Edit October 2018 Content Why treat Atrial Fibrillation AFib How does concomitant AFib therapy benefit your patients Who can benefit from concomitant AFib therapy Concomitant ID: 1006852
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1. AFib Therapy Concomitant to Heart SurgeryEdit: October 2018
2. ContentWhy 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 riskStandardized lesions with reproducible success ratesThe Left Atrial Appendage – a threat to all AFib patients
3. 1. Why Treat Atrial Fibrillation (AFib)?
4. More than200,000peopleARE DIAGNOSEDWITH AFIBEVERY 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 4 adults over 40WILL DEVELOP ATRIAL FIBRILLATION IN THEIR LIFETIME22. 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 ARE33. 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 strokesare caused by Atrial Fibrillation44. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. European Heart Journal doi:10.1093/eurheartj/ehw210
8. IN 2017512 MILLION Europeanssuffered from AF.BY 20205,that number will be15 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 RhythmLouagie 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. 37pts Afib Treated (nPAF)66pts AFib Not Treated (nPAF)91% ± 7% conversion to Sinus Rhythm at 5 years33% ± 7% conversion to Sinus Rhythm at 5 years
11. Concomitant AFib Ablation Significantly Increases Freedom from Long-Term StrokesItoh 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. 394pts Afib Treated(In Sinus Rhythm)Note: A stroke was defined as a neurological deficit concomitant with ischemic image findings on a computed tomography or a magnetic resonance imaging97.9% at 5y92.4% at 10y84.4% at 5y76.6% at 10y116pts Afib Treated(Not in Sinus Rhythm)
12. Performing Concomitant AFib Ablation in CABG Patients Reduces All-Cause Mortality by >40% Rankin J.S et 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) 471-4773,119pts Afib Not Treated626pts Afib TreatedRankin J.S et al, Surgical ablation of atrial fibrillation concomitant to coronary artery bypass grafting provides cost-effective mortality reduction, 2018 AATS presentation, in review JTCS.CABG vs. CABG + AF Ablation Mortality over 1 ye. Data represent % chance of death at each time interval (days)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
13. Patients with AFib Undergoing Concomitant AFib Ablation Have Significantly Better Mid-Term Survival Than Those Who Do NotLee R et al. Midterm survival in patients treated for atrial fibrillation: A propensity-matched comparison to patients without a history of atrial fibrillation. J Thorac Cardiovasc Surg. 2012;143:1341–1351. 565pts AFib Treated248pts AFib Untreated2449pts without AFibConcomitant AFib ablation to either isolated AVR, MVR or CABG+valve gave AFib patients similar survival than that of patients without a history of AFib
14. AFib Ablation Concomitant to Heart Surgery Significantly Improves Long-Term SurvivalLouagie 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. 37pts AFib Treated (nPAF)66pts AFib Not Treated (nPAF)Kaplan-Meier estimate of postoperative survival including hospital mortality 89% ± 5% 5y survival60% ± 7% 5y survival
15. Fukunaga et al, Effect of surgery for atrial fibrillation associated with mitral valve disease. The Annals of Thoracic Surgery. 2008;86(4):1212–1217.108ptsAFib Treated (In Sinus Rhythm)136ptsIntractable or AFib UntreatedConcomitant AFib Ablation Significantly Decreases All Cardiac Complications At Mid- And Long-TermActuarial freedom from all cardiac complications such as death, valve deterioration, valve thrombosis, thromboembolism including stroke, anticoagulation-related bleeding, pacemaker implantation, congestive heart failure, reoperation86.0% at 5y80.4% at 10y
16. Forlani S et 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. Concomitant AFib Ablation Significantly Improves Patients Quality of Life
17. 3. Who Can Benefit from Concomitant AFib Therapy?
18. 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]).What Do All The Experts in the Field Say?60 Experts From 11 Organizations
19. AFib Ablation Concomitant To Mitral Surgery is Recommended: COR I, LOE B-NR2017 HRS/EHRA/ECAS/APHRS/SOLAECE Expert Consensus Statement on Catheter and Surgical Ablation of Atrial FibrillationCalkins H et al, Heart Rhythm 10 (2017) e275-e444
20. AFib Ablation Concomitant To AVR, AVR+CABG, CABG is Recommended: COR I, LOE B-NR2017 HRS/EHRA/ECAS/APHRS/SOLAECE Expert Consensus Statement on Catheter and Surgical Ablation of Atrial FibrillationCalkins H et al, Heart Rhythm 10 (2017) e275-e444
21. *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 EvidenceConcomitant Mitral OperationsConcomitant w/AVR/CABG/AVR+CABGStand-AloneLAAMSurgical Ablation Guidelines are Advancing
22. 4. Concomitant AFib Therapy Does NOT Increase the Surgical Risk
23. “CABG/AVR Patients With AFib Can Undergo Ablation WITHOUT Increased Surgical Risk”PurposeMethodsResultsEvaluate the safety and efficacy of concomitant AFib ablation in AFib patients undergoing CABG surgery and/or AVRSingle center retrospective study30 month Median Follow-upN=375 (129 intervention; 246 control)LAA excised and over sewn, PVI for PAF, bi-atrial for NPAFNo 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 riskAl-Atassi T et al, Ann Thorac Surg 104 (2017) 515-522
24. Even A Full Cox Maze With Atriotomy Concomitant to AVR or CABG Does NOT Increase Operative RiskAd N et al, J Thorac Cardiovasc Surg 143 (2012) 936-944No increase in morbidity due to concomitant Maze procedureNo 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)
25. A Full Maze IV With Atriotomy Concomitant to CABG, AVR, MVR Improves Survival WITHOUT Increasing Postoperative Morbidity or MortalityMusharbash FN et al, J Thorac Cardiovasc Surg 155 (2018) 159-170Concomitant AFib Surgery improves survival compared with untreated AF patients:62% vs 42% at 10 years p=0.014Pts receiving concomitant AFib Surgery have similar survival to pts without history of AF: 63% vs 55% at 10 years p=0.929AF treatedAF untreatedAF treatedNo AFNo difference in 30-d mortality: 3% vs 4% p=0.534No 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)
26. 5. Standardized Lesions With Reproducible Success Rates
27. Pulmonary Vein Isolation and Left Atrial Appendage OcclusionPVI 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 OcclusionPVI + Box: ~55-70% Afib Free1,21Voeller 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 Thorac Cardiovasc Surg 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 OcclusionLALS: ~73-86% Afib Free1,2 ~15-20% fewer Atrial Flutter31Barnett SD, Ad N.. Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. J Thorac Cardiovasc Surg 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. Semin Thorac Cardiovasc Surg 2000;12:20-4.
30. Maze IV Lesion Set and Left Atrial Appendage OcclusionMAZE IV: ~80-90% Afib Free1,2,3,41Philpott 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 Thorac Cardiovasc Surg 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 OptionsApproachSA Reported Experiences conc w/ SHDAblation Duration1. Pulmonary Vein Isolation (PVI)PAF~65-90%5,13,14+nPAF~40-60%6,132. Box Set Lesion (Box)nPAF~55-70%7,15++3. Left Atrial Lesion Set (LAL)nPAF~73-86%8,1715-20% fewer atrial flutter9+++4. Bi-Atrial Lesion Set (MAZE)nPAF~80-90% 10,11,12,16++++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.PVI Catheter Outcomes w/ Lone AfibPAF~47 - 80% 47% - 1 ablation174% - 2 ablations180% - 3 ablations1~70% - meta-analysis2nPAF~25% - 52%25% -1 ablation443% - multiple ablations352% - multiple ablations4~50% - meta-analysis2Note: + = TimeReported Experiences:3 mo – 3 year retro- & prospective peer-reviewed publications both on and off AADs
32. Appendices
33. Mitral Valve Surgery (COR:1 LOE:A)Aortic Valve or CABG Surgery(COR: I, LOE: B)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)