Concomitant Atrial FibrillationConcomitant Atrial Fibrillation

- allways Maze? -- allways Maze? -

Robert JM KlautzRobert JM Klautzchief department Cardiothoracic Surgerychief department Cardiothoracic Surgery

Get Rhythm 2006Get Rhythm 2006

QuestionsQuestions

• What do we want to achieve?What do we want to achieve?

• SRSR

• reduce need for OAC / AADreduce need for OAC / AAD

• freedom from palpitationsfreedom from palpitations

• freedom from TE / strokefreedom from TE / stroke

• improve LV functionimprove LV function

• What is achieved by the primary procedure?What is achieved by the primary procedure?

• Which patients benefit, what is the price?Which patients benefit, what is the price?

Concomitant AFConcomitant AF

• definitiondefinition• AF in a patient undergoing cardiac surgeryAF in a patient undergoing cardiac surgery

• Type of SurgeryType of Surgery• Mitral valve surgeryMitral valve surgery• Aortic valve surgeryAortic valve surgery• CABGCABG

• Type of AFType of AF• paroxysmalparoxysmal• persistentpersistent• permanentpermanent

Bleeding Risk with WarfarinBleeding Risk with Warfarin

• Major HaemorrhageMajor Haemorrhage

4.6% /yr4.6% /yr

• hospitalization, transfusion, or surgeryhospitalization, transfusion, or surgery

Chimowitz et al NEJM 2005

ICH risk:0.1% /yr no ACRR AC 0.5%disabilty doubled

ICH risk:0.1% /yr no ACRR AC 0.5%disabilty doubled

Prevalence of Preoperative AFPrevalence of Preoperative AF- likelyhood of concomitant treatment -- likelyhood of concomitant treatment -

STS database 2004-2006STS database 2004-2006

Gammi et al Ann Thor Surg 2008

AF in Mitral Valve DiseaseAF in Mitral Valve Disease- prevalence -- prevalence -

AF in medically treated MV disease:linearized rate 5% per year !

AF in medically treated MV disease:linearized rate 5% per year !

Grigioni et al JACC 2002

AF in Mitral Valve DiseaseAF in Mitral Valve Disease- risk -- risk -

Grigioni et al JACC 2002

AF is an independent risk factor for death in MR patientsAF is an independent risk factor for death in MR patients

Survival after Mitral Valve SurgerySurvival after Mitral Valve Surgery- pre-operative SR vs AF -- pre-operative SR vs AF -

Ngaage et al Ann Thorac Surg 2004

If AF is a risk factor for bad outcome

in MV disease

and after MV surgery

Can we modify it ?

If AF is a risk factor for bad outcome

in MV disease

and after MV surgery

Can we modify it ?

Cox Maze III + MV surgery

Remains gold standard regarding lesion set

Superior freedom from Afib MCT + RCT

? 80 % at 5 years

Superior freedom from Stroke / TE MCT (trend in RCT)

No survival benefit (yet)

But: obsolete

Combined MV & AF SurgeryCombined MV & AF Surgery

Wong et al Ann Thorac Surg 2006

MV surgery and AF interventionMV surgery and AF intervention

• RCT 6 mo AFRCT 6 mo AF

• 24 MV repair + Biatrial modRF24 MV repair + Biatrial modRF

• 25 MV repair + intensive rhythm control25 MV repair + intensive rhythm control

von Oppell et al. Eur J CardioThor Surg 2009

• 63% of pts with SR after 63% of pts with SR after

AF-ablation had normal AF-ablation had normal

atrial function atrial function

• RadiofrequencyRadiofrequency

• Dry / IrrigatedDry / Irrigated

• Unipolar / BipolarUnipolar / Bipolar

• CryothermiaCryothermia

• High Frequency UltrasoundHigh Frequency Ultrasound

• MicrowaveMicrowave

• LaserLaser

Combined MV & AF SurgeryCombined MV & AF Surgery- new energy sources -- new energy sources -

Electrophysiological Goals in AF SurgeryElectrophysiological Goals in AF Surgery

What do we aim for?Conduction block

Eliminate triggers/fociEliminate triggers/foci

PV isolation (complex or box)PV isolation (complex or box)

Reduce substrateReduce substrate

Connecting line roof LAMitral isthmus lineConnecting line roof LAMitral isthmus line

LALA

RARA Intercaval? Free wall? Isthmus ?Intercaval? Free wall? Isthmus ?

How to decide on an approach?How to decide on an approach?

First: STANDARDIZE

Then: INDIVIDUALIZE

First: STANDARDIZE

Then: INDIVIDUALIZE

Lesion sets for AF SurgeryLesion sets for AF Surgery

Paroxysmal AF: pulmonary vein isolation (PVI)Paroxysmal AF: pulmonary vein isolation (PVI)

Epicardially closed beating heart, off-pump

Energy source bipolar RF

cryothermia

Access minimal access possible

Lesion sets for AF SurgeryLesion sets for AF Surgery

Persistent / permanent AF: substrate reductionPersistent / permanent AF: substrate reduction

Epicardially limited to box lesion only

Energy source HIFU (ultrasound) (+ mitral isthmus)

cryothermia

bipolar RF

Access minimal access possible

Lesion sets for AF SurgeryLesion sets for AF Surgery

Endocardially Full CM III / “derivative”

Energy source bipolar RF

cryothermia

(cut and sew)

Access minimal access possible (CM IV)

Persistent / permanent AF: substrate reductionPersistent / permanent AF: substrate reduction

How to standardize - Concomitant AFHow to standardize - Concomitant AF

CONCOMITANT AF:

sternotomy in general, minimal access in selected cases

paroxysmal cases: PVI only (off-pump)

persistent cases: more extensive lesions – epi-endocardial

How to standardize - Concomitant AFHow to standardize - Concomitant AF- extended pulmonary vein isolation -- extended pulmonary vein isolation -

Benussi et al J Thorac Cardiovasc Surg 2005

How to standardize - Concomitant AFHow to standardize - Concomitant AF- mitral isthmus line -- mitral isthmus line -

Benussi et al J Thorac Cardiovasc Surg 2005

How to standardize - Concomitant AFHow to standardize - Concomitant AF

CONCOMITANT AF:

Trade off:- Quite invasive for aortic valve or CABG procedures

Question:- Right sided lesions ?

How to standardize - Concomitant AFHow to standardize - Concomitant AF- right sided lesions -- right sided lesions -

Barnett et al J Thorac Cardiovasc Surg 2006

How to standardize - Concomitant AFHow to standardize - Concomitant AF- right sided lesions -- right sided lesions -

PM implantation rate not studied

Barnett et al J Thorac Cardiovasc Surg 2006

How to standardize - Concomitant AFHow to standardize - Concomitant AF- right sided lesions -- right sided lesions -

"Addition of right atrial lesions conferred no additional benefit in these patients"

"Addition of right atrial lesions conferred no additional benefit in these patients"

"…both the left atrial combined with cavotricuspid isthmus ablation and biatrial procedures had similar outcomes despite

significant shorter CPB times in the LA group"

"…both the left atrial combined with cavotricuspid isthmus ablation and biatrial procedures had similar outcomes despite

significant shorter CPB times in the LA group"

Combined MV & AF SurgeryCombined MV & AF Surgery- Left Atrial Appendage -- Left Atrial Appendage -

Garcia-Fernandez et al JACC 2003

Combined MV & AF SurgeryCombined MV & AF Surgery- Left Atrial Appendage -- Left Atrial Appendage -

Retrospective analysis of 205 MV replacement pts

14 % SR

58 ligation LAA (6 incomplete)

69 months: 27 TE events

Absence of LAA ligation vs TE: OR 6.7

Including incomplete LAA ligation: OR 11.9

Garcia-Fernandez et al JACC 2003

Combined MV & AF SurgeryCombined MV & AF Surgery- Left Atrial Appendage -- Left Atrial Appendage -

Kanderian et al JACC 2008

Combined MV & AF SurgeryCombined MV & AF Surgery- Left Atrial Appendage -- Left Atrial Appendage -

Kanderian et al JACC 2008

LAA ClosureLAA Closure- Watchman Device -- Watchman Device -

Holmes et al Lancet 2009

• Atrioventricular Block – PM implantationAtrioventricular Block – PM implantation

• Collateral DamageCollateral Damage

• Lesions related tachy-arrythmiasLesions related tachy-arrythmias

Surgery for Atrial FibrillationSurgery for Atrial Fibrillation- inherent risks -- inherent risks -

ESC Guideline AF 2010ESC Guideline AF 2010

Concomitant AF SurgeryConcomitant AF Surgery- the future -- the future -

• Patient-specific approachPatient-specific approach

• Assessment of conduction blockAssessment of conduction block

• Team up with EP cardiologistTeam up with EP cardiologist

• TrialsTrials

• CRAFT-CABGCRAFT-CABG

Allways Maze?Allways Maze?

• Fewer lesionsFewer lesions

• Patients with paroxysmal AF: PVIPatients with paroxysmal AF: PVI

• LAALAA

• No ablationNo ablation

• low chance of succeslow chance of succes• large atrium, (very) long standinglarge atrium, (very) long standing

• high riskhigh risk• elderly patientelderly patient