Chapters Transcript Video Surgical Ablation of Atrial Fibrillation uh So America Hunger. I'm one of the Sentara mid atlantic cardiothoracic surgeons. I'm just gonna talk for the next few minutes on surgical ablation for atrial fibrillation. So with surgical ablation similar to catheters were trying to disrupt these macro re entrance circuits. Um And the gang logic plexi that inter bait the atria and they play a role in initiating the atrial fibrillation. Um We're creating these full thickness non conducting scar tissue to do this and really every line has to connect to something else that's non conducting either another ablation line. And incision. Some sort of scar tissue. And what we're chasing after. Um are these circular oval tracks. And these are what I'm referring to with the M. R. C. S. And there's six major ones and the to a tree. It's the Kaveh, the S. P. C. The I. V. C. The pulmonary veins. Um And the atrial appendages are the primary focus of our surgical ablation. So the full surgical ablation. The current iteration is the cox maze for um The maze one was first done in a human in 1987 at Washington University by dr cox. Um It was all cut. And so when it was first done. So every single one of these lines was initially a full thickness cut in the atrium. This was not very well adopted. It's challenging to do. It was difficult to replicate. There was a lot of blocks seen early and most of those early incisions have been replaced with energy devices. So the gray areas are really the only incisions we make plus one little incision in the atrial appendage. The red represents radio frequency ablation which is very quick to do. And then the blue lines are the cry ablation lines and cry ablation takes a little bit longer. Each burn is a couple of minutes. Um And there's sometimes a third one that will do but it's very good for anchoring onto the valve itself so that we don't have any gaps. And the left side of the picture is obviously the left atrium, the right side is our right side of maize. And so that's great for persistent a fib or for already in the atrium a much quicker easier And and most surgeons minds lower risk approaches the pulmonary vein isolation. Um And this works well with paroxysmal atrial fibrillation because early on 90% of these triggers that initiate the atrial fibrillation are in and around the pulmonary veins. Um So by doing these were taking care of most of those and additionally we get some additional background ranch and tracks by the atrial appendage clip which has the additional benefit of stroke reduction as you get more episodes of atrial fibrillation. The atrium adapts to support the A. Fib dilates. And then at that point the P. V. I becomes ineffective and it's really a full maze. So we wouldn't do just this if the patient had persistent atrial fibrillation. We think that it's very important for us to follow our results. Not just assume that it went well because that's how we decide where we're at, how we improve upon that. And within the group we follow all these patients at one week, three weeks, three months, six months, one year and then yearly thereafter. And it's really a collaboration with us and the electrophysiology team. It takes about 6-12 weeks for those scar lines to anchor and to really decide whether the ablation has worked or not. So it's a little bit of a different mentality than something like a valve or bypass where we know leaving the operating room. There's good revascularization or the valve is working. Takes a few months to know whether this worked and ep helps us to decide which patients can come off anti coagulation, how to manage the successes the failures. Um and if they are failures, what to do about it, do they warrant additional mapping and catheter ablation? Um and we followed these patients by sending them a Zio patch and they put it on, they mail it back to us and any atrial fibrillation flutter or atrial tachycardia greater than 30 seconds is what we consider a failure. Um And it's from our perspective it's pretty easy to have a failure. Um Any break in our technique. Any break in the line is enough to make the whole procedure a failure. But overall we do a good job with this when you're looking at paroxysmal atrial fibrillation. Um and I know these are only two years. We've obviously been doing them longer but we've been tracking in this format for about the last two years. We have about an 80-90% success for the paroxysmal atrial fibrillation. And this encompasses all of the all of the ablation. The P. V. I. Is the full cox maze is um and were more on the 90 plus percent for the persistent and long standing persistent atrial fibrillation. This encompasses 282 patients within our database were actively following 100 and four of them. Um if someone's failed we still keep them in the database, we still follow them and the ones who fall out or either they refuse they move they don't want to wear the Zio patch or insurance won't cover it. Um The compliment intervention rate or the C. I. R. Is the patients who have some history of atrial fibrillation that we did some sort of ablation on. So within the group um where six surgeons with 1/7 who starts tomorrow starts monday. Um And we do a fibrillation in 83% of those patients. This is at two years and 90% success rate for the all comers. I chose two years to highlight the durability of this but the six month and the one year mark looked about the same. It was 89% As for who and how we decide to do the ablation. These are 2017 guidelines which was an update from earlier in the 2010s. And the guidelines suggest really is a class one a indication anyone who were doing a mitral valve or something where we're opening one of the atrium. We should be doing a surgical ablation on um for any type of atrial fibrillation, paroxysmal persistent or longstanding persistent. And it's actually a one a recommendation even if we're not opening the chambers if we're doing an A. V. R. Cabbage to still do the ablation as long as they're symptomatic and they've either failed catheter ablation or failed some sort of anti arrhythmic attempt. This is the standalone ablation which is patients where we're solely going in there to do an ablation. So these aren't getting astronomy for any reason other than the atrial fibrillation. And these are two A. And two B. Recommendations. So reasonable or reasonable to consider and a patient who's failed catheter ablation. They're symptomatic from the atrial fibrillation or there failing their anti arrhythmic stew refer them for surgery solely for the purpose of treating their atrial fibrillation and then I include this um this is our sts guidelines really. They're largely the same as the medical guidelines with the addition of adding the statement which I think is very important that we can add surgical ablation without any additional risk of morbidity or mortality. And in fact for these patients that if say I'm doing a bypass procedure on and I add a pulmonary vein isolation And God forbid they go on to die. It's still just considered a cabbage procedure because the P. V. I really isn't considered a separate procedure. It's not felt to add any sort of risk. So this is a blessing and a curse. It's to try to encourage us to consider that we should be doing this for everyone because it doesn't add risk. But obviously it falls back on the surgeon to make sure that our results are 100% just as good if we add a cox maze or a pulmonary vein isolation. Um So in summary the ablation provides safe, effective durable freedom from atrial fibrillation. Our partnership with R. E. P. Colleagues really ensures coordination of the patients, both for those that are successful and the fortunately small numbers that are not successful. Um And we think that it's important that we continue to track our numbers. Um I showed you our group numbers but we also look at our individual surgeon numbers so we can make sure that we are all individually achieving the results that are expected um For the best results. Thank you Published Created by Related Presenters Eric Unger, M.D. SurgerySurgery - Cardiothoracic View full profile