Surgical Therapy of Atrial Fibrillation Brian S. Cain, MD Kaiser Permanente CV Surgery East Bay Cardiac Services Program Why Treat Lone Atrial Fibrillation? Especially With an Operation? 1
Symptomatic Presentation If pressed most asymptomatic patients will admit to symptoms ATRIA Study 5.6 Million People 2.5 Million People Go AS et al, JAMA, May 9, 2001; 285 (No 18):2370-75. KAISER Northern California 17,974 adults with AF Perhaps now (2008)-- greater than 20-25,000 Kaiser Members! Go AS et al, JAMA, May 9, 2001; 285 (No 18):2370-75. 2
Prevalance, % 12 10 8 6 4 2 0 Epidemiologic Burden Atrial Fibrillation is the Most Common Arrhythmia in the US 0.1 0.2 women 0.4 0.9 Atria Study: Prevalence by Age and Sex men 1.7 1.0 1.7 3.0 <55 55-59 60-64 65-69 70-74 75-79 80-84 >85 Age, years NUMBER Women 530 370 566 895 1438 1572 1291 1732 Men 1259 634 934 1426 1507 1896 1374 759 3.4 5.0 5.0 7.3 7.2 10.3 9.1 11.1 Go AS et al, JAMA, May 9, 2001; 285 (No 18):2370-75. AFFIRM TRIAL Adverse Events Rate Control Rhythm Control p-value Ischemic Stroke 79 (5.9%) 84 (7.3%) Intracranial Bleed 31 (2.0%) 29 (2.1%) 0.799 Major Hemorrhage 106 (7.6%) 96 (6.9%) 0.473 Pts. Hospitalized 1218 (70%) 1375 (78%) <0.001 AF at time of event 45 (69%) 25 (36%) INR 2.0 24 (30%) 18 (22%) INR 2.0 28 (35%) 17 (20%) N Engl J Med 2002;347:1825-33. ECONOMIC IMPACT ON KAISER SYSTEM Members with Atrial Fibrillation consume a disproportionate share of resources. Prescriptions (anticoagulants +/- rate and rhythm control drugs, others) Primary Care visits Decreased sense of well being Testing/Monitoring Cardioversions Emergency room visits (for strokes, bleeding incidences, arrhythmia episodes) Hospitalization costs (acute stroke, limb ischemia, bowel infarction) Stroke rehabilitation treatment Mortality costs Heart Failure - Cardiac Remodeling Chronic drain on our constrained resources Loss of KP membership from death. 3
Is a cure possible? Cox-Maze III Electrophysiology of AF Maze Procedure SAN LAA PV S RAA AVN YES! 1994 Annals Thor Surg Cures 89 % AF @ 5 yr. (no meds) 4
IMPACT OF COX-MAZE III ON STROKE RATE AF, positive risk factors, previous TE, no anticoagulant. AF, positive risk factors, no previous TE, no anticoagulant. AF, positive risk factors, previous TE, anticoagulant. AF, positive risk factors, no previous TE, anticoagulant. AF, no positive risk factors, no previous TE, no anticoagulant. After the Cox-Maze III Cox JL Jo Thorac Cardiovasc Surg 1999; 118(9):833-40. Cox-Maze III 10 Year Data Early intervention important! Gaynor SL, et al. J Thorac Cardiovasc Surg 2005 Jan;129(1):104-11). Is there an easier way? 5
Yes! 2 mm 1.8 mm Concomitant Surgical Approach Paroxysmal/ Persistent Atrial Fibrillation Cleveland Clinic Experience: 211 of 513 Patients 89-92% Free @ 12 Mo. 89-92% Free @ 12 Mo. 89-92% Free @ 12 Mo. 89-92% Free @ 12 Mo. Gillinov AM, et al. J Thorac Cardiovasc Surg. 2005 Jun;129 (6):1322-9. 6
Permanent Atrial Fibrillation Cleveland Clinic Experience: 288 of 513 Patients 79% Free @ 12 Mo. 79% Free @ 12 Mo. 50% Free @ 12 Mo. Gillinov AM, et al. J Thorac Cardiovasc Surg. 2005 Jun;129 (6):1322-9. Has partnering with our electrophysiology colleagues been valuable? YES! Electrophysiological EndPoints LOM Hwang Circulation 2000 Micro reentrant circuits Sueda Ann Thorac Surg 1997 PV foci Haissaguerre NEJM 1998 Vagal Ganglia Pappone Circulation 2004 Dominant Spiral Wave Mandapati Circulation 2000 7
HRS Consensus Document Cardiac Surgeons and Electrophysiologists come together! HRS task force. Heart Rhythm Vol 4, No 6 June 2007. AF Treatment Alternatives Desired Effect Considerations Cure Manage Drugs Electrical DCC/Abl+PPM Catheter Ablation Surgical Ablation Restore NSR Reduce Stroke Rate Control Restore NSR Paced rhythm Restore NSR Restore NSR Reduce stroke Often ineffective Not well tolerated AV Node is ablated Recurrence rate high Expensive Safe inpatient Moderate recurrence AF Multiple redo may occur Safe inpatient Reproducible results Efficacy rates of 90% LAA addressed Advantage of Epicardial Approach Pulmonary veins Ganglionated Plexi Left Atrial Appendage (House Clots) 8
Minimally Invasive Surgical Treatment for patients with symptomatic, drug refractory Atrial Fibrillation - Video assisted, beating heart - Bi-lateral Pulmonary Vein (Antrum) Isolation - Connecting lesions with transpolar pen - Partial autonomic denervation - Division of ligament of Marshall - LAA exclusion OR Lab Self contained: Pace, Sense, Stimulate, Ablate, Record, Print Minimally Invasive Surgical Treatment 9
Skin Incision/10 mm Port Video 10
AF Mechanism Trigger vs. Wavelet Paroxysmal < 7 Days Long Standing Persistent > 1 Yr Persistent 7 Day 1 Yr. Freedom from Atrial Fibrillation, Flutter, & Antiarrhythmic Drugs Type of AF Paroxysmal Persistent Success (%) 91% 80% Compliant with 2007 standards Heart Rhythm Society Follow-up @ 12 Months @ 12 Months KAISER Northern California Operative MiniMaze Results 3 month EKG 6 month EKG 12 month EKG 76% NSR 82% NSR 100% NSR Mixed bag of 80% paroxysmal and 20% persistent patients 11
KAISER Northern California Operative Concomitant Maze Results 3 month EKG 6 month EKG 12 month EKG Paroxysmal 75% NSR 79% NSR 85% NSR Chronic (LT persistent) 29% NSR 40% NSR 13% NSR Mixed bag of lesions, surgeons, cases with CABGs and Valves Connecting Lesions Promising Long Standing Results ECONOMIC IMPACT ON KAISER SYSTEM AF may be treated or managed by a number of modalities including: Rate +/- rhythm control = expensive with modern anti-arrhythmics Anti-coagulation = $1000/year - decreasing stroke rates by 68% Catheter ablations (6-8 month backlog) Paroxysmal... 46% off meds Paroxysmal.. 80% with meds Minimally Invasive Maze (Mini-Maze) procedures Paroxysmal.. >90% off meds Persistent. 80% off meds Long standing persistent promising (not published yet)? 80% 12
Minimally Invasive Surgical Treatment Symptomatic AF patients who prefer a surgical approach Have failed one or more attempts at catheter ablation Not candidates for catheter ablation HRS task force. Heart Rhythm Vol 4, No 6 June 2007. For more information: Kaiser CV Surgery (510) 869-8658 13