Surgeons Role in Atrial Fibrillation

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1 Atrial Fibrillation Surgeons Role in Atrial Fibrillation Steven J Feldhaus, MD, FACS 2015 Cardiac Symposium September 18, 2015 Stages of Atrial Fibrillation Paroxysmal (Intermittent) Persistent (Continuous) Longstanding Persistent (>1year) Updated Stages Paroxysmal (PAF) Non-Paroxysmal (N-PAF) Demographics of Atrial Fibrillation Over 2.5 million Americans affected Approximately 160,000 new cases annually Incidence increases with age Doubles with each decade of life Annual Utilization of Health Care Resources Due to AF 350,000 hospitalizations 5.0 million office visits 276,000 emergency department visits 234,000 hospital outpatient department visits $26 Billion annually in US alone $8,700 annually per patient with AF 1

2 Cardiovascular Complications In AF Patients Are More Common Heart Failure Stroke Chest Pain Tachycardia Palpitations COMPLICATIONS Acute Myocardial Infarction PREVALENCE 3 X Higher 2 X Higher 2 X Higher 5 X Higher 3 X Higher 2.5 X Higher Current Therapy Approach Medical Anticoagulation Cardioversion Rate control Rhythm maintenance Interventional Ablate the AV node and Pace Left Atrial Ablation Surgical Left or Bi-Atrial Ablation LAAM Indications for Interventional or Surgical Ablation Focal vs. Non-Focal Arrhythmias Medication failure Medication intolerance Anticoagulation contraindication Stroke or TIA on anticoagulation Previous failed catheter ablation Patient with AF undergoing other heart surgery Patient prefers a more aggressive approach Micro-Reentrant Focus Macro-Reentrant Circuit Small-Rotor Large-Rotor 2

3 Completed Maze-IV Procedure Objective of the Maze IV Lesions Patient Selection to Treat Concomitant AF 1. CABG patients with AF 2. AVR patients with AF 3. Mitral patients with AF Current Treatment of Concomitant AF 81,000 Not Treated 76% 21,000 Treated 26% Source: Agency for Health Care Quality and Research (AHRQ) Cost and Utilization Project Nationwide Inpatient Sample

4 Under Treatment by Procedure Coronary Artery Bypass with AF Diagnosis MV/Aortic Valve Procedures with AF Diagnosis 35% 30% 25% Reasons Given for Not Treating Concomitant AF Concern about Added Risk 55,000 93% 4,000 7% 27,000 61% 20% 15% 17,000 39% 10% 5% Source: Agency for Health Care Quality and Research (AHRQ) Cost and Utilization Project Nationwide Inpatient Sample % Adds too much complexity to the primary procedure Added on pump time Reported results may not be reproducible in private practice Not willing to introduce any additional patient risks to primary procedure Lack of society consensus on patient selection, lesion set or energy source Is Risk Increased? Restoration of Normal Sinus Rhythm Do we increase the operative risk by adding the Cox Maze III procedure to aortic valve replacement and coronary artery bypass surgery? Ad N, Henry L, Hunt S, Holmes SD Inova Heart and Vascular Institute, Cardiac Surgery Research, Falls Church, VA J Thor Cardiovas Surg, 2012 Apr;143(4): doi: /j.jtcvs Epub 2012 Jan 13. Treated AF The addition of the Cox Maze III procedure to AVR or CABG did not convey an increase in major morbidity and perioperative risk. The Cox Maze III may significantly improve their outcome. Untreated AF Louagie et al: Ann Thorac Surg,

5 Freedom from Long-Term Strokes Improved Long-Term Survival Treated AF No AF Treated AF Untreated AF Untreated AF p = Itoh et al: Eur J Cardiothorac Surg, 2006 Lee et al: J Thor CardiovascSurg, 2012 Consensus Recommendation of Societies 2012 Consensus Statement on Surgical AF: The Objective of Each Lesion It is advisable that all patients with documented AF referred for other cardiac surgeries undergo a left or biatrial procedure for AF at an experienced center, unless it will add significant RISK Heart Rhythm Society American College of Cardiology American Heart Association Society of Thoracic Surgeons European Heart Rhythm Association European Cardiac Arrhythmia Society Complete Conduction Block 5

6 Freedom from AF % Surgical ablation as treatment for the elimination of atrial fibrillation: a meta-analysis. Barnett SD, Ad N. Journal of Thoracic and Cardiovascular Surgery, 2006 May;131(5): Success rates reported for Bi-Atrial Lesions and LA Lesions only Both RA and LA Lesions RA and LA lesions No RA lesions Percent Freedom from AF 50 No RA Lesions * p < mth * 1 yr * 2 yr * 3 yr * Bilateral Unilateral Years The LAA and Strokes Comparative Perioperative Stroke Rate All Strokes (100%) CABG + MVR 90% Ischemic 10% Hemorrhagic CABG + AVR CABG + MV Repair AVR + MVR 20% are Associated with AF MV Repair MVR AVR 95% have LAA Thrombi = 130,000 Strokes / yr CABG Maze + Above National Adult Cardiac Surgery Database 6

7 LAA Surgical Occlusion Technologies for Surgical Ablation Bipolar Radiofrequency Microwave Laser Unipolar Radiofrequency Cryoablation High frequency ultrasound LAA Exclusion Without A Maze Lone AF pt with contraindication to OAC and not a candidate for a Maze Procedure Lone AF pt who develops CVA/TIA while on OAC LAA Exclusion as a standalone procedure Thoracoscopic use of the AtriClip One hour operative time, extubate in OR CICU vs CTU POD1 Discharge Previous OHS not necessarily a contraindication Summary 1. There are a number of documented advantages in treating concomitant AF at the time of CABG, MVR and AVR surgery. 2. All of the major societies agree that concomitant AF should be treated at the time of other cardiac surgery. 3. The Left Atrial Appendage should be occluded in every patient who has AF. 4. Every caregiver has a role in AF management. 7

8 Online Resources stopafib.org afstat.com treatafib.org Heart-vavle-surgery.com Thank You! Questions? Credit Slides: Dr. John Johnkoski Dr. Kevin Rist Dr. James Cox 8

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