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  1. Concomitant Atrial Fibrillation- allways Maze? - Robert JM Klautzchief department Cardiothoracic Surgery

  2. Get Rhythm 2006

  3. 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?

  4. 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

  5. Bleeding Risk with Warfarin • Major Haemorrhage4.6% /yr • hospitalization, transfusion, or surgery ICH risk: 0.1% /yr no AC RR AC 0.5% disabilty doubled Chimowitz et al NEJM 2005

  6. Prevalence of Preoperative AF- likelyhood of concomitant treatment - STS database 2004-2006 Gammi et al Ann Thor Surg 2008

  7. AF in Mitral Valve Disease- prevalence - AF in medically treated MV disease: linearized rate 5% per year ! Grigioni et al JACC 2002

  8. AF in Mitral Valve Disease- risk - AF is an independent risk factor for death in MR patients Grigioni et al JACC 2002

  9. Survival after Mitral Valve Surgery- pre-operative SR vs AF - Ngaage et al Ann Thorac Surg 2004

  10. If AF is a risk factor for bad outcome in MV disease and after MV surgery Can we modify it ?

  11. Combined MV & AF Surgery Cox Maze III + MV surgery Remains gold standard regarding lesion set Superior freedom from Afib MCT + 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

  12. 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

  13. Combined MV & AF Surgery- new energy sources - • Radiofrequency • Dry / Irrigated • Unipolar / Bipolar • Cryothermia • High Frequency Ultrasound • Microwave • Laser

  14. 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 ?

  15. How to decide on an approach? First: STANDARDIZE Then: INDIVIDUALIZE

  16. 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

  17. Lesion sets for AF Surgery Persistent / permanent AF: substratereduction Epicardiallylimited to box lesion only Energy source HIFU (ultrasound) (+ mitral isthmus) cryothermia bipolar RF Access minimal access possible

  18. Lesion sets for AF Surgery Persistent / permanent AF: substratereduction Endocardially Full CM III / “derivative” Energy source bipolar RF cryothermia (cut and sew) Access minimal access possible (CM IV)

  19. 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

  20. How to standardize - Concomitant AF- extended pulmonary vein isolation - Benussi et al J Thorac Cardiovasc Surg 2005

  21. How to standardize - Concomitant AF- mitral isthmus line - Benussi et al J Thorac Cardiovasc Surg 2005

  22. How to standardize - Concomitant AF • CONCOMITANT AF: • Trade off: • Quite invasive for aortic valve or CABG procedures • Question: • - Right sided lesions ?

  23. How to standardize - Concomitant AF- right sided lesions - Barnett et al J Thorac Cardiovasc Surg 2006

  24. How to standardize - Concomitant AF- right sided lesions - PM implantation rate not studied Barnett et al J Thorac Cardiovasc Surg 2006

  25. 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"

  26. Combined MV & AF Surgery- Left Atrial Appendage - Garcia-Fernandez et al JACC 2003

  27. 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

  28. Combined MV & AF Surgery- Left Atrial Appendage - Kanderian et al JACC 2008

  29. Combined MV & AF Surgery- Left Atrial Appendage - Kanderian et al JACC 2008

  30. LAA Closure- Watchman Device - Holmes et al Lancet 2009

  31. Surgery for Atrial Fibrillation- inherent risks - • Atrioventricular Block – PM implantation • Collateral Damage • Lesions related tachy-arrythmias

  32. ESC Guideline AF 2010

  33. Concomitant AF Surgery- the future - • Patient-specific approach • Assessment of conduction block • Team up with EP cardiologist • Trials • CRAFT-CABG

  34. 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