledge and skills to apply all forms of procedures as required.