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Atrial Fibrillation Ablation: Convergent Procedure

Atrial Fibrillation Ablation: Convergent Procedure . CA3 Cardiac Conference Andrew Grandin , MD September 18 th , 2013. Atrial Fibrillation: The Basics Epidemiology. The most common sustained cardiac arrhythmia More prevalent in men than women More prevalent with increasing age

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Atrial Fibrillation Ablation: Convergent Procedure

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  1. Atrial Fibrillation Ablation: Convergent Procedure CA3 Cardiac Conference Andrew Grandin, MD September 18th, 2013

  2. Atrial Fibrillation: The BasicsEpidemiology • The most common sustained cardiac arrhythmia • More prevalent in men than women • More prevalent with increasing age • More prevalent with concomitant heart disease

  3. Atrial Fibrillation: The BasicsMorbidity • AF can have adverse consequences related to: • Reduction in cardiac output • Atrial and atrial appendage thrombus formation • Exacerbation of ischemic heart disease • Symptoms from AF can be debilitating • AF tends to be progressive • AF is an independent predictor of longterm mortality

  4. Atrial Fibrillation: The BasicsCost • An AF patient costs $8,600 more in annual medical costs than a population matched non AF patient • $26 billion annually • Of that $6 billion direct costs of managing AF

  5. Atrial Fibrillation: The BasicsClassification • Paroxysmal AF • Recurrent AF (≥2 episodes) that terminates spontaneously in seven days, usually less than 24 hours • Persistent AF • AF that fails to self-terminate in seven days. Often require pharmacologic or electrical cardioversion to restore sinus rhythm • Long-standing persistent AF • Persistent AF that has lasted continuously for one year or more • Permanent AF • Persistent AF where the decision has been made to no longer pursue rhythm control • Lone AF • Any of the above classifications of AF in the absence of structural heart disease. • First detected or diagnosed AF • Independent of duration or presence/absence of symptoms

  6. Atrial Fibrillation: The BasicsMedical Management (In 1 slide or less!) • Rate versus rhythm control strategies • Rate control goals • Strict versus moderate • Anticoagulation • Warfarin INR 2-3 • Aspirin • Dabigitran • CHADS  CHADS2  CHA2DS2-VASc • Risk factors predictive of embolic stroke risk

  7. Principles of cardiac electrical propagation:What’s gone wrong in AF? • Multiple re-entrant circuits • Paroxysmal AF EP mapping and pulmonary veins • PV lined by endothelium • Atrium lined by endocardium • Transition zone gradual and notable for high electrical activity • Autonomous and can fire 300-400 cycles/min • Persistent AF features changes in atrial substrate

  8. Breaking the circuit:Cox maze III (The Gold Standard) • James L Cox MD • Work began in 1980 • Scar tissue in the heart does not conduct electrical impulses • Several unsuccessful operations in the mid 1980s • 1st Maze procedure performed September 25th, 1987 • Open heart surgery, full CPB, multiple atriotomies on both RA and LA

  9. Breaking the circuit:Cox maze III (The Gold Standard) Cox et al, 1996

  10. Breaking the circuit:Cox maze III (The Gold Standard) • 198 patients underwent Cox maze III • 112 with lone AF (64% paroxysmal, 36% persistent) • 86 with a concomitant cardiac procedure (48% paroxysmal, 52% persistent) • High efficacy • In lone AF group, 92% AF free at 10 years • In concomitant group, 97% AF free at 14 years • No difference in efficacy between paroxysmal and persistent AF • Why wasn’t it widely adopted? Prasad et al, 2003

  11. Breaking the circuit:Cox Maze III  Mini maze  Wolf Mini maze (MIS) • Simplified lesion sets • PVI, LOM, ganglionatedplexi LA, LAA • Energy ablation versus physical cut and sew • Thoracoscopyversus sternotomy • Off pump versus on pump • Excellent results for paroxysmal AF

  12. Breaking the circuit:Catheter ablation • Venous access • Femoral • Jugular • Cross interatrial septum • EP mapping • Fluoroscopic and ultrasound guidance • Multiple catheter ablation points to create linear ablations

  13. Breaking the circuit:Catheter ablation—longterm durability • Cohort of 100 patients undergoing their first ablation • 64% paroxysmal AF, 22% persistent, 14% longstanding persistent • Arrhythmia-free survival after a single procedure • 40% at 1 year, 36% at 2 years, 28% at 5 years • A significant portion required 2 or more ablations to return to NSR • Arrhythmia-free survival after a last procedure • 87% at 1 year, 81% at 2 years, 63% at 5 years Weerasooriyaet al, 2011

  14. Weaknesses of single modality ablations • Mini maze • Invasive • Sternotomyvsthoracoscopy • Certain lesions cannot be created by epicardial ablation • EP mapping not as sophisticated with epicardialvsendocardial technique • Catheter ablation • Time-consuming • Some difficulty creating complete linear lesions • Some difficulty creating transmural lesions without injury to other mediastinal structures • Radiation exposure • Significantly less efficacy with persistent AF • Ability to ligate LAA?

  15. DrRobo VS DrCorsello Dr Quinn VS Dr Carpenter DrWeldner VS DrSesselberg Dr Buchanan VS Dr Cutler

  16. Putting egos aside… Electrophysiology Cardiothoracic Surgery

  17. Combined procedures • Hybrid procedure • MIS maze (thoracoscopic) plus EP catheter ablation • Dual EpicardialEndocardial Persistent AF (DEEP AF) clinical study • Convergent procedure • Pericardioscopic ablation plus EP catheter ablation

  18. Pericardioscopic ablation Kiser et al, 2011. Civello, 2012.

  19. New approach, new toys

  20. Potential advantages • No thoracoscopy/thoracotomy • No lung isolation • No need to takedown pericardial reflections • No sternotomy/CPB • Epicardial unipolar ablation for posterior LA wall • Energy directed away from surrounding mediastinal structures • Single small incision

  21. Potential issues related to surgical approach • Limited visualization • Rare potential for great vessel injury without ability for immediate surgical control • CRASH onto bypass • Exclusion of left atrial appendage not straightforward • ? Lariat device

  22. Convergent Procedure • Surgeon’s goals • Electrically isolate the posterior left atrium • Ablate the pulmonary veins • Ablate the ligament of Marshall • Recognize and limit the potential for thermal injury to adjacent mediastinal structures • Electrophysiologist’s goals • Interrogate pulmonary veins and complete ablation • Interrogate posterior left atrium and confirm electrical silence • (Ablate the coronary sinus) • (Ablate the cavotricuspid isthmus)

  23. Kiser et al,2011.

  24. Civello, 2012. Robinson et al, 2012.

  25. Convergent procedure: best of both worlds?

  26. *EARLY* results • Small, single-center case series • Patients with persistent or longstanding persistent AF • Failed AAD, some failed endocardial ablations or considered unsuitable for catheter ablation • Rigorous follow-up • Promising early results • Free from AF at 12 months, ~90% • Free from AF and off AAD, ~70%

  27. Complications • Major • Atrioesophagel fistula (frequently fatal) • Symptomatic pericardial effusion/tamponade • Minor • Pericarditis • Ventral incisional hernia

  28. Issues going forward with convergent procedure • Cost-effectiveness? • Expensive ablation probes • Long procedure times • Average 3-day hospitalization post-op • Evidence-based benefits? • Hybrid approach in feasibility trials (phase I and II) • Convergent approach IDE trials still needed for device FDA approval • Standardized ablation lesion patterns? • Study endpoints • Longterm durability? • Current data are small case series with 12 month f/u • Unknown if similar attrition rate as seen with catheter ablations alone

  29. Convergent procedure at MMC • Administrative approval? • Roll-out • Site visits • Logistics • OR vs EP lab vs both (until hybrid OR, 2015 at the earliest) • Likely looking at epicardial portion in OR (with CPB stand-by) and then transport under same anesthetic to EP lab

  30. Anesthesia considerations • Development of standardized protocol • GETA, single lumen ETT • Access • Large peripheral IV • Radial a-line • ? Central line • Intraoperative anticoagulation • Transport from OR to R8 • Staffing issues

  31. Questions?

  32. References • “Overview of atrial fibrillation.” www.uptodate.com • www.stopafib.org • Spector, P. “Principles of Cardiac Electric Propagation and Their Implications for Re-entrant Arrhythmias” CircArrhythmElectrophysiol. 2013;6:655-661 • Lee et al. “Catheter ablation of atrial arrhythmias: state of the art” Lancet. 2012; 380: 1509–19 • Prasad, et al. “The Cox maze III procedure for atrial fibrillation: Long-term efficacy in patients undergoing lone versus concomitant procedures.” J ThoracCardiovascSurg. 2003;126:1822-8 • Cox, JL et al. “An 8 1/2-year clinical experience with surgery for atrial fibrillation.”Ann Surg. 1996; 224(3): 267–275 • Weerasooriyaet al. “Catheter Ablation for Atrial Fibrillation Are Results Maintained at 5 Years of Follow-Up?” JACC. 2011; 57(2):160–6 • Kiser et al. “The Convergent Procedure is a Collaborative Atrial Fibrillation Treatment” The Journal of Innovations in Cardiac Rhythm Managemen., 2011; 2: 289–293 • Civello, K. “Shifting Paradigms: A New Comprehensive Multi-Disciplinary Approach to Atrial Fibrillation” EP Lab Digest. 2012; 12(11): 30-1 • Robinson et al. “Maximizing Ablation, Limiting Invasiveness, and Being Realistic About Atrial Fibrillation: The Convergent Hybrid Ablation Procedure for Advanced AF” EP Lab Digest. 2013; 13(6): 34-6

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