CIRUGIA DE LA   FA   AISLADAPOR VIA QUIRURGICAPorquê e cuando ?
Common believes     or myths ….??Surgery is too agressiveSurgical results are unclear...Doubtful clinical benefit ….El...
Facts….. Surgical results are better than percutaneous  approaches Percutaneous approaches have unproven effect  in many...
TECHNIQUESMAZE `4´                   operation  (Cox, JTCVS1991)•Isolation Pulm Veinssurgical division LA (Melo,EJCTS 199...
CLINICAL ISSUES Can the cut and sew technique be  replaced by ablation methodology ? When we treat afib is enough to app...
Clinical presentationLONE ATRIAL FIBRILLATIONAFIB and concomitant cardiac disease
Surgical treatment of atrial fibrillation; a systematic review*               K Khargi, B Hutten, B Lemkec, T Deneked    E...
Surgical ablation as treatment for the elimination of atrial       fibrillation: A meta-analysis     Barnett, Ad,      J T...
RegistryAtrialFibrillationSurgery   1st post operative yearMortality    27 / 1680Changes of RhythmSinus rhythm          ...
Registry afib surgery                         Survival after the 1st year of FUP              100                         ...
RegistryAtrialFibrillationSurgery            Predictors for sinus rhythm                            OR      CI 95%        ...
RAFS registry                               Log rank p=0.03395   376   127      56   30     18   7    3     SSR132   125  ...
AFib surgery in mitralsReturn to sinus rhythm high and dependent of patient selectionPts returning to stable SR have a s...
Clinical presentationAFIB and concomitant cardiac disease LONE ATRIAL FIBRILLATION    intermitent, permanent
CIRUGIA DE LA   FA   AISLADAPOR VIA QUIRURGICAPorquê e cuando ?
EUROPACE 2007Results of percutaneousablation for the treatment ofpermanent atrial fibrilationare not acceptable … Carlo Pa...
Phenotypes of ischemic CVA Doença de grandes vasos                    Doença de                    pequenos vasosCardioemb...
EPIDEMIOLOGY                  CVA in Portugal   Prevalence: 8% over age 60 anos   Incidence: 2 - 3 / 1000h / year   1ª ...
AF and stroke in Portugal Around 20000 CVA / year 1/3 are ISCHEMIC Out of these 20 to 25 % are due to  Lone AF ˜ 20 % ...
Role of anticoag in TE      events / year %Prevention   warfine     controlprimary      1.8/3           5secundary    8.5/...
RISK FACTORS  CONVENTIONAL e EMERGINGModifiable             Non modifiable Hypertension          Age                    ...
Comparison studies        Rythm vs Rate                         % / year                   thromboembolic eventsPIAF, RACE...
Location of thrombus in TE events             due to atrial fibrilationMetaanalysis from 4792 patientsBlackshear. Ann Thor...
Watchman PROTECT AF  – Warfarin-vs-    Watchman  – Preliminary studies
PLAATO
PLAATO DEVICE
Can we improve the outcome of    some stroke patients ?
AF SURGERY REDUCES TE EVENTS in mitralsDe Lima . Ann Thorac Surg           2004;77:2089-95Akpinar.    Eur J Cardioth Surg ...
Registry afib surgery                                Log rank p=0.03395   376   127      56    30     18    7     3   SSR1...
LAApendage             Mitral Patients 205 mitral prosthesis pts   – Sinus rhythm 14,1%   – Mechanical 187 / Bioprosthesi...
Rate vs rythm control            trials   Treating AF only,              TE events rate         leaving the               ...
Watchman PROTECT AF  – Warfarin-vs-    Watchman  – Preliminary studies
PLAATO
PLAATO DEVICE
Why to remove the LAA? Over 90% clots initiate in the LAA Surgery can remove it using no  endoluminal foreign bodies Re...
Methods for LAA exclusion- Suture ligation– Stappling or similar– Welding– Clipping– Band
Left Atrial Appendage Obliteration in Atrial Fibrillation  Thoracoscopic Extracardiac Obliteration of the Left Atrial Appe...
LONE AFIBJournal   Year   Author   N    technic   M   Suce F-up   TE                                         %   s %      ...
CIRUGIA DE LA   FA   AISLADAPOR VIA QUIRURGICAPorquê e cuando ?
Lone AF         Surgical indicationsPrevious TE ( risk > 5 % / year ) LA prone to TE events (TEE)Pts with 1 failed perc...
DoentesN                             38 Genero                       24 M Idade (anos)    67       30 a 83 Patologia  ...
PATOLOGIA Tipo FA Paroxistica / persistente 12 PermanenteCardiopatia concomitanteMitral 10 26             Aortica 2 Tricus...
TerapeuticaCEC   sem    25 com 13Apêndice AE     remoção 18, excl 20Ablação FA            33Toracoscopia           5
Resultados hospitalares Mortalidade        2 doentes Internamento (dias )  9±6             moda 5 Ritmo sinusal aos 6 me...
Resultados tardios Follow-upDuração   6 a 98 meses (media 36)Eventos  mte não cardíaca      2        AVC              1  ...
1 year after surgery for        2 strokes and        2 cerebral bleedingsOAC ?
Sobrevida livre de AVC   (Kaplan Meyer)
Conclusões A cirurgia da FA com exclusão do apêndice AE provocou uma redução substancial do TE tardio esperado• Esta opçã...
Left Atrial Appendage Obliteration in Atrial Fibrillation  Thoracoscopic Extracardiac Obliteration of the Left Atrial Appe...
Case: 59 y, male, acute afasia, hemiparesis           Fibrynolisis, 2h after symptoms                                     ...
CD34
Estudo FATE 2                                   AVC e FA                                                       Contraindic...
Stroke before cardiac surgeryYear   N major cardiac    Preop        %         operations      CVA/TIA2006        1027     ...
RESTORING SINUS RHYTHM         IN PATIENTS WITHPREVIOUS PACEMAKER IMPLANTATION  SUBMITTED TO CARDIAC SURGERY              ...
Rhythm at follow-up (months )       (%)            Discharge     6 mo        12 mo           24 moN pts             33    ...
CIRCULATION 2005
CIRCULATION 2005
LESS AGRESSIVE APPROACHESNo ECC, easy recovery, small incisions, painless ?     AUTOR     ENERGI   LAapend   Mini-incisisõ...
CD34
Cirugía de la fibrilacion aislada por vía quirurgica
Cirugía de la fibrilacion aislada por vía quirurgica
Cirugía de la fibrilacion aislada por vía quirurgica
Cirugía de la fibrilacion aislada por vía quirurgica
Cirugía de la fibrilacion aislada por vía quirurgica
Cirugía de la fibrilacion aislada por vía quirurgica
Cirugía de la fibrilacion aislada por vía quirurgica
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Cirugía de la fibrilacion aislada por vía quirurgica

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Cirugia de la fibrilacion auricular aislada por via quirurgica

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Cirugía de la fibrilacion aislada por vía quirurgica

  1. 1. CIRUGIA DE LA FA AISLADAPOR VIA QUIRURGICAPorquê e cuando ?
  2. 2. Common believes or myths ….??Surgery is too agressiveSurgical results are unclear...Doubtful clinical benefit ….Electrophysiologists do it …
  3. 3. Facts….. Surgical results are better than percutaneous approaches Percutaneous approaches have unproven effect in many subgroups of patients Surgery was very agressive … Surgery eliminates the LA appendage with no intravascular foreign bodies. If ANS needs modulation surgeons are better positioned to do it
  4. 4. TECHNIQUESMAZE `4´ operation (Cox, JTCVS1991)•Isolation Pulm Veinssurgical division LA (Melo,EJCTS 1997) ,bilat isol c/ RF ablation (Melo, RPCard 1998,EJCTS 1999)•+- aditional lines
  5. 5. CLINICAL ISSUES Can the cut and sew technique be replaced by ablation methodology ? When we treat afib is enough to approach the left atrium ? Are we reporting all significant variables that interfere with results ? Can we compare results ……
  6. 6. Clinical presentationLONE ATRIAL FIBRILLATIONAFIB and concomitant cardiac disease
  7. 7. Surgical treatment of atrial fibrillation; a systematic review* K Khargi, B Hutten, B Lemkec, T Deneked European Journal of Cardio-thoracic Surgery 27 (2005) 258–265 48 studies were included comprising 3832 patients; 2279 in group ablation and 1553 in cut/sew maze. The postop SR rates were 78.3 vs. 84.9% (p« 0.03). The “cut and sew” Maze III was conducted in younger pts (55.0 vs. 61.2 years; p«0.005), more often to treat paroxysmal (22.9 vs. 8.0%; p«0.05) and lone AF (19.3 vs. 1.6%). Different energies were mostly used to treat permanent AF (92.0%), and as a concomitant mitral procedure (98.4%) and increasingly in combination with non-mitral surgery (18.5%). After correction for these variations, the postoperative SR conversion rates did not differ significantly anymore (p « 0.260).
  8. 8. Surgical ablation as treatment for the elimination of atrial fibrillation: A meta-analysis Barnett, Ad, J Thorac Cardiovasc Surgery 2006.131;5: 1029 69 studies were included in this analysis. 5885 total patients were involved. Pts undergoing surgical ablation (range, 90.4- 85.4) demonstrated significantly greater rates of freedom from af compared with those seen in control patients (range, 47.2-60.9). Survival rates among patients with biatrial surgical procedures (range, 94.9-92.8) were similar to those who had left atrial procedures only (range, 93.9-89.4) pts undergoing biatrial ablation (range, 92.0-87.1) vs (86.1-73.4) demonstrated superior freedom from atrial fibrillation at all time points.
  9. 9. RegistryAtrialFibrillationSurgery 1st post operative yearMortality 27 / 1680Changes of RhythmSinus rhythm 23 %Afib / flutter 18 %Other 12 %TE events 16
  10. 10. Registry afib surgery Survival after the 1st year of FUP 100 sSR 90 OthersPercent survival Log rank p=0.01 80 70 N at Risk 60 608 292 145 97 63 38 17 sSR 351 186 114 84 59 37 12 Others 959 478 259 181 122 75 29 Total 50 12 24 36 48 60 72 84 Months after Surgery
  11. 11. RegistryAtrialFibrillationSurgery Predictors for sinus rhythm OR CI 95% p 1 yearLA < 55 mm 1.57 1.06-2.3 <.02Concomit CABG .39 .2 - .75 =.005 4 yearsLA < 55 mm 3.56 1.62-7.83 <.0002Biatrial ops 2.54 1.24-2.54 =.011
  12. 12. RAFS registry Log rank p=0.03395 376 127 56 30 18 7 3 SSR132 125 45 28 21 17 7 1 SAF/Flutter SAF/Flutter58 51 25 7 4 2 0 0 Others585 552 187 91 55 37 14 4 Total
  13. 13. AFib surgery in mitralsReturn to sinus rhythm high and dependent of patient selectionPts returning to stable SR have a significant reduction of TE eventsThese pts seem to have better survival …..Do they require anticoagulation ?
  14. 14. Clinical presentationAFIB and concomitant cardiac disease LONE ATRIAL FIBRILLATION intermitent, permanent
  15. 15. CIRUGIA DE LA FA AISLADAPOR VIA QUIRURGICAPorquê e cuando ?
  16. 16. EUROPACE 2007Results of percutaneousablation for the treatment ofpermanent atrial fibrilationare not acceptable … Carlo Pappone , June 2007
  17. 17. Phenotypes of ischemic CVA Doença de grandes vasos Doença de pequenos vasosCardioembolismo Outras causas: dissecção
  18. 18. EPIDEMIOLOGY CVA in Portugal Prevalence: 8% over age 60 anos Incidence: 2 - 3 / 1000h / year 1ª cause of mortality above age of 65 y – 3x mortality due to CAD – Superior to all deaths of cancer 1st cause of dependence of, care in adults – ~ 50% dependents
  19. 19. AF and stroke in Portugal Around 20000 CVA / year 1/3 are ISCHEMIC Out of these 20 to 25 % are due to Lone AF ˜ 20 % of these have contraindication for anticoagulation Within the first year after stroke the risk for death or a new stroke is > 10 %
  20. 20. Role of anticoag in TE events / year %Prevention warfine controlprimary 1.8/3 5secundary 8.5/9 10.6 / 6.5 EAFT(93), SIFA(97)
  21. 21. RISK FACTORS CONVENTIONAL e EMERGINGModifiable Non modifiable Hypertension  Age  Gender Diabetes  Race Smoking Hyperlipidemia Emerging Drink abuse Infection / inflamation Obesity abdominal Genetic factors Sedentarian habits
  22. 22. Comparison studies Rythm vs Rate % / year thromboembolic eventsPIAF, RACE, rate rythmSTAF, HOTCAFE,AFFIRM 3.5 3.9
  23. 23. Location of thrombus in TE events due to atrial fibrilationMetaanalysis from 4792 patientsBlackshear. Ann Thor Surg. 1996 Thrombus (%) LA append Rheumatic pts (3504) 57 22 Lone afib pts (1288) 17 91
  24. 24. Watchman PROTECT AF – Warfarin-vs- Watchman – Preliminary studies
  25. 25. PLAATO
  26. 26. PLAATO DEVICE
  27. 27. Can we improve the outcome of some stroke patients ?
  28. 28. AF SURGERY REDUCES TE EVENTS in mitralsDe Lima . Ann Thorac Surg 2004;77:2089-95Akpinar. Eur J Cardioth Surg 2003;24:233-30Deneke. Eur H Jr 2002;23:558-66 PRTJessurun J Cardiov Surg 2002;44: 9-18Bando J Thorac Cardiov Surg 2002; 124: 575-83Handa J Thorac Cardiov Surg 1999; 118: 628-35Chen J Cardiovasc Electroph 2001; 12: 867-74 RCSRaani Eur J Cardiothor Surg 2001; 19: 438-42Jatene Eur J Cardiothor Surg 2000; 17: 117-24Guang Eur J Cardiothor Surg 2002; 21: 249-54 Summary Cohen’s effect SR 1.78 stroke .44
  29. 29. Registry afib surgery Log rank p=0.03395 376 127 56 30 18 7 3 SSR132 125 45 28 21 17 7 1 SAF/Flutter SAF/Flutter58 51 25 7 4 2 0 0 Others585 552 187 91 55 37 14 4 Total Melo et al. J Thoracic Cardiov Surgery. 2008,Abril
  30. 30. LAApendage Mitral Patients 205 mitral prosthesis pts – Sinus rhythm 14,1% – Mechanical 187 / Bioprosthesis 18 Results – 52 exclusions ( 6 uncomplete) : 3,4% embolic events – 153 no exclusion : 17 % embolic events Garcia-Fernandez, 2004. JACC
  31. 31. Rate vs rythm control trials Treating AF only, TE events rate leaving the % / year appendage alonePIAF, RACE, rate rythmSTAF, HOTCAFE, solving is not 3.5 3.9AFFIRM embolism
  32. 32. Watchman PROTECT AF – Warfarin-vs- Watchman – Preliminary studies
  33. 33. PLAATO
  34. 34. PLAATO DEVICE
  35. 35. Why to remove the LAA? Over 90% clots initiate in the LAA Surgery can remove it using no endoluminal foreign bodies Results from the ablation operations have few late embolic events Sinus rhythm recovery appears to be insufficient to < stroke risk Cardiac denervation may play a role….
  36. 36. Methods for LAA exclusion- Suture ligation– Stappling or similar– Welding– Clipping– Band
  37. 37. Left Atrial Appendage Obliteration in Atrial Fibrillation Thoracoscopic Extracardiac Obliteration of the Left Atrial Appendage for Stroke Risk Reduction in Atrial Fibrillation J Blackshear, MD,* W. D Johnson, MD,† JOdell, MD,*V Baker, RN,*M RN,† L Pearce, MS,‡ C Stone, MD,† D Packer, MD,H Schaff, MDJournal of the American College of Cardiology Vol. 42, No. 7, 2003
  38. 38. LONE AFIBJournal Year Author N technic M Suce F-up TE % s % %JTCVS 1999 Cox 306 Mz1,3 2 99 11 0.1JTCVS 2000 Mc 23 Mz3 0 90 4 Carthy ATS 2007 Stulak 70 Mz3 2 80 5 0RPcard 2000 Melo 10 IBVP 0 90 2 0 ATS 2002 Mohr 40 LA 0 92 2 0 proc
  39. 39. CIRUGIA DE LA FA AISLADAPOR VIA QUIRURGICAPorquê e cuando ?
  40. 40. Lone AF Surgical indicationsPrevious TE ( risk > 5 % / year ) LA prone to TE events (TEE)Pts with 1 failed percut reinterv Contraindication for A/C/ Contraindication for ablation
  41. 41. DoentesN 38 Genero 24 M Idade (anos) 67 30 a 83 Patologia FA isolada 25 com cardiopt concomit 13 Risco AVC (CHADS score )/ano 4,6 a 7,3 %
  42. 42. PATOLOGIA Tipo FA Paroxistica / persistente 12 PermanenteCardiopatia concomitanteMitral 10 26 Aortica 2 Tricuspida 2Coronária 4Remoção trombos AE 2Redução volume AE 1
  43. 43. TerapeuticaCEC sem 25 com 13Apêndice AE remoção 18, excl 20Ablação FA 33Toracoscopia 5
  44. 44. Resultados hospitalares Mortalidade 2 doentes Internamento (dias ) 9±6 moda 5 Ritmo sinusal aos 6 meses posoperatório• Em FA isolada 20 / 31 - 65 %• Com cardiop concmte 9 / 12 – 75 %
  45. 45. Resultados tardios Follow-upDuração 6 a 98 meses (media 36)Eventos mte não cardíaca 2 AVC 1 AIT 18 doentes interromperam A/C Taxa linearizada TE 0,9 % / ano
  46. 46. 1 year after surgery for 2 strokes and 2 cerebral bleedingsOAC ?
  47. 47. Sobrevida livre de AVC (Kaplan Meyer)
  48. 48. Conclusões A cirurgia da FA com exclusão do apêndice AE provocou uma redução substancial do TE tardio esperado• Esta opção deve ser consideradanos dtes com FA, de risco pararepetição• Indispensável maior experiência,para ser uma opção mandatória naprevenção secundária de AVC
  49. 49. Left Atrial Appendage Obliteration in Atrial Fibrillation Thoracoscopic Extracardiac Obliteration of the Left Atrial Appendage for Stroke Risk Reduction in Atrial Fibrillation J Blackshear, MD,* W. D Johnson, MD,† JOdell, MD,*V Baker, RN,*M RN,† L Pearce, MS,‡ C Stone, MD,† D Packer, MD,H Schaff, MDJournal of the American College of Cardiology Vol. 42, No. 7, 2003
  50. 50. Case: 59 y, male, acute afasia, hemiparesis Fibrynolisis, 2h after symptoms before90 min after
  51. 51. CD34
  52. 52. Estudo FATE 2 AVC e FA Contraindicação Anticoagulação anticoagulaçãoTrat médico Cirurgia + trat médico Trat médico Cirugia + trat médico
  53. 53. Stroke before cardiac surgeryYear N major cardiac Preop % operations CVA/TIA2006 1027 84 82007 1080 71 7 Pathology N % CAD 64/824 8 Valve disease 63/869 7 Other (lone af) 28
  54. 54. RESTORING SINUS RHYTHM IN PATIENTS WITHPREVIOUS PACEMAKER IMPLANTATION SUBMITTED TO CARDIAC SURGERY and CONCOMITANT SURGICAL ABLATION OF ATRIAL FIBRILLATIONJoao Q Melo, Michael Knaut, Ottavio Alfieri, Stefano Benussi, Mathew Williams, Fernando Hornero, Teresa Santiago RAFS Registry Investigators EACTS , Geneve 2007
  55. 55. Rhythm at follow-up (months ) (%) Discharge 6 mo 12 mo 24 moN pts 33 22 21 14 SR 21 ( 64) 10 (46) 11 (52) 8 (57) SRpac depen 3 ( 9) 4 (18) 3 (14) - AF 9 (27) 8 (36) 7 (33) 6 (43)
  56. 56. CIRCULATION 2005
  57. 57. CIRCULATION 2005
  58. 58. LESS AGRESSIVE APPROACHESNo ECC, easy recovery, small incisions, painless ? AUTOR ENERGI LAapend Mini-incisisões Tipo A removal lesão Maessen MW Não Hemitorax D box R Wolf Bipolar Sim Hemit D e E BIPV RF A Saltman MW Sim Hemit D e E Box J Melo Bipolar Sim Sub-xifoid + BIPV RF hemit E
  59. 59. CD34

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