SURGICAL TREATMENT OF ATRIAL FIBRILLATION 1 Incidence of

SURGICAL TREATMENT OF ATRIAL FIBRILLATION 1/ Incidence of AF: 5% of the population > 60 years, - 600 000 candidates for AF surgery in USA 2/ Etiologies: among patients applying for a life insurance: 40% lone AF, 60% with cardiopathy 3/ Restoration of sinus rhythm after valve repair depends upon the duration of AF (> 1 year) and left atrium dimensions (>60 mm) 4/ The presence of preoperative AF does not influence the operative risk Specific surgical procedures aiming at treating atrial fibrillation must add minimal morbidity Chua JTCS 1993 & Obadia JTCS 1997

ATRIAL EXCLUSION LINES which tracing? 1/ Original Cox-Maze III procedure 2/ Hemicox: left maze procedure 3/ Exclusion of the pulmonary veins (+ left appendage exclusion)

CLASSICAL COX-MAZE III left appendage right appendage sup. veina cava septal incision pulmonary veins tricuspid mitral inf. veina cava

LEFT COX-MAZE PROCEDURE left appendage pulmonary veins mitral

EXCLUSION OF THE PULMONARY VEINS left appendage pulmonary veins

COX-MAZE PROCEDURE associated to mitral valve surgery N = 40 Indications: Chronic AF > 6 months Intermittent AF (left maze) AGE: 15 -71 YRS 35 5 (49+16 YRS) ETIOLOGIES OF MITRAL VALVE DISEASE: degenerative 20 rheumatic 17 others 3

MITRAL VALVE PROCEDURE associated to the Cox-maze MAZE DURATION complete: 52 min left: 23 min

RESULTS complete maze = left maze • • • mortality: 1 (2, 5%) (septic shock) reoperation for bleeding: 3 coronary bypass for circumflex stenosis 1 pace maker (complete maze) fluid retention (complete maze) 4 – lower limbs edema : 4 – pericardial effusion: 2 – pleural effusion: 2 1

POSTOPERATIVE EKG complete maze = left maze n = 39 immediate 1 month AT 1 MONTH, FREEDOM FROM AF: 75%

LATE EKG 18 pts with complete maze 1 month 1 year AT ONE YEAR: FREEDOM FROM AF: 69%

POSTOPERATIVE TREATMENT anticoagulants antiarhythmics Transient stroke at 10 mths, sinus with AC : 1

DOPPLER following COX-MAZE PROCEDURE evidence for atrial transport e a tricuspid flow mitral flow

ATRIAL WALL in chronic atrial fibrillation fat transformation muscular hypertrophy C. Guiraudon in La fibrillation auriculaire JY Le Heuzey 1997 p 51

COX-MAZE PROCEDURE INDICATIONS AF intermit. / chronic indication lone AF other 308 58% 42% 56% 44% 221 20% 80% 25% 75% Mc Carthy 100 22% 78% 23% 77% 0% 100% N Cox World Heart Foundation Schaff Mayo Clinic Cleveland Clinic Izumoto Iwate, Japon 104

COX-MAZE OPERATION RESULTS Cox CPB mortality fluid ret. pace maker - 2, 9% 6% 15% 1, 4% - 3, 2% 1% yes 6% 2% - 6% World Heart Foundation Schaff 122 mn Mayo Clinic Mc Carthy 120 mn Cleveland Clinic Izumoto Iwate, Japon 177 mn

COX-MAZE OPERATION RESULTS free from AF postop. intermittent AF late 99% 38% 99% World Heart Foundation Schaff 90% 38% 70% 3 yrs - 33% 90% 3 yrs 72% - 65% 5 yrs Mayo Clinic Mc Carthy Cleveland Clinic Izumoto Iwate, Japon

COX-MAZE OPERATION RECENT ADVANCES 1/ Results of patients with rheumatic vs degenerative MV disease are identical Lee, Annals 2003: 75: 57 -61 2/ Right sided maze does not arrythmogenic substrate of lone AF and may not be necessary Jessurun, Europace 2003; 5: 39 -46 3/ The maze operation does not influence atrial volumes in patients with lone AF / mitral surgery reduces LA volume Jessurun, Annals 2003; 75: 51 -6 4/ The left maze can be performed through a minimally invasive approach Akpinar, Eur J Card Surg 2003; 24: 223 -30

ENERGY SOURCES which ablation technique? 1/ Surgical cut and sew = GOLD STANDARD 2/ Radiofrequency 3/ Cryogenic injury 4/ Microvawe TRANSMURALITY ?

RADIOFREQUENCY ABLATION technical approach endocardial epicardial

RADIOFREQUENCY ABLATION epicardial & endocardial probes histology showing transmural lesion

RADIOFREQUENCY PROCEDURE INDICATIONS N Le Tourneau AF Surgery Intermit. chronic mitral aortic/CABG 69 19% 50% 100% - 200 0% 100% 81% 19% 132 8% 92% 98% 2% Eur Soc Card 2003 Sie Eur Soc Card 2003 Benussi Eur JCS 2003: 17; 524

RADIOFREQUENCY PROCEDURE RESULTS 6 months 3 years AF free Intermit. Chronic AF free Le Tourneau 67% 21% 12% Eur Soc Card 2003 Sie 73% Eur Soc Card 2003 Benussi Eur JCS 2003: 17; 524 79% - - 77%

RADIOFREQUENCY ABLATION RECENT CONCEPTS 1/ No transmurality when atrial wall thickness > 4 mm 2/ The epicardial is less efficient than the endocardial approach (epicardial fat + circulating blood) Thomas, Annals 2003: 75: 543 -8 3/ Atrioesophageal fistula is a potential complication: cachectic patient, LA ectasia, TEE probe Mohr, J Thorac CVS 2002; 123: 919 -27 4/ Circumflex coronary stenosis is a potential complication Fayad, Annals 2003; 76: 1291 -3 5/ Age at surgery and postop arrhytmias are predictive factors of a negative outcome Benussi, Eur J Card Surg 2003; 17: 524 -9

CONCLUSIONS 1/ The Cox-Maze operation is very efficient in restoring normal sinus rhythm in chronic or intermittent. AF and remains the gold standard 2/ The left maze seems to be as efficient as the complete maze in pts with mitral valve disease 3/ Radiofrequency ablation could be an important adjunct in pts with lone/non-mitral related AF 4/ Antiarrhythmics are often necessary to maintain a good long term results 5/ The TE risk is decreased but not eliminated