Clinical factors impacting outcomesfollowing surgical ablationfor Atrial Fibrillation

Ovidio A. García-Villarreal, MDMonterrey, MX

DISCLOSURE

• NO DISCLOSURES

• NO FINANCIAL GRANTS

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INTRODUCTION

• The success of the Cox-maze procedure is dependent on manydifferent technical and clinical variables.

• Maze procedure is a concept, and electrophysiological concept, especially designed to eliminate all possible macro-reentrantcircuits in BOTH ATRIA.

• FULL BIATRIAL LESION PATTERN, whatever the case may be.

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COX-MAZE PROCEDURE

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TRADITIONAL CLINICAL FACTORS AFFECTING THE OUTCOME• PATIENT AGE• PREOPERATIVE DURATION OF AF• LEFT ATRIAL SIZE• TYPE of AF

• Stand alone• Concomitant

• Mitral • Rheumatic• Degenerative

• Other than Mitral• SURGEON’S EXPERIENCE• ENERGY SOURCES

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PREOPERATIVE DURATION OF ATRIAL FIBRILLATION

• 1 year prediction model: • a 5-yr increase in AF duration,

0.8% reduction in success

• 2 year prediction model: • a 5-yr increase in AF duration,

0.8% reduction in success

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LEFT ATRIAL SIZE

• 1 year prediction model: • a 1-cm increase in LA size,

0.4% reduction in success

• 2 year prediction model: • a 1-cm increase in LA size,

1.0% reduction in success

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WHAT SIZE of the left atrium?

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Type of AF (Lone vs Concomitant)

0

10

20

30

40

50

60

70

80

90

100

0 2 4 6 8 10

Lone AF Concomitant AF

11286

P = 0.64

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TIME (YEARS)

FRE

E F

RO

M A

F (%

)

80

64

65

60 38

46

6

11

13

21

Prasad SM, et al. J Thorac Cardiovasc Surg 2003; 126: 1822-8

8884

91 90 87 89

72

90 91 8983 83

7672

3 MONTHS 6 MONTHS 1 YR 2 YR 3 YR 4 YR 5 YR

FREE

DO

M O

F AT

A (%

)

TIME AFTER OPERATION

Rheumatic Degenerative

Labin JE, et al. J Thorac Cardiac Surg 2017; doi: 10.1016/j.jtcvs.2017.03.152.

Rheumatic vs Degenerative MV Disease

Cox-maze III/IV + CABG / AVR

Damiano JR, et al. J Thorac Cardiovasc Surg 2003; 126: 2016-21Ad N, et al. J Thorac Cardiovasc Surg 2012; 143: 936-44Schill MR, et al. J Thorac Cardiovasc Surg 2017; 153: 1087-94Damiano JR, et al. Heart Rhythm 2014; 11: 39-45

9894

98

74

84 8188

47

DAMIANO 2003 AD 2012 SCHILL 2017 THE CURE-AF TRIAL 2014

(%)

Free ATA Free ATA/AAD

Comparison of ENERGY SOURCE groups on return to sinus rhythm without antiarrhythmic drugs during follow-up (asterisks denote significant differences).

7986

79 8173 75

70

7972 69

6257

6 12 24 36 48 60

Cryothermal Bipolar RF + Cryo

* *

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% S

inus

rhyt

hm

months

*

Ad N, et al. Ann Thorac Surg 2017;104:29–35

SURGEON’S EXPERIENCE

• 1-year prediction model• a reduction by 50 cases of surgeon experience is associated with a

1.0% reduction in success.

• 2-year prediction model• a reduction by 50 cases of surgeon experience is associated with a

0.2% reduction in success.

• Ad N. J Thorac Cardiovasc Surg 2014; 148: 881-7

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• CONCLUSIONS:• Preoperative duration of AF• Left atrial size• Surgeon’s experience• Energy source

• Well standardized protocol• Full biatrial lesion pattern

• RF ablation + Cryothermia• Cryothermia alone• Cut-and-sew + Cryothermia

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Clinical Factors Impacting Outcomes FollowingSurgical Ablation for Atrial Fibrillation

Thank You