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nullMicrowave Ablation For Chronic Atrial FibrillationMicrowave Ablation For Chronic Atrial FibrillationLi Poa, M.D., F.A.C.S. Director of Perioperative Services Enloe Medical Center Chico, CaliforniaThe Future of Cardiac Intervention (National Health Council)The Future of Cardiac Intervention (National Health Council)Stent and intravascular intervention expected to double over next 3 years CABG volume to decline about 10% with cardiac surgery primarily expanding in EPS and CHF such as ablative surgery, biventricular pacing, LV remodeling, and cardiac muscle augmentation. Valvular volume to increase about 20% by 2005Chronic Atrial FibrillationChronic Atrial FibrillationAffects 2 million people in the US alone with a 9% 5 year morbidity from anticoagulation and a 5% / year risk of stroke As high as an 80 % risk of stroke at 8 years in the Japanese study group (Kitamura) Available treatment modalities include surgical “Maze”, cryotherapy, radiofrequency, irrigating radiofrequency, microwave, and laser Surgical Maze success best overall but Microwave has the least complications and the best ease of useMicrowave Ablation: ~ 3000 patients Microwave Ablation: ~ 3000 patients Open Heart 2300 patients 75% success - 0 to 4 year follow upBeating Heart – Off-Pump 700 patients 80% success - 0 to 2 year follow upNo adverse eventsMIS – Off-Pump Mini Thoracotomy 3 cases Robotic 2 cases Thoracoscopy 2 casesnull2 cm - FLEX 2TM4 cm - FLEX 4TM7 cm - FLEX 7null“...specimens were characterized by myocellular damage involving the full thickness of the atrial wall, where thickness ranged from 4 - 5 mm to 1 cm.” Clinical Histopathology and Ultrastructural Analysis of Myocardium following Microwave Energy Ablation Eric Manasse MD, Piergiuseppe Colombo MD, Paola Braidotti PhD, Massimo Roncalli MD-PhD, Roberto Gallotti MD (submitted to the Annals of Th. Surg.)nullfrom: In Vitro and In Vivo Evaluation of the Thermal Patterns and Lesions of Catheter Ablation with a Microwave Monopole Antenna David Keane MD, Ph.D., Jeremy Ruskin MD, Nancy Norris, Pierre-Antoine Chapelon, Dany Berube, Ph.D. nullBeating-Heart SurgeryEpicardial ablation Endocardial viewnullTransmural LesionViable TissueBeating-Heart SurgerynullDr. Maessen - Maastricht, Netherlands (Off-pump)40 patients (32 cAF, 8 pAF) acute discharge FU 40/40 26/39 32/39 (82%) 10 patients 8 - 11 months 10 patients 6 - 8 months 19 patients 0 - 6 months Presented at ISMICS - 2002nulln = 31 (mitral valve) 26/31 (84%) in sinus rhythm Dr. Zembala - Zabrze, Poland (Arrested Heart)Presented at CTT - 2002null29 patients (concomitant surgeries) 14 MV - 15 CABG 92% in NSR Follow-up: 8 patients more than 6 months 21 patients between 1 and 5 months submitted to the Annals of Th. Surg. - 2002Prof. Schutz - Munich, Germany (Arrested Heart)null14 patients (beating-heart and arrested-heart) 79% in NSR (11/14) 64% without AA drug Follow-up: mean 131 days (63 - 331 days) Prof. Gallotti / Dr. Manasse - Milan, Italy (Arrested Heart)Presented at CTT - 2002null12 patients (on-pump, concomitant surgeries) 75% in NSR Follow-up: up to 3 months Dr. Gillinov - Cleveland Clinic (Arrested Heart)Dresden ExperienceDresden Experience211 consecutive patients with documented atrial fibrillation for average of 6.8 years concomitant MVR, CABG, AVR, and TVRSurvival 98%, no MW complications 70% NSR at 6 months 68% NSR at 1 year with normal atrial transport function 23% had a postop PPM implantnullThe International Medical Group Conference “How to Treat Atrial Fibrillation During Mitral Valve Surgery”, Anno Diegeler, 21 July 2001The Dresden experience - Dr. Michael Knaut (Arrested Heart)Patient Population: n = 120 At least 6 months of documented chronic AF Refractory to at least 2 AA drugs 1 Year Results: 70-75% in sinus rhythm (n = 60) Sub-Populations Bypass: 60% in sinus rhythm Mitral replacement: 70% in sinus rhythm Mitral repair: 71% in sinus rhythm Tricuspid: 75% in sinus rhythm Aortic: 85% in sinus rhythm Comparative study on Concomitant Atrial FibrillationComparative study on Concomitant Atrial FibrillationGroup A - 62 patients with no ablation during surgery survival 94.2% NSR in 6% of MVD; 9% with CAD; and 5% with AVD disease processesGroup B - 88 patients receiving MW ablation with their surgery survival 98% NSR in 62% of MVD; 70% with CAD; and 82% with AVD disease processesKnaut, M; et al Dresden, Germanynull10- 15 patients per subgroup Microwave = 91% (11/12 NSR) Radiofrequency = 65% Cryoablation = 55% 7 to 12 month follow-upPresented at EACTS - 2001Dr. Graffigna - Trento, Italy (Arrested Heart)nullDr. Kshettry & Dr. Saltman Minneapolis & Stony Brook (Off-pump)21 cAF patients (all Mitral Valve)Submitted STS - 2003Acute 13 (62%) NSR 5 (24%) paced rhythm 1 ( 7%) JCT rhythm 2 (10%) AF Follow-up (1 - 3 months) (n = 20) 17 (85%) NSR 3 (15%) AF Dr. David Kress and Dr. Murali DharanDr. David Kress and Dr. Murali Dharan20 patients (18 epicardial, 2 endocardial) 100% left OR in sinus or paced rhythm 75% free of AF at discharge 73% of chronic pts free of AF at 3 months (11/15) 80% pf paroxysmal pts free of AF at 3 months (4/5) No perioperative complications, deaths, or collateral damagePresented at NASPE, May 2002Presented at NASPE, May 2002Dr. Tom Molloy Portland, OR Dr. Tom Molloy Portland, OR 19 patients (9 off-pump, 10 on-pump) 100% left OR in sinus or paced rhythm 62% free of AF at discharge 89% of pts free of AF at last follow-up (17/19) Only 37% (7/19) are still on anti-arrhymthic drugPresented at New Era, January 2003Dr. Donald Thomas Chicago, IL Dr. Donald Thomas Chicago, IL 22 patients (11 off-pump, 11 on-pump) 100% left OR in sinus or paced rhythm 86% of pts (19/22) free of AF at last follow-upSubmitted to ISMICS, 2003Cardiology EP ExperienceCardiology EP ExperiencePrimary foci appear to be at endovascular muscular sheaths at vascular insertion points initial attempts at primary ablation within pulmonary veins led to pulmonary vein stenosisPresent EP technique involves encircling pulmonary vein orifices ablating on endocardial surface of atrium but presently takes an average of 5-6 hours in expert hands using catheter based approach.null RSPVRIPVLAAMVLSPVLIPVEndocardial Left Atrial Ablationnull RAATVEndocardial Right Atrial AblationCSIVCSVCSeptotomynullnullnullCardiomyopathy SupportCardiomyopathy Support Initial cardiomyoplasty trials from Singapore and French groups now have 15-23% 10 year survival rates larger population now considered in reopened trials given that atrial fibrillation was an initial contraindication in the first groups with concurrent atrial ablative surgery synchrony is achievableEnloe ExperienceEnloe ExperienceConcomitant cardiac surgery in patient with chronic (3 months) atrial fibrillation or recurrent paroxysmal atrial fibrillation Failure of AA drug preop Isthmus ablation when R atrial approach37 left atrial ablations 21 epicardial, 16 endocardial 6 right sided ablations Success rates 87 % success in endocardial 85 % success in epicardial PreAblation IssuesPreAblation IssuesEnsure atrium is free of clot especially when contemplating epicardial ablation If performing concomitant “off-pump” CABG, recommend performing lateral wall distal anastomoses prior to ablation Ensure complete, detailed identification of pulmonary vein anatomy looking for all possible aberranciesTechnical ConsiderationsTechnical ConsiderationsEnsure adequacy of ablation, take the time to make crossing lesions Try to keep ablation surfaces relatively dry Endocardial ablation: Ensure 1) blood flow through coronaries and 2) TEE probe pulled back. Epicardial ablation : Ensure avoidance of coronary arteries, coronary sinus, and pulmonary artery Remember that Atrial Natriuretic Peptide production occurs in the atrial appendages and full ligation/removal can cause transient renal insufficiencyPostoperative managementPostoperative managementContinue patient on antiarrhythmic medication for 2-3 months, use aggressive cardioversion protocol for atrial fibrillation Continue patient on anticoagulation therapy for 2-3 months May need temporary cardiac stimulation for initial 48-72 hour period of atrial stunning so definitely have atrial pacing capabilityMicrowave Ablation ExperienceMicrowave Ablation Experience3000 cases performed worldwide with no adverse effects 700 epicardial cases thus far and 7 by minimally invasive approaches Success rates are approximately 100% upon leaving the OR with 1/3 going back into atrial fibrillation upon discharge but then range from 74 - 92% successful conversion and retention of NSR at 6 months postoperatively