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RF Ablation of Atrial Fibrillation in Valvular Heart Surgery Patients

RF Ablation of Atrial Fibrillation in Valvular Heart Surgery Patients. Željko Sutlić. Introduction. The incidence of chronic atrial fibrilation (AF) is age dependent: 1% of the general population 4% in pts > 60 years 7% in pts > 70 years 60-80 % in pts with significant mitral valve disease.

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RF Ablation of Atrial Fibrillation in Valvular Heart Surgery Patients

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  1. RF Ablation of Atrial Fibrillation in Valvular Heart Surgery Patients Željko Sutlić

  2. Introduction • The incidence of chronic atrial fibrilation (AF) is age dependent: • 1% of the general population • 4% in pts > 60 years • 7% in pts > 70 years • 60-80 % in pts with significant mitral valve disease

  3. AF - TYPES • paroxsismal AF • persistant AF • permanent AF

  4. Criteria for Success • Sinus Rhythm • Absence of intermittent AF • Absence of atrial flutter • Atrial transport function • Restricted antiarrhythmic medication

  5. Criteria • Indication for mitral valve repair/replacement or coronary artery disease • Chronic atrial fibrillation (>6 months) • Electrocardiographical confirmation of diagnosed chronic atrial fibrillation by 24 hour holter monitoring • EF > 30 % • Age: 18 – 80 years • Informed consent

  6. Atrial fibrillation in Patients Undergoing Mitral Valve Surgery: Why AF Surgery? • Incidence of AF varies between 30 – 50% • Curative AF surgery can eliminate the need for anticoagulation by restoring sinus rhythm, particulary important in patients having valve repair • Rate of anticoagulation-related bleeding after mechanical valve surgery is between 0,3 to 4,9 events/ patient year • Bleeding rates with mitral bioprosthesesare less but stillsignificant (0,6 – 2,1 episodes/patient year) in part due to the need for anticoagulation for AF

  7. Atrial Fibrillation: Surgical Therapy • Cox developed the Maze Procedure – first performed in 1987 at Barnes Jewish Hospital • High rate of surgical cure for atrial fibrillation (>90%) without antiarrhythmic therapy • Indications: • Drug refractory AF • Arrhythmia intolerance • Recurrent thromboembolism

  8. Atrial fibrillation and Mitral Valve Disease • Should all patients with atrial fibrillation who are referred for mitral valve surgery undergo a concomitant Cox-Maze procedure? • Let's look at our long term surgical results in these patients!

  9. Cox-Maze III Procedure • Cox-Maze III first performed in 1988 • Maze-like surgical incisions • Based on theory of multiple macro-reentrant circuits

  10. The Cox Maze Procedure:Evolution of the Surgical Approach • The Cox Maze I was abandoned because of a high incidence of chronotropic incompetence and pacemaker implantation • The Cox Maze II was replaced because of its' technical difficulty • The Cox Maze III has remained the gold standard since 1988 and has extraordinary long term efficacy

  11. The Cox-Maze Procedure:Surgical Objectives • Cure of atrial fibrillation • Restoration of A-V synchrony • Preservation of atrial function • Discontinuation of anticoagulation and anti-arrhythmic drugs

  12. Cox-Maze III ProcedurePatient Populations • Lone atrial fibrillation • Atrial fibrillation in association with organic heart disease: • valvular heart disease • ischemic heart disease

  13. Freedom form AF All Patients Cox JL. Surg Treat of AF, San Francisco, June 2003

  14. Freedom from AF LM versus CM Cox JL. Surg Treat of AF, San Francisco, June 2003

  15. Efficacy of Surgical Maze Procedure for Atrial Fibrillation

  16. Cox-Maze III Procedure with Mitral Surgery: Washington University Experience • 65 consecutive patients between January 1988 – May 2003; mean follow-up = 3.6 years • Avarage duration AF: 5.2 years (0,5–28 years) • Paroxysmal AF: 41% • Operative mortality : 1/65 ( 1.5% ) • Freedom from AF at 10 years: 97% • No late strokes!

  17. Advantages of the COX-MAZE III Procedure • High cure rate (>90%) • Proven long-term efficacy • Applicable to both persistent and paroxysmal AF • Eliminates the late risk of stroke in a high risk population • Requires no additional devices except for a cryoprobe

  18. Shortcomings of the COX-MAZE III Procedure • Requires cardiopulmonary bypass and an arrested heart • Adds to cross-clamp time • Few surgeons perform the operation due to its' complexity • Significant morbidity • pacemaker requirement and left atrial dysfunction

  19. Cox-Maze III Procedure for AF Postoperative Management • Diuretics • Lasix • Spironolactone • Coumadin • 3 months • Discontinue if in NSR • Anti-arrhythmic drugs • 2 months • Discontinue if in NSR • Postoperative sinus node dysfunction • 10 – 15 % of patients • Wait 7-10 days before implanting pacemaker

  20. The Cox Maze Procedure:Goals of a Less Invasive Approach • Preserve the high success rates of the Cox-Maze III procedure while decreasing its' morbidity • Simplify and/or decrease the number of atrial incisions to shorten the procedure and increase its' adoption rate among surgeons • Replace surgical incisions with linear lines of ablation using various energy sources: • Cryosurgery • Radiofrequency • Microwave • Laser • Ultrasound

  21. Radiofrequency energy • similar to electrocautery • very fast AC current • no depolarisation of the heart • monopolar or bipolar • irrigated or not irrigated (early)

  22. Dry vs- Irrigated Electrode Tissue Heat Distribution

  23. Complications of RF Ablation for Atrial Fibrillation • CVA • TIA • Tamponade • Aortic tear • Pulmonary vein stenosis • Damage to MV apparatus • Phrenic nerve injury • Coronary artery injury

  24. Surgical procedure (began on april 2003) • MVR and TVP 6 patients • MVR and CABG 1 patient • average aortic clamp time 94 ± 42 min • average pump time 124 ± 25 min

  25. Table 1. Clinical characteristics (n=7) 3/4

  26. Table 2. Echocardiographic variables

  27. Table 3. Single case (male, 58 years old, MVR + TVP)

  28. Surgery for Atrial Fibrillation:Established Facts and Surgical Approach • We have very effective, though invasive, operation with high success rates • Patients who are candidates for Cox Maze procedure should not be deprived of a curative, known procedure for a theoretical lesion set performed with unproven technology • New procedures and technology should be subject to rigorous prospective clinical trials • New lesion sets should be based on known mechanisms of atrial fibrillation

  29. Will There Be a Role for Surgery in the Future? • Yes, for the symptomatic patient: • Who requires other concomitant cardiac surgical procedures • Coronary artery disease • Valvular heart disease • Congenital disease • With prior thromboembolic complications • For persistent and "permanent" atrial fibrillation • Possibly • With paroxysmal atrial fibrillation if performed via minimally invasive techniques

  30. Catheter Ablation Techniques for Atrial Fibrillation: Conclusions • Effective (60-80%) for drug refractory paroxysmal AF with pulmonary vein triggers • Targets PV-LA junction, with linear line to MVA, possible linear lesion across Bachman's bundle • Prolonged procedures, requires transseptal access to the LA • Lesions constrained by biophysical properties of tissue • Complications approach 5% • TIA/CVA • Pulmonary vein stenosis • Cardiac tamponade • Aortic tear, coronary injury • One of multiple tools available

  31. Everything should be made as simple as possible. But not simpler. Albert Einstein

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