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AFib Therapy Concomitant to Heart Surgery

Understand the importance of treating Atrial Fibrillation (AFib) concomitant to heart surgery. Learn about the benefits for patients, risks, and successful outcomes. Discover who can benefit and why standardized lesions are crucial. Stay informed on the threat of Left Atrial Appendage in AFib patients.

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AFib Therapy Concomitant to Heart Surgery

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  1. AFib Therapy Concomitant to Heart Surgery Edit: October 2018

  2. Content Why treat Atrial Fibrillation (AFib)? How does concomitant AFib therapy benefit your patients? Who can benefit from concomitant AFib therapy? Concomitant AFib therapy does NOT increase the surgical risk Standardized lesions with reproducible success rates The Left Atrial Appendage – a threat to all AFib patients

  3. 1. Why Treat Atrial Fibrillation (AFib)?

  4. More than 200,000 people ARE DIAGNOSED WITH AFIB EVERY YEAR IN EUROPE ALONE1. 1. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal doi:10.1093/eurheartj/ehw210

  5. 1 IN 4adults over 40 WILL DEVELOP ATRIAL FIBRILLATION IN THEIR LIFETIME2 2. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal doi:10.1093/eurheartj/ehw210

  6. PEOPLE WITH ATRIAL FIBRILLATION ARE3 3. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal doi:10.1093/eurheartj/ehw210

  7. IN EUROPE ALONE, 15-20%of strokes are caused by Atrial Fibrillation4 4. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal doi:10.1093/eurheartj/ehw210

  8. IN 20175 • 12 MILLIONEuropeans suffered from AF. BY 20205, that number will be • 15 MILLION. 5. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal doi:10.1093/eurheartj/ehw210

  9. 2. How Does Concomitant AFib Therapy Benefit Your Patients?

  10. AFib Ablation Concomitant to Heart Surgery Efficiently Restores Normal Sinus Rhythm 37pts Afib Treated (nPAF) 91% ± 7%conversion to Sinus Rhythm at 5 years 66pts AFib Not Treated(nPAF) 33% ± 7% conversion to Sinus Rhythm at 5 years Louagie Y, Buche M, Eucher P, Schoevaerdts JC, Gerard M, Jamart J, et al. Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone. Ann Thorac Surg. 2009;87:440–6.

  11. Concomitant AFib Ablation Significantly Increases Freedom from Long-Term Strokes 97.9% at 5y 92.4% at 10y 394pts Afib Treated (In Sinus Rhythm) 116pts Afib Treated (Not in Sinus Rhythm) 84.4% at 5y 76.6% at 10y Note: A stroke was defined as a neurological deficit concomitant with ischemic image findings on a computed tomography or a magnetic resonance imaging Itoh A, Kobayashi J, Bando K, Niwaya K, Tagusari O, Nakajima H. et al. The impact of mitral valve surgery combined with maze procedure. Eur J Cardiothorac Surg. 2006;29(6):1030–5.

  12. Performing Concomitant AFib Ablation in CABG Patients Reduces All-Cause Mortality by >40% Concomitant AFib ablation in CABG patients with persistent AF showed a 42% reduction in all-cause mortality at 1 year and 29% reduction at 2 year 3,119pts Afib Not Treated 626pts AfibTreated CABG vs. CABG + AF Ablation Mortality over 1 ye. Data represent % chance of death at each time interval (days) Rankin J.Set al, One-year Mortality and Costs after Surgical Ablation for Atrial Fibrillation Concomitant to Coronary Artery Bypass Grafting, Eur J Cardiothorac Surg 2017 53(3) 471-477 Rankin J.Set al, Surgical ablation of atrial fibrillation concomitant to coronary artery bypass grafting provides cost-effective mortality reduction, 2018 AATS presentation, in review JTCS.

  13. Patients with AFib Undergoing Concomitant AFib Ablation Have Significantly Better Mid-Term Survival Than Those Who Do Not Concomitant AFib ablation to either isolated AVR, MVR or CABG+valve gave AFib patients similar survival than that of patients without a history of AFib 2449pts without AFib 565ptsAFib Treated 248pts AFib Untreated Lee Ret al. Midterm survival in patients treated for atrial fibrillation: A propensity-matched comparison to patients without a history of atrial fibrillation. J ThoracCardiovasc Surg. 2012;143:1341–1351.

  14. AFib Ablation Concomitant to Heart Surgery Significantly Improves Long-Term Survival 89% ± 5%5y survival 37pts AFib Treated (nPAF) 60% ± 7% 5y survival 66pts AFib Not Treated(nPAF) Kaplan-Meier estimate of postoperative survival including hospital mortality Louagie Y, Buche M, Eucher P, Schoevaerdts JC, Gerard M, Jamart J, et al. Improved patient survival with concomitant Cox Maze III procedure compared with heart surgery alone. Ann Thorac Surg. 2009;87:440–6.

  15. Concomitant AFib Ablation Significantly Decreases All Cardiac Complications At Mid- And Long-Term 86.0% at 5y 80.4% at 10y 108pts AFib Treated (In Sinus Rhythm) 136pts Intractable or AFib Untreated Actuarial freedom from all cardiac complications such as death, valve deterioration, valve thrombosis, thromboembolism including stroke, anticoagulation-related bleeding, pacemaker implantation, congestive heart failure, reoperation Fukunagaet al, Effect of surgery for atrial fibrillation associated with mitral valve disease. The Annals of Thoracic Surgery. 2008;86(4):1212–1217.

  16. Concomitant AFib Ablation Significantly Improves Patients Quality of Life Forlani Set al. Conversion to sinus rhythm by ablation improves quality of life in patients submitted to mitral valve surgery. Ann Thorac Surg. 2006;81(3):863–7.

  17. 3. Who Can Benefit from Concomitant AFib Therapy?

  18. What Do All The Experts in the Field Say? 60 Experts From 11 Organizations Endorsed by the Society of Thoracic Surgeons (STS), the American College of Cardiology (ACC) ,the American Heart Association (AHA) the Canadian Heart Rhythm Society (CHRS) , the Japanese Heart Rhythm Society (JHRS), and the Brazilian Society of CardiacArrhythmias (Sociedade Brasileira de Arritmias Cardíacas[SOBRAC]).

  19. AFib Ablation Concomitant To Mitral Surgery is Recommended: COR I, LOE B-NR 2017 HRS/EHRA/ECAS/APHRS/SOLAECE Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation Calkins H et al, Heart Rhythm 10 (2017) e275-e444

  20. AFib Ablation Concomitant To AVR, AVR+CABG, CABG is Recommended: COR I, LOE B-NR 2017 HRS/EHRA/ECAS/APHRS/SOLAECE Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation Calkins H et al, Heart Rhythm 10 (2017) e275-e444

  21. Surgical Ablation Guidelines are Advancing * Concomitant Mitral Operations Concomitant w/AVR/CABG/AVR+CABG Stand-Alone LAAM Badhwar, et al. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. The Annals of Thoracic Surgery, 2017; 103: 329-41. AHA/ACC/HRS Atrial Fibrillation Guideline. JACC Vol. 64, no. 21. December 2, 2014.*2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm, Vol 14, No 10, October 2017. AVR/CABG concomitant ablation Class I LOR for symptomatic persistent and long-standing persistent “refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication”Meier et al, EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion. EuroIntervention. 2014Dr. Cox performed first surgical ablation using maze I; Cox JL, J. JP, RB, et al. Successful surgical treatment of atrial fibrillation. Review and clinical update. JAMA 1991; 266: 1976-80.COR = Class of Recommendation LOE = Level of Evidence

  22. 4. Concomitant AFib Therapy Does NOT Increase the Surgical Risk

  23. “CABG/AVR Patients With AFib Can Undergo Ablation WITHOUT Increased Surgical Risk” Purpose Evaluate the safety and efficacy of concomitant AFib ablation in AFib patients undergoing CABG surgery and/or AVR Methods Single center retrospective study 30 month Median Follow-up N=375 (129 intervention; 246 control) LAA excised and over sewn, PVI for PAF, bi-atrial for NPAF Results • No difference in hospital mortality: 4.7% vs 5.3% (p=0.791) • No difference in stroke: • 3.1% vs 3.3% (p=0.937) • Ablation group had less post-op AF: 27% vs 78% (p<0.0001) • Ablation added 22-32 mins of cross-clamp time without increased surgical risk Al-Atassi T et al, Ann ThoracSurg104 (2017) 515-522

  24. Even A Full Cox Maze With Atriotomy Concomitant to AVR or CABG Does NOT Increase Operative Risk • No increase in morbidity due to concomitant Maze procedure • No increase in morbidity despite the longer bypass time • (164.4 vs 108.8 mins, p<0.001) • 94% of pts who received the Maze procedure were in sinus rhythm at 1 year (81% off class I and III antiarrhythmic drugs) Ad N et al, J Thorac Cardiovasc Surg143 (2012) 936-944

  25. A Full Maze IV With Atriotomy Concomitant to CABG, AVR, MVR Improves Survival WITHOUT Increasing Postoperative Morbidity or Mortality AF treated AF treated No AF AF untreated Concomitant AFib Surgery improves survival compared with untreated AF patients: 62% vs 42% at 10 years p=0.014 Pts receiving concomitant AFib Surgery have similar survival to pts without history of AF: 63% vs 55% at 10 years p=0.929 • No difference in 30-d mortality: 3% vs 4% p=0.534 • No difference in postoperative morbidity even with longer Cardiopulmonary bypass time (193±43 vs 132±53 min, p<0.001) and crossclamp time (97±29 vs 87±38 min, p<0.001) Musharbash FN et al, J Thorac Cardiovasc Surg155 (2018) 159-170

  26. 5. Standardized Lesions With Reproducible Success Rates

  27. Pulmonary Vein Isolation and Left Atrial Appendage Occlusion PVI Alone: ~40-60% Afib Free1,2(nPAF) 1Gillinov AM, Gelijns AC, Parides MK, DeRose JJ, Moskowitz AJ, Voisine P, et al. Surgical ablation of atrial fibrillation during mitral-valve surgery. N Engl J Med. 2015 Apr 9; 372(15):1399–409. 2Vinay Badhwar, J. Scott Rankin, Ralph J. Damiano, A. Marc Gillinov, Faisal G. Bakaeen, James R. Edgerton, Jonathan M. Philpott, Patrick M. McCarthy, Steven F. Bolling, Harold G. Roberts, Vinod H. Thourani, Rakesh M. Suri, Richard J. Shemin, Scott Firestone, Niv Ad. The Society of Thoracic Surgeons 2017 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation. The Annals of Thoracic Surgery, 2017; 103: 329-41.

  28. Box Lesion Set and Left Atrial Appendage Occlusion PVI + Box: ~55-70% Afib Free1,2 1Voeller RK, Bailey MS, Zierer A, Lall SC, Sakamoto S, Aubuchon K et al. Isolating the entire posterior left atrium improves surgical outcomes after the Cox Maze procedure. J ThoracCardiovascSurg 2008;135:870–7. 2Gillinov, A. M., Bhavani, S., Blackstone, E. H., Rajeswaran, J., Svensson, L. G., Navia, J. L., ... & McCarthy

  29. Left Atrial Lesion Set and Left Atrial Appendage Occlusion LALS: ~73-86% Afib Free1,2 ~15-20% fewer Atrial Flutter3 1Barnett SD, Ad N.. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. J ThoracCardiovascSurg 2006;131:1029-35. 2Ad, N., Holmes, S. D., Lamont, D., & Shuman, D. J. (2017). Left-Sided Surgical Ablation for Patients With Atrial Fibrillation Who Are Undergoing Concomitant Cardiac Surgical Procedures. The Annals of thoracic surgery, 103(1), 58-65. 3Cox JL, Ad N. The importance of cryoablation of the coronary sinus during the Maze procedure. SeminThoracCardiovascSurg 2000;12:20-4.

  30. Maze IV Lesion Set and Left Atrial Appendage Occlusion MAZE IV: ~80-90% Afib Free1,2,3,4 1Philpott JM, Zemlin CW, Cox JL, Stirling M, Mack M, Hooker RL, et al. The ABLATE Trial: Safety and Efficacy of Cox Maze-IV Using a Bipolar Radiofrequency Ablation System. Ann Thorac Surg. 2015. November;100(5):1541–8. 2Gaynor SL, Schuessler RB, Bailey MS, et al. Surgical treatment of atrial fibrillation: predictors of late recurrence. J ThoracCardiovascSurg 2005;129:104-11. 3Weimar T, Bailey MS, Watanabe Y. et al. The Cox-maze iv procedure for lone atrial fibrillation: A single center experience in 100 consecutive patients. J Interv Card Electrophysiol. 2011;31(1):47–54. 4Schill, M. R., Musharbash, F. N., Hansalia, V., Greenberg, J. W., Melby, S. J., Maniar, H. S., ... & Damiano, R. J. (2017). Late results of the Cox-maze IV procedure in patients undergoing coronary artery bypass grafting. The Journal of thoracic and cardiovascular surgery, 153(5), 1087-1094.

  31. Success Rate of Lesion Set Options Note: + = Time Reported Experiences: 3mo – 3 year retro- & prospective peer-reviewed publications both on and off AADs The success of various procedures may be influenced by several factors which may predict the outcome. Duration of pre procedural Afib, type of Afib, lesion set performed, left atrial size, patient’s age, atrial fibrillation wave <1.0mm, experience of the operator, left atrial reduction, and device used.

  32. Appendices

  33. Concomitant AFib Ablation Has The Same Level of Evidence as Mitral Valve Surgery (COR I, LOE A), and Aortic Valve or CABG Surgery (COR I, LOE B) Mitral Valve Surgery (COR:1 LOE:A) Aortic Valve or CABG Surgery (COR: I, LOE:B)

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