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SURGICAL TREATMENT OF ATRIAL FIBRILLATION. 1/ Incidence of AF: 5% of the population > 60 years, - 600 000 candidates for AF surgery in USA 2/ Etiologies: among patients applying for a life insurance: 40% lone AF, 60% with cardiopathy

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slide1

SURGICAL TREATMENT OF ATRIAL FIBRILLATION

1/ Incidence of AF: 5% of the population > 60 years, - 600 000 candidates for AF surgery in USA

2/ Etiologies: among patients applying for a life insurance: 40% lone AF, 60% with cardiopathy

3/ Restoration of sinus rhythm after valve repair depends upon the duration of AF (> 1year) and left atrium dimensions (>60mm)

4/ The presence of preoperative AF does not influence the operative risk

Specific surgical procedures aiming at treating atrial fibrillation must add minimal morbidity

Chua JTCS 1993 & Obadia JTCS 1997

slide2

ATRIAL EXCLUSION LINES

which tracing?

1/ Original Cox-Maze III procedure

2/ Hemicox: left maze procedure

3/ Exclusion of the pulmonary veins

(+ left appendage exclusion)

slide3

CLASSICAL COX-MAZE III

left appendage

right appendage

sup. veina cava

septal incision

pulmonary veins

tricuspid

mitral

inf. veina cava

slide4

LEFT COX-MAZE PROCEDURE

left appendage

pulmonary veins

mitral

slide5

EXCLUSION OF THE PULMONARY VEINS

left appendage

pulmonary veins

cox maze procedure associated to mitral valve surgery
COX-MAZE PROCEDUREassociated to mitral valve surgery

N = 40

Indications:

Chronic AF > 6 months 35

Intermittent AF (left maze) 5

AGE: 15-71 YRS (49+16 YRS)

ETIOLOGIES OF MITRAL VALVE DISEASE:

degenerative 20

rheumatic 17

others 3

slide7

MITRAL VALVE PROCEDURE

associated to the Cox-maze

MAZE DURATION

complete: 52 min

left: 23 min

results complete maze left maze
mortality: 1 (2,5%) (septic shock)

reoperation for bleeding: 3

coronary bypass for circumflex stenosis 1

pace maker (complete maze) 1

fluid retention (complete maze) 4

lower limbs edema : 4

pericardial effusion: 2

pleural effusion: 2

RESULTScomplete maze = left maze
postoperative ekg complete maze left maze

POSTOPERATIVE EKGcomplete maze = left maze

n = 39

immediate

1 month

AT 1 MONTH, FREEDOM FROM AF: 75%

late ekg

18 pts with complete maze

LATE EKG

1 month

1 year

AT ONE YEAR: FREEDOM FROM AF: 69%

postoperative treatment
POSTOPERATIVE TREATMENT

anticoagulants

antiarhythmics

Transient stroke at 10 mths, sinus with AC : 1

slide12

DOPPLER following

COX-MAZE PROCEDURE

evidence for atrial transport

e

e

a

a

tricuspid flow

mitral flow

slide13

ATRIAL WALL

in chronic atrial fibrillation

fat transformation

muscular hypertrophy

C. Guiraudon in La fibrillation auriculaire JY Le Heuzey 1997 p51

cox maze procedure indications
COX-MAZE PROCEDURE INDICATIONS

AF indication

N intermit. / chronic lone AF other

Cox

World Heart

Foundation

Schaff 221 20% 80% 25% 75%

Mayo Clinic

Mc Carthy 100 22% 78% 23% 77%

Cleveland Clinic

Izumoto 104 0% 100% 0% 100%

Iwate, Japon

308 58% 42% 56% 44%

cox maze operation results
COX-MAZE OPERATION RESULTS

CPB mortality fluid ret. pace maker

Cox - 2,9% 6% 15%

World Heart

Foundation

Schaff 122 mn 1,4% - 3,2%

Mayo Clinic

Mc Carthy 120 mn 1% yes 6%

Cleveland Clinic

Izumoto 177 mn 2% - 6%

Iwate, Japon

slide16

COX-MAZE OPERATION RESULTS

free from AF free from AF

postop. intermittent AF late

99% 38% 99%

World Heart

Foundation

Schaff 90% 38% 70% 3 yrs

Mayo Clinic

Mc Carthy - 33% 90% 3yrs

Cleveland Clinic

Izumoto 72% - 65% 5yrs

Iwate, Japon

slide17

COX-MAZE OPERATION

RECENT ADVANCES

1/ Results of patients with rheumatic vs degenerative MV disease are identical

Lee, Annals 2003:75:57-61

2/Right sided maze does not arrythmogenic substrate of lone AF and may not be necessary

Jessurun, Europace 2003;5:39-46

3/ The maze operation does not influence atrial volumes in patients with lone AF / mitral surgery reduces LA volume

Jessurun, Annals 2003;75:51-6

4/ The left maze can be performed through a minimally invasive approach

Akpinar, Eur J Card Surg 2003;24:223-30

slide18

ENERGY SOURCES

which ablation technique?

1/ Surgical cut and sew = GOLD STANDARD

2/ Radiofrequency

3/ Cryogenic injury TRANSMURALITY ?

4/ Microvawe

slide19

RADIOFREQUENCY ABLATION

technical approach

endocardial

epicardial

slide20

RADIOFREQUENCY ABLATION

epicardial & endocardial probes

histology showing

transmural lesion

radiofrequency procedure indications

N

AF

Intermit. chronic

Surgery

mitral aortic/CABG

Le Tourneau

Eur Soc Card 2003

69

19% 50%

100% -

Sie

Eur Soc Card 2003

200

0% 100%

81% 19%

Benussi

Eur JCS 2003:17;524

132

8% 92%

98% 2%

RADIOFREQUENCY PROCEDURE INDICATIONS
radiofrequency procedure results

6 months

AF free Intermit. Chronic

3 years

AF free

Le Tourneau

Eur Soc Card 2003

67% 21% 12%

Sie

Eur Soc Card 2003

73%

Benussi

Eur JCS 2003:17;524

79% - -

77%

RADIOFREQUENCY PROCEDURE RESULTS
slide23

RADIOFREQUENCY ABLATION

RECENT CONCEPTS

1/ No transmurality when atrial wall thickness > 4 mm

2/The epicardial is less efficient than the endocardial approach (epicardial fat + circulating blood)

Thomas, Annals 2003:75:543-8

3/ Atrioesophageal fistula is a potential complication: cachectic patient, LA ectasia, TEE probe

Mohr, J Thorac CVS 2002;123:919-27

4/ Circumflex coronary stenosis is a potential complication

Fayad, Annals 2003;76:1291-3

5/ Age at surgery and postop arrhytmias are predictive factors of a negative outcome

Benussi, Eur J Card Surg 2003;17:524-9

slide24

CONCLUSIONS

1/ The Cox-Maze operation is very efficient in

restoring normal sinus rhythm in chronic or

intermittentAF and remains the gold standard

2/ The left maze seems to be as efficient as the

complete maze in pts with mitral valve disease

3/ Radiofrequency ablation could be an important

adjunct in pts with lone/non-mitral related AF

4/ Antiarrhythmics are often necessary to maintain

a good long term results

5/ The TE risk is decreased but not eliminated