Cirugia de la fibrilacion auricular aislada por via quirurgica

1. CIRUGIA DE LA
FA AISLADA
POR VIA QUIRURGICA
Porquê e cuando ?

2. Common believes
or myths ….??
Surgery is too agressive
Surgical results are unclear...
Doubtful clinical benefit ….
Electrophysiologists do it …

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. TECHNIQUES
MAZE `4´ operation
(Cox, JTCVS1991)
•Isolation Pulm Veins
surgical division LA (Melo,EJCTS 1997) ,
bilat isol c/ RF ablation (Melo, RPCard 1998,
EJCTS 1999)
•+- aditional lines

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. Clinical presentation
LONE ATRIAL FIBRILLATION
AFIB and concomitant cardiac disease

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. 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. RegistryAtrialFibrillationSurgery
1st post operative year
Mortality 27 / 1680
Changes of Rhythm
Sinus rhythm 23 %
Afib / flutter 18 %
Other 12 %
TE events 16

10. Registry afib surgery
Survival after the 1st year of FUP
100
sSR
90 Others
Percent 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. RegistryAtrialFibrillationSurgery
Predictors for sinus rhythm
OR CI 95% p
 1 year
LA < 55 mm 1.57 1.06-2.3 <.02
Concomit CABG .39 .2 - .75 =.005
 4 years
LA < 55 mm 3.56 1.62-7.83 <.0002
Biatrial ops 2.54 1.24-2.54 =.011

12. RAFS registry
Log rank p=0.03
395 376 127 56 30 18 7 3 SSR
132 125 45 28 21 17 7 1 SAF/Flutter
SAF/Flutter
58 51 25 7 4 2 0 0 Others
585 552 187 91 55 37 14 4 Total

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. Clinical presentation
AFIB and concomitant cardiac disease
LONE ATRIAL FIBRILLATION
intermitent, permanent

15. CIRUGIA DE LA
FA AISLADA
POR VIA QUIRURGICA
Porquê e cuando ?

16. EUROPACE 2007
Results of percutaneous
ablation for the treatment of
permanent atrial fibrilation
are not acceptable …
Carlo Pappone , June 2007

17. Phenotypes of ischemic CVA
Doença de
grandes vasos
Doença de
pequenos vasos
Cardioembolismo
Outras causas: dissecção

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. 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. Role of anticoag in TE
events / year %
Prevention warfine control
primary 1.8/3 5
secundary 8.5/9 10.6 / 6.5
EAFT(93), SIFA(97)

21. RISK FACTORS
CONVENTIONAL e EMERGING
Modifiable Non modifiable
 Hypertension  Age
 Gender
 Diabetes
 Race
 Smoking
 Hyperlipidemia Emerging
 Drink abuse Infection / inflamation
 Obesity abdominal Genetic factors
 Sedentarian habits

22. Comparison studies
Rythm vs Rate
% / year
thromboembolic events
PIAF, RACE, rate rythm
STAF, HOTCAFE,
AFFIRM
3.5 3.9

23. Location of thrombus in TE events
due to atrial fibrilation
Metaanalysis from 4792 patients
Blackshear. Ann Thor Surg. 1996
Thrombus (%)
LA append
Rheumatic pts (3504) 57 22
Lone afib pts (1288) 17 91

24. Watchman
 PROTECT AF
– Warfarin-vs-
Watchman
– Preliminary studies

25. PLAATO

26. PLAATO DEVICE

27. Can we improve the outcome of
some stroke patients ?

28. AF SURGERY REDUCES TE EVENTS in mitrals
De Lima . Ann Thorac Surg 2004;77:2089-95
Akpinar. Eur J Cardioth Surg 2003;24:233-30
Deneke. Eur H Jr 2002;23:558-66
PRT
Jessurun J Cardiov Surg 2002;44: 9-18
Bando J Thorac Cardiov Surg 2002; 124: 575-83
Handa J Thorac Cardiov Surg 1999; 118: 628-35
Chen J Cardiovasc Electroph 2001; 12: 867-74 RCS
Raani Eur J Cardiothor Surg 2001; 19: 438-42
Jatene Eur J Cardiothor Surg 2000; 17: 117-24
Guang Eur J Cardiothor Surg 2002; 21: 249-54
Summary Cohen’s effect SR 1.78
stroke .44

29. Registry afib surgery
Log rank p=0.03
395 376 127 56 30 18 7 3 SSR
132 125 45 28 21 17 7 1 SAF/Flutter
SAF/Flutter
58 51 25 7 4 2 0 0 Others
585 552 187 91 55 37 14 4 Total
Melo et al. J Thoracic Cardiov Surgery. 2008,Abril

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. Rate vs rythm control
trials
Treating AF only,
TE events rate
leaving the
% / year
appendage alone
PIAF, RACE, rate rythm
STAF, HOTCAFE, solving
is not
3.5 3.9
AFFIRM
embolism

33. Watchman
 PROTECT AF
– Warfarin-vs-
Watchman
– Preliminary studies

34. PLAATO

35. PLAATO DEVICE

38. 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….

39. Methods for LAA exclusion
- Suture ligation
– Stappling or similar
– Welding
– Clipping
– Band

41. 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, MD
Journal of the American College of Cardiology Vol. 42,
No. 7, 2003

42. LONE AFIB
Journal Year Author N technic M Suce F-up TE
% s %
%
JTCVS 1999 Cox 306 Mz1,3 2 99 11 0.1
JTCVS 2000 Mc 23 Mz3 0 90 4
Carthy
ATS 2007 Stulak 70 Mz3 2 80 5 0
RPcard 2000 Melo 10 IBVP 0 90 2 0
ATS 2002 Mohr 40 LA 0 92 2 0
proc

43. CIRUGIA DE LA
FA AISLADA
POR VIA QUIRURGICA
Porquê e cuando ?

44. 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

45. 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 %

46. PATOLOGIA
Tipo FA
Paroxistica / persistente
12
Permanente
Cardiopatia concomitante
Mitral 10
26 Aortica 2 Tricuspida 2
Coronária 4
Remoção trombos AE 2
Redução volume AE 1

47. Terapeutica
CEC sem 25 com 13
Apêndice AE
remoção 18, excl 20
Ablação FA 33
Toracoscopia 5

48. 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 %

49. Resultados tardios
 Follow-up
Duração 6 a 98 meses (media 36)
Eventos mte não cardíaca 2
AVC 1
AIT 1
8 doentes interromperam A/C
Taxa linearizada TE 0,9 % / ano

50. 1 year after surgery for
2 strokes and
2 cerebral bleedings
OAC ?

51. Sobrevida livre de AVC
(Kaplan Meyer)

52. Conclusões
 A cirurgia da FA com exclusão do
apêndice AE provocou uma redução
substancial do TE tardio esperado
• Esta opção deve ser considerada
nos dtes com FA, de risco para
repetição
• Indispensável maior experiência,
para ser uma opção mandatória na
prevenção secundária de AVC

53. 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, MD
Journal of the American College of Cardiology Vol. 42,
No. 7, 2003

54. Case: 59 y, male, acute afasia, hemiparesis
Fibrynolisis, 2h after symptoms
before
90 min after

57. CD34

58. Estudo FATE 2
AVC e FA
Contraindicação
Anticoagulação
anticoagulação
Trat médico Cirurgia + trat médico Trat médico Cirugia + trat médico

60. Stroke before cardiac surgery
Year N major cardiac Preop %
operations CVA/TIA
2006 1027 84 8
2007 1080 71 7
Pathology N %
CAD 64/824 8
Valve disease 63/869 7
Other (lone af) 28

61. RESTORING SINUS RHYTHM
IN PATIENTS WITH
PREVIOUS PACEMAKER IMPLANTATION
SUBMITTED TO CARDIAC SURGERY
and
CONCOMITANT SURGICAL ABLATION
OF ATRIAL FIBRILLATION
Joao Q Melo, Michael Knaut, Ottavio Alfieri, Stefano Benussi,
Mathew Williams, Fernando Hornero, Teresa Santiago
RAFS Registry Investigators
EACTS , Geneve 2007

62. Rhythm at follow-up (months ) (%)
Discharge 6 mo 12 mo 24 mo
N pts 33 22 21 14
SR
21 ( 64) 10 (46) 11 (52) 8 (57)
SR
pac depen 3 ( 9) 4 (18) 3 (14) -
AF 9 (27) 8 (36) 7 (33) 6 (43)

63. CIRCULATION 2005

64. CIRCULATION 2005

65. LESS AGRESSIVE APPROACHES
No 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

66. CD34