Concomitant Atrial Fibrillation
- allways Maze? -
Robert JM Klautz
chief department Cardiothoracic Surgery
Get Rhythm 2006
Questions
• What do we want to achieve?
• SR
• reduce need for OAC / AAD
• freedom from palpitations
• freedom from TE / stroke
• improve LV function
• What is achieved by the primary procedure?
• Which patients benefit, what is the price?
Concomitant AF
• definition
• AF in a patient undergoing cardiac surgery
• Type of Surgery
• Mitral valve surgery
• Aortic valve surgery
• CABG
• Type of AF
• paroxysmal
• persistent
• permanent
Bleeding Risk with Warfarin
• Major Haemorrhage
4.6% /yr
• hospitalization, transfusion, or surgery
ICH risk:
0.1% /yr no AC
RR AC 0.5%
disabilty doubled
Chimowitz et al NEJM 2005
Prevalence of Preoperative AF
- likelyhood of concomitant treatment STS database 2004-2006
Gammi et al Ann Thor Surg 2008
AF in Mitral Valve Disease
- prevalence -
AF in medically treated MV disease:
linearized rate 5% per year !
Grigioni et al JACC 2002
AF in Mitral Valve Disease
- risk -
AF is an independent risk factor for death in MR patients
Grigioni et al JACC 2002
Survival after Mitral Valve Surgery
- 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 ?
Combined MV & AF Surgery
Cox Maze III + MV surgery
Remains gold standard regarding lesion set
Superior freedom from AfibMCT + RCT
? 80 % at 5 years
Superior freedom from Stroke / TE
MCT (trend in RCT)
No survival benefit (yet)
But: obsolete
Wong et al Ann Thorac Surg 2006
MV surgery and AF intervention
• RCT 6 mo AF
• 24 MV repair + Biatrial modRF
• 25 MV repair + intensive rhythm control
• 63% of pts with SR after
AF-ablation had normal
atrial function
von Oppell et al. Eur J CardioThor Surg 2009
Combined MV & AF Surgery
- new energy sources -
• Radiofrequency
• Dry / Irrigated
• Unipolar / Bipolar
• Cryothermia
• High Frequency Ultrasound
• Microwave
• Laser
Electrophysiological Goals in AF Surgery
What do we aim for?
Conduction block
Eliminate triggers/foci
Reduce substrate
LA
PV isolation (complex or box)
Connecting line roof LA
Mitral isthmus line
RA
Intercaval? Free wall?
Isthmus ?
How to decide on an approach?
First: STANDARDIZE
Then: INDIVIDUALIZE
Lesion sets for AF Surgery
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 Surgery
Persistent / 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 Surgery
Persistent / permanent AF: substrate reduction
Endocardially
Full CM III / “derivative”
Energy source
bipolar RF
cryothermia
(cut and sew)
Access
minimal access possible (CM IV)
How 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 AF
- extended pulmonary vein isolation -
Benussi et al J Thorac Cardiovasc Surg 2005
How to standardize - Concomitant AF
- mitral isthmus line -
Benussi et al J Thorac Cardiovasc Surg 2005
How to standardize - Concomitant AF
CONCOMITANT AF:
Trade off:
- Quite invasive for aortic valve or CABG procedures
Question:
- Right sided lesions ?
How to standardize - Concomitant AF
- right sided lesions -
Barnett et al J Thorac Cardiovasc Surg 2006
How to standardize - Concomitant AF
- right sided lesions -
PM implantation rate not studied
Barnett et al J Thorac Cardiovasc Surg 2006
How to standardize - Concomitant AF
- right sided lesions -
"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"
Combined MV & AF Surgery
- Left Atrial Appendage -
Garcia-Fernandez et al JACC 2003
Combined MV & AF Surgery
- 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 Surgery
- Left Atrial Appendage -
Kanderian et al JACC 2008
Combined MV & AF Surgery
- Left Atrial Appendage -
Kanderian et al JACC 2008
LAA Closure
- Watchman Device -
Holmes et al Lancet 2009
Surgery for Atrial Fibrillation
- inherent risks -
• Atrioventricular Block – PM implantation
• Collateral Damage
• Lesions related tachy-arrythmias
ESC Guideline AF 2010
Concomitant AF Surgery
- the future -
• Patient-specific approach
• Assessment of conduction block
• Team up with EP cardiologist
• Trials
• CRAFT-CABG
Allways Maze?
• Fewer lesions
• Patients with paroxysmal AF: PVI
• LAA
• No ablation
• low chance of succes
• large atrium, (very) long standing
• high risk
• elderly patient