Surgical Ablation: Which Lesion Set for Which Patient? Patrick M. McCarthy MD, FACC Director of the Bluhm Cardiovascular Institute Chief of Cardiac Surgery Division Heller-Sacks Professor of Surgery in the Feinberg School of Medicine May 2, 2010 AATS /STS Adult Cardiac Surgery Symposium Toronto, ON, Canada
Disclosures None
AF Ablation Surgery has become the Standard of Care Pre-op AF is Dangerous 11% of Cardiac Operations: STS Maze in 54.7% of MV operations AF Ablation surgery is safe and effective ( ~80%)
But, There is Variability in the Lesion Set and Technology Used for AF Ablation
Decision Points Which Operation? Primary vs. Reop Symptoms; tachy-med Cardiomyopathy Age Stroke history Recent Onset LA Size
Lesion sets Biatrial = LA Box and MV Annulus; RA set PVI = Bilateral antral isolation (RF Clamp) LA Only Classic (Cut and Sew)
Decision Making Do You Open LA Anyway? Add MV Annulus Do You Open RA Anyway? Biatrial AF Symptoms; CVA; Young; Long Duration? Biatrial AVR; CAB; Short Duration? PVI BUT if AVR; CAB: Pt has symptoms, CVA, Young, Long duration: Consider LA or Biatrial Classic: When you are operating for AF or want the best result
How To
Box Lesion
MV Annulus Lesion
What About Reop MV?
LA Dome Lesion
Inferior LA Lesion
MV Annulus Lesion
RA Lesions
C.S. TV Annulus Lesion
Bilateral PVI
NMH Registry Data 408 pts; 4 04 to 12 08; 1 surgeon 95% of pts with AF had Ablation 5 lesion sets - Classic Maze - Biatrial - LA only - PVI only - HIFU box lesion Prospective follow-up since Jan 2006 J Thorac Cardiovasc Surg 2010;139 (4):860-7
# of Procedures Maze Procedure Volume 2004-2008 60 50 Biatrial Left-Only 40 30 20 10 0 2004 2005 2006 2007 2008 Year J Thorac Cardiovasc Surg 2010; 139 (4):860-7
NMH Data 04 08 Mortality: 1.7% (0; stand-alone) CVA: 1.2% TIA: 0.7% LOS 6 days D/C Rhythm AF: 24%; 5.9% Classic Maze (p < 0.001) Follow-up: 16 % Antiarrhythmics 44% Warfarin J Thorac Cardiovasc Surg 2010;139 (4):860-7
Freedom from AF Freedom from AF and no Ablation
Percent of Patients Freedom from Atrial Fibrillation at Last Rhythm 100 90 80 70 N=58 N=77 N=15 N=22 N=39 60 50 40 30 20 10 0 Classic BiAtrial Left HIFU PVI Maze Type J Thorac Cardiovasc Surg 2010; 139(4):860-7
Summary More Extensive Lesions, and Transmural, give best results Easy to add this for MV, TV: even in reop Biatrial Lesions for symptomatic, young pts, prior CVA Realistically may not be best for elderly pts with recent onset AF, needing AVR, CAB Classic when you need the BEST result
The Key Point Matching the Lesion to the Patient
Characteristics J Thorac Cardiovasc Surg 2010;139(4):860-7
J Thorac Cardiovasc Surg 2010 ; 13 9 (4):8 60-7
Classic Maze Low rate of Ablation: 4.4% (n = 3 ) Mitral Isthmus (n = 2) RU PVI (n = 1) 94% Free from AF
HIFU Group Higher rate of ablation: 37.5% 100% Incomplete Box Lesion 73% Free from AF
Left Ablation Only (LA + PVI) Low rate of Ablation: 3.4 % (n = 8/225) High Failure rate from RA: 75 % (n = 6/8) MV Isthmus: n = 2 Box Lesion (cryoablation): n = 1 79.5 % Free from AF
Mitral Isthmus Ablation (LA; Biatrial; Classic) Low rate of Ablation: 4.8% (n = 16/134) MV Isthmus: 38 % (n = 6/16) Box Lesion or PV: 44 % (n = 7/16) 85.7% Free from AF
Conclusions AF Surgery Safe and Generally Effective HIFU: High Rate of Ablation and Failure of the Box Lesion LA lesions only: Risk of RA foci lead to failure MV Isthmus: A source for failure even when treated Classic Maze: Still the Gold Standard
Northwestern Strategy If a patient goes to cardiac surgery with a history of AF, that patient will receive an Intervention for AF.
Which Pts Should be Treated? Highly Symptomatic Patients Young, Low Risk Emboli, Failed Catheter Ablation
Which Pts To Avoid? 85 y/o, 6.5 cm LA, 15 yr history AF, 35 % EF, needs mini-avr Third time redo CAB Rheumatic redo triple valve Morbidly obese
Patient/Technique Selection MVR: PVI + MV lesion CAB, AVR, Aortic case, LV aneurysm: PVI +/- LA Appendage Closure On pump: Excise LAA (Classic Maze) or Close LAA (MVR); Ligate LAA at the base (CABG/AVR), oversewn or excised Off pump: Mini-Maze + Hybrid EP ablation
NMH Management Cut and Sew Mini-Maze / Hybrid EP Ablation 91% with AF History are Treated MVR: Bipolar RF and Cryo; Biatrial > 50% AVR, CAB, Aneurysm: PVI, bipolar RF, Close LAA More lesions if Symptomatic Redo MVR: Biatrial and Cryo
The More Extensive the Lesion Set the Better the Result Biatrial > LA Alone Classic Maze > Bipolar RF Within Reason
All must Create Transmural Lesions! No Collateral Damage No Char Ideally Off Pump
Extended (Biatrial) Lesions: If the LA is Open (MV) Or Permanent AF Or Symptomatic AF Or Right side surgery (TV repair)
PV Isolation: Wolf Procedure CAB, AVR, Aneurysm and PAF Elderly patients
Off Pump PVI + HIFU: Symptomatic AF patients preferring minimal-invasive approach
NMH Approach: Surgery and EP Monitoring Success AF Nurse Lockout EP 2 mo; Surgery: 3-6 mo Definition > 30 seconds Freedom from symptoms Interval 3 mo, 6 mo, 12 mo, annually
NMH Approach: Surgery and EP Monitoring Success Methods Pacemaker/ICD AF Express/Cardio Net Lifewatch 48 hour Holter monitor
Additional Procedures LA Appendage Closure Ganglionic Plexus Ablation LA isthmus lesion RA isthmus lesion
Patient Factors Left Atrial Size Age Etiology of MV Disease LV Function
Trying to Make Sense of A Bewildering Array of: Patient Factors AF Pathologies Lesions Technologies
Techniques: Briefly All Maze Operations are not the Same
Technologies Cut and Sew Cryoablation Unipolar RF Bipolar RF Microwave HIFU Laser
LA Appendage Stapling
Lesion Sets Classic Maze III Pulm Vein (Antrum) Isolation PVI with MV annular lesion Biatrial or Maze IV
Classic Maze Procedure Pulmonary Vein Box Lesion MV Annulus to Box Lesion SVC-IVC TV Annulus Flutter lines X2 Excision of LAA