Hybrid Ablation of AF in the MAZE III Procedure Operating Room: I s - PowerPoint PPT Presentation

9/8/2012 Hybrid Ablation of AF in the MAZE III Procedure Operating Room: I s There a Need? Paul J. Wang, MD Amin Al-Ahmad, MD Gan Dunnington, MD Stanford University Cox J, et al. Ann Thorac Surg. 1993;55:578-580. Treatment Algorithms for AF: 2011 Spectrum of Atrial Fibrillation Update MAINTENANCE OF SINUS RHYTHM Least • Paroxysmal, LA <5.0 cm Advanced • Persistent, LA < 5.0 cm Coronary artery No (or minimal) Hypertension Heart failure disease • Paroxysmal, LA >5.0cm heart disease • Persistent, LA >5.0cm Dronedarone Dofetilide Substantial LVH Amiodarone Flecainide Dronedarone Dofetilide Propafenone Sotalol • Long-Standing Persistent Sotalol No Yes (>1 year) LA < 5.0 cm Amiodarone Catheter Dofetilide ablation Dronedarone • Long-Standing Persistent Amiodarone Catheter Catheter Flecainide Amiodarone ablation ablation Propafenone Most Sotalol (>1 year), LA >5.0cm Advanced Amiodarone Catheter Catheter Dofetilide ablation ablation . 2011 ACCF/AHA/HRS Focused Update on Management of Patients with Atrial Fibrillation (Updating the 2006 Guideline) J Am Coll Cardiol 2011; 57:223-42. Differences from 2006 Highlighted by P Wang compared to Fuster V et al. J Am Coll Cardiol. 2006;48:e149-246. 1

9/8/2012 Spectrum of Atrial Fibrillation Spectrum of Atrial Fibrillation Least Least • Paroxysmal, LA <5.0 cm • Paroxysmal, LA <5.0 cm Catheter Advanced Advanced • Persistent, LA < 5.0 cm • Persistent, LA < 5.0 cm Ablation • Paroxysmal, LA >5.0cm • Paroxysmal, LA >5.0cm • Persistent, LA >5.0cm • Persistent, LA >5.0cm • Long-Standing Persistent • Long-Standing Persistent (>1 year) LA < 5.0 cm (>1 year) LA < 5.0 cm • Long-Standing Persistent • Long-Standing Persistent Most Most (>1 year), LA >5.0cm (>1 year), LA >5.0cm Advanced Advanced What is your estimate of freedom from AF at 1 Which single (not repeat) procedure has the year of 1 catheter ablation procedure with LA 6.0 highest success for achieving freedom from AF ? cm and AF persistently for 5 years ? A. 20-30% A. Catheter ablation 67% 86% B. 50% B. Thoracoscopic Maze C. 70% C. Thoracoscopic Maze plus Catheter ablation 29% D. 90% 5% 10% 3% 0% Catheter ablat... Thoracoscopic ... Thoracoscopic ... % % % % 0 0 0 0 3 5 7 9 - 0 2 2

9/8/2012 Procedure Methodology – Rationale for a Hybrid AF Procedure Hybrid Approach • Does any catheter ablation procedure have a single procedure success of 50%, 80% or more in these patients at 1yr, 2yr, 5yr? For example, patient with AF 5 years and LA 6.0 cm – Long-standing persistent AF – Large atria • Highest single procedure success • Rapid procedural recovery • Reasonable risk 12 Hybrid Epicardial Ablation Procedure Lesion Set Lesions consist of: • Patient is intubated with double lumen endotracheal tube -Pulmonary Vein Isolation -Roof and inferior connecting • Patient is prepped in usual manner lesions • Small incisions are made for 5mm or -Lesion from the left superior 10mm diameter access ports pulmonary vein to the left atrial appendage • Access ports are inserted in the right chest -LA isthmus lesion from LI PV to AV groove 3

9/8/2012 Epicardial Surgical Ablation- Right Side Epicardial Surgical Ablation- Left Side • Right Side GP Testing and Ablation • Right Antral Ablation Left Side GP Testing and Ablation • Start Right Roof line through Transverse Sinus using Ablation • Obliterate Ligament of Marshall Pen (approximately half of the line to be completed from the right side) • Left Antral Isolation • Start Right sided inferior line using Ablation (approximately • Finish ablation of the Roof Line and half of the line to be completed from the right side) extend from LSPV to left atrial appendage • Optional: SVC to IVC linear line with Ablation Pen or Transpolar Pen (discontinue line at junction of IVC at area of using Ablation Pen no recorded electrograms) • Finish ablation of the Inferior Line using • Optional: Encircling SVC lesion using the bipolar clamp Ablation Pen and/or Ablation Pen Setup Epicardial Surgical Ablation Lines • A line from the inferior (caudad) box lesion towards the mitral annulus using the Ablation Pen • Ablation will stop 1-2 cm before reaching the atrioventricular groove, to avoid injury to the left circumflex coronary artery. 4

9/8/2012 Breaking Through Skin to Make Marking Port Port Maneuvering Devices Maneuvering Scope 5

9/8/2012 Right PV Dissection. Aorta svc Post la Head of dome Patient La pa ap La dome svc Pulm Artery Right superior rspv PV Waterston’s Groove Grabber holds end of the Lighted Dissection tape and will advance behind the PV SVC SVC Waterstone;s groove RPA and below Waterson’s groove SVC PA RSPV RS PA PV Lighted dissection RIPV under RIPV comes in transverse sinus 6

9/8/2012 Pinching tool pulls off the Lighted Dissection tape from the lighted articulated dissection tool pericardium Hilum of lung where pv enter lung Lung Endocardial Catheter Ablation • Insert multipolar Coronary Sinus catheter into CS for standard EP mapping and ablation LA AP techniques • Place multi electrode diagnostic HIS catheters in position for guidance of CS cannulation and LSPV transseptal puncture common trunk • Create Right Cavotricuspid Isthmus Lesion LIPV • Check for bidirectional Right Cavotricuspid Isthmus block 7

9/8/2012 Endocardial Catheter Ablation Endocardial Catheter Ablation • Perform Transseptal puncture • Complete ablation to the Mitral Valve Isthmus Lesion • Assess the LAA surgical lesion for presence of bidirectional block. If incomplete block exists, • Test for bidirectional Mitral Valve block complete the ablation lesion using an • Check for both Right and Left entrance and endocardial approach. exit block PVIs • Check Posterior Box for isolation Endocardial Catheter Ablation Hybrid Endocardial Ablation Procedure • Re-Check bidirectional block for Right • Endocardial Right Atrial Isthmus Lesion: Cavotricuspid Isthmus Lesion - RA Isthmus lesion will be • Check Encircling SVC Lesion for entrance and completed by the EP exit block 8

9/8/2012 Right Superior Pulmonary Vein Right Inferior Pulmonary Vein Post-Epicardial Ablation Post-Epicardial Ablation Left Superior Pulmonary Vein Left Inferior Pulmonary Vein Post-Epicardial Ablation Post-Epicardial Ablation 9

9/8/2012 N=47 Courtesy of Mark La Meir: Netherlands/Belgium Courtesy of Mark La Meir: Netherlands/Belgium and Univ Virginia and Univ Virginia What is the Contribution of What is the Contribution of Endocardial catheter ablation Endocardial catheter ablation stage? stage? • 27 patients; EP study within 4 days: • All gaps were ablated 2.2+1.8 days • 16.9 + 9 months • 10 persistent; 17 long-standing persistent • 23 patients free of AF and off AAD (85%) • Iso: 13 patients had 1 atrial flutter • 3 free off AF with AAD (11%) • All patients had antral and SVC isolation • 1 patient had AF despite AAD(4%) • 28 gaps in 17 patients • No atrial flutter requiring repeat ablation • Roof near LSPV 10/27 (37%); floor near RIPV 4/27 (15%); mitral line 10/12 (83%) Mahapatra S et al Heart Rhythm Journa 2011:S315 Mahapatra S et al Heart Rhythm Journa 2011:S315 10

9/8/2012 Take Home Messages Which single (not repeat) procedure has the highest success for achieving freedom from AF ? • Success of single procedure is low in patients with large atria and long-standing A. Catheter ablation persistent AF B. Thoracoscopic Maze 84% • Hybrid approach appears to result in a low C. Thoracoscopic Maze plus AF recurrence rate with low likelihood of Catheter ablation atrial flutters • Further studies are needed to examine 12% 4% this approach in a larger patient population Catheter ablat... Thoracoscopic ... Thoracoscopic ... Thank You Paul.J.Wang@stanford.edu 11