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