Traitement de la FA vu par le
chirurgien cardiaque:
State of the art
Dr. Remes
Chirurgien Cardiaque
29 nov, 2014
BHC, Brux...
FA: Physiopathologie
Physiopathologie
FA: Physiopathologie
Persistent atrial fibrillation in a goat model of chronic left atrial overload
Jan Remes, MD,b Thomas J. van Brakel, MD, P...
Persistent atrial fibrillation in a goat model of chronic left atrial overload
Jan Remes, MD,b Thomas J. van Brakel, MD, P...
• Symptomes génants
• Risques d’AVC x 5
• Risque de mortalité élevé
La Clinique:
Traitement chirugicale
• Concomitant Procedures
• Stand alone Therapy
Stand alone
procedure
Cox Maze I/II/III procedure
• 1987, 198 pts
• Designed to interrupt macro reentrant
circuits.
• Maintained AV synchrony
Co...
Data gathering without rigorous follow up:
Mailed questionnaire or tel interview
• Mean follow up 5.4y
• The overall freed...
Concomitant
procedures
Some data
In only 40,6% of the patients with AF, a
concomitant surgical procedure was
performed!
Data North America 2005 -...
Some data
In the first 10 years after surgery, coronary
artery bypass graft patients with untreated
AF face a 24% increase...
Some data
When the duration of AF preoperatively >6m,
the risk of remaining in AF after surgery is
70-80%
Influence of Atr...
Left sided lesion set: Cox Maze IV
Left sided lesion set: Cox Maze IV
Left sided lesion set: Cox Maze IV
Left sided lesion set: Cox Maze IV
Left sided lesion set: Cox Maze IV
Left sided lesion set: Cox Maze IV
Left sided lesion set: Cox Maze IV
Right sided lesion set: Cox Maze IV
Right sided lesion set: Cox Maze IV
Right sided lesion set: Cox Maze IV
Right sided lesion set: Cox Maze IV
Right sided lesion set: Cox Maze IV
Right sided lesion set: Cox Maze IV
Closure of the LAA
Excision or exclusion of left atrial appendage
Sans Sievers
European Journal of Cardio Thoracic Surgery...
Closure of the LAA
• Endocardial – epicardial
• Multiple pursstrings
• Closure vs resection
• The problem of a residual st...
Closure vs resection
Closure:
• Residual stump
• Risk of residual flow communication
Resection:
• Residual stump
• More ef...
LAA: incomplete ligation
Surgical Left Atrial Appendage LigationIs Frequently Incomplete:A Transesophageal Echocardiograph...
Success of Surgical Left Atrial
Appendage Closure
Success of Surgical Left Atrial Appendage Closure, Assessment by Transes...
Success of Surgical Left Atrial
Appendage Closure
Success of Surgical Left Atrial Appendage Closure, Assessment by Transes...
Energy Sources: Unipolar
• Cryothermy
• Radiofrequency
• Microwave
• …
,
Energy Sources
• Cryothermy
• -20° -30°, 2minutes
• Disadv: Only on the arrested heart
Energy Sources: Bipolar
• Bipolar radiofrequency
Bipolar radiofrequency
Adv:
• Energy delivered between 2close electrodes
• Tissue conductance -> transmurality
Disadv:
• L...
Surgical Maze Procedure as a Treatment for Atrial Fibrillation:
A Meta-Analysis of Randomized Controlled Trials
Melissa H....
The Cox maze IV procedure: Predictors
of late recurrence.
R Damiano
Freedom from AF 1y: 89%
The Cox maze IV procedure: Pre...
The Cox maze IV procedure: Predictors
of late recurrence.
R Damiano
The Cox maze IV procedure: Predictors of late recurren...
The Cox maze IV procedure: Predictors
of late recurrence.
R Damiano
The Cox maze IV procedure: Predictors of late recurren...
The Cox maze IV procedure: Predictors
of late recurrence.
R Damiano
The Cox maze IV procedure: Predictors of late recurren...
The effect of ablation technology on
surgical outcomes after the Cox-maze
procedure: A propensity analysis
The effect of a...
Stand alone
procedure
The Mini invasive way
Types of procedures:
• Pulmonary vein isolation
• Pulmonary vein isolation plus GP ablation
• Pulm vein isolation, GP abla...
Pulmonary vein isolation:
M. Gillinov, 2006
They reported that ablation
procedure did not affect the
incidence of ablation...
Pulmonary vein isolation plus GP ablat:
• Promising
• No randomized data exist to clearly
define its potential benefit
Pulm vein isolation, GP ablation &
additional lines
Krul SPJ, Driessen AHG, van Boven WJ, Linnenbank AC, Geuzebroek GSC et...
Pulm vein isolation, GP ablation &
additional lines
Krul SPJ, Driessen AHG, van Boven WJ, Linnenbank AC, Geuzebroek GSC et...
Pulm vein isolation, GP ablation &
additional lines
Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M et ...
FAST study
Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M et
al.
Atrial fibrillation catheter ablation...
FAST study
Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M et
al.
Atrial fibrillation catheter ablation...
FAST study
Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M et
al.
Atrial fibrillation catheter ablation...
Ad N,
Préparation opératoire
• Défibrillateur ext
• Intubation double
luminaire
• ETO
• Voie centrale
• Ligne artérielle
•...
En bref:
• Thoracoscopie (3 entrées), bilatérale
• RF énergie bipolaire (Atricure)
• Isolation des veines pulmonaires
• Lé...
Lone AF: critèes d’indication
FA: fortement symptomatique
FA: fortement symptomatique
Durée de la FA: ?
FA
Durée de la FA: ?
Dimensions de l’OG
• A/P parasternal: < 55mm
• 4Ch view: < 60mm
FA
Durée de la FA: ?
Dimensions de l’OG
Fonction respiratoire acceptable
• %FVC > 60-70%
• %FEV1 > 60-70%
FA
Durée de la FA: ?
Dimensions de l’OG
Fonction respiratoire acceptable
Fonction cardiaque acceptable
• Pas d’instabilité...
Energy Sources
• Bipolar radiofrequency
• Bipolar endo/epi application
• Ideal for PV isolation & connectin lines
• Multi ...
Energy Sources
• Bipolar radiofrequency
• Bipolar endo/epi application
• Ideal for PV isolation & connectin lines
• Multi ...
Traitement de la FA vu par le
chirurgien cardiaque:
State of the art
Dr. Remes
Chirurgien Cardiaque
29 nov, 2014
BHC, Brux...
Indications for surgical AF: (ESC 2010)
• Symptomatic AF patients undergoing cardiac
surgery (IIA-A).
• Asymptomatic AF pa...
Traitement de la FA vu par le chirurgien cardiaque : state of the art. (Dr J. Remes)
Traitement de la FA vu par le chirurgien cardiaque : state of the art. (Dr J. Remes)
Traitement de la FA vu par le chirurgien cardiaque : state of the art. (Dr J. Remes)
Prochain SlideShare
Chargement dans…5
×

Traitement de la FA vu par le chirurgien cardiaque : state of the art. (Dr J. Remes)

931 vues

Publié le

Traitement de la FA vu par le chirurgien cardiaque : state of the art.
Par le Dr J. Remes

Publié dans : Santé & Médecine
  • Soyez le premier à commenter

  • Soyez le premier à aimer ceci

Traitement de la FA vu par le chirurgien cardiaque : state of the art. (Dr J. Remes)

  1. 1. Traitement de la FA vu par le chirurgien cardiaque: State of the art Dr. Remes Chirurgien Cardiaque 29 nov, 2014 BHC, Bruxelles
  2. 2. FA: Physiopathologie Physiopathologie
  3. 3. FA: Physiopathologie
  4. 4. Persistent atrial fibrillation in a goat model of chronic left atrial overload Jan Remes, MD,b Thomas J. van Brakel, MD, PhD,a Gil Bolotin, MD, PhD,a Christian Garber, MD. The Journal of Thoracic and Cardiovascular Surgery 2008, Volume 136, Number 4 1005-11 FA: Physiopathologie
  5. 5. Persistent atrial fibrillation in a goat model of chronic left atrial overload Jan Remes, MD,b Thomas J. van Brakel, MD, PhD,a Gil Bolotin, MD, PhD,a Christian Garber, MD. The Journal of Thoracic and Cardiovascular Surgery 2008, Volume 136, Number 4, 1005-11 FA: Physiopathologie
  6. 6. • Symptomes génants • Risques d’AVC x 5 • Risque de mortalité élevé La Clinique:
  7. 7. Traitement chirugicale • Concomitant Procedures • Stand alone Therapy
  8. 8. Stand alone procedure
  9. 9. Cox Maze I/II/III procedure • 1987, 198 pts • Designed to interrupt macro reentrant circuits. • Maintained AV synchrony Cox JL, Schuessler RB, D’Agostino HJ Jr, et al. The surgical treatment of atrial fibrillation. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg. 1991;101:569-83.
  10. 10. Data gathering without rigorous follow up: Mailed questionnaire or tel interview • Mean follow up 5.4y • The overall freedom from symptomatic AF was 97% Cox JL, Schuessler RB, D’Agostino HJ Jr, et al. The surgical treatment of atrial fibrillation. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg. 1991;101:569-83.
  11. 11. Concomitant procedures
  12. 12. Some data In only 40,6% of the patients with AF, a concomitant surgical procedure was performed! Data North America 2005 - 2010 Ad N, Suri RM, Gammie JS, et al: Surgical ablation of atrial trends and outcomes in North America. J Thorac Cardiovasc Surg 144: 1051-1060, 2012
  13. 13. Some data In the first 10 years after surgery, coronary artery bypass graft patients with untreated AF face a 24% increase in mortality compared with those who do not have AF. Quader MA, McCarthy PM, Gillinov AM, et al: Does preoperative atrial fibrillation reduce sur- vival after coronary artery bypass grafting? Ann Thorac Surg 77:1514- 1524, 2004
  14. 14. Some data When the duration of AF preoperatively >6m, the risk of remaining in AF after surgery is 70-80% Influence of Atrial Fibrillation on Outcome Following Mitral Valve Repair Eric Lim, MBChB, MRCS; Clifford W. Barlow, DPhil, FRCS; A. Reza Hosseinpour, FRCS; Circulation. 2001;104[suppl I]:I-59-I-63.)
  15. 15. Left sided lesion set: Cox Maze IV
  16. 16. Left sided lesion set: Cox Maze IV
  17. 17. Left sided lesion set: Cox Maze IV
  18. 18. Left sided lesion set: Cox Maze IV
  19. 19. Left sided lesion set: Cox Maze IV
  20. 20. Left sided lesion set: Cox Maze IV
  21. 21. Left sided lesion set: Cox Maze IV
  22. 22. Right sided lesion set: Cox Maze IV
  23. 23. Right sided lesion set: Cox Maze IV
  24. 24. Right sided lesion set: Cox Maze IV
  25. 25. Right sided lesion set: Cox Maze IV
  26. 26. Right sided lesion set: Cox Maze IV
  27. 27. Right sided lesion set: Cox Maze IV
  28. 28. Closure of the LAA Excision or exclusion of left atrial appendage Sans Sievers European Journal of Cardio Thoracic Surgery 1 (2012)136-37
  29. 29. Closure of the LAA • Endocardial – epicardial • Multiple pursstrings • Closure vs resection • The problem of a residual stump
  30. 30. Closure vs resection Closure: • Residual stump • Risk of residual flow communication Resection: • Residual stump • More effective, • More agressive, • Takes more time Excision or exclusion of left atrial appendage Sans Sievers European Journal of Cardio Thoracic Surgery 1 (2012)136-37
  31. 31. LAA: incomplete ligation Surgical Left Atrial Appendage LigationIs Frequently Incomplete:A Transesophageal Echocardiographic Study JACC 2000, Vol. 36, No. 2, 468-71 S. Katz, MD, FACC, Theofanis Tsiamtsiouris, MD, Robert M. Applebaum, MD, FACC, Arthur Schwartzbard, MD, FACC, Paul A. Tunick, MD, FACC, Itzhak Kronzon, Postop TOE after Mitr surg + ligation: Incomplete ligation in 36% of patients If incomplete: 50% presented thrombus If incomplete: 22% presented TE events
  32. 32. Success of Surgical Left Atrial Appendage Closure Success of Surgical Left Atrial Appendage Closure, Assessment by Transesophageal Echocardiography Anne S. Kanderian, MD,* A. Marc Gillinov, MD,† Gosta B. Pettersson, MD, PHD,† Eugene Blackstone, MD,† Allan L. Klein, MD, FACC* J Am Coll Cardiol 2008;52:924–9) Successful LAA closure occurred more often with excision (73%) than suture exclusion (23%) and stapler exclusion (0%) (p 0.001).
  33. 33. Success of Surgical Left Atrial Appendage Closure Success of Surgical Left Atrial Appendage Closure, Assessment by Transesophageal Echocardiography Anne S. Kanderian, MD,* A. Marc Gillinov, MD,† Gosta B. Pettersson, MD, PHD,† Eugene Blackstone, MD,† Allan L. Klein, MD, FACC* J Am Coll Cardiol 2008;52:924–9) Stroke/TIA was evidenced in 11% of pts with successful LAA closure and in 15% of pts with unsuccessful closure (p 0.61).
  34. 34. Energy Sources: Unipolar • Cryothermy • Radiofrequency • Microwave • … ,
  35. 35. Energy Sources • Cryothermy • -20° -30°, 2minutes • Disadv: Only on the arrested heart
  36. 36. Energy Sources: Bipolar • Bipolar radiofrequency
  37. 37. Bipolar radiofrequency Adv: • Energy delivered between 2close electrodes • Tissue conductance -> transmurality Disadv: • Limited lesion sets (jaws epi & jaws endo) !!! COMBINE !!!
  38. 38. Surgical Maze Procedure as a Treatment for Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials Melissa H. Kong, Renato D. Lopes, Jonathan P. Piccini, Vic Hasselblad, Tristram D. Bahnson & Sana M. Al-Khatib Surgical Maze Procedure as a Treatment for Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials Melissa H. Kong, Renato D. Lopes, Jonathan P. Piccini, Vic Hasselblad, TristramD. Cardiovascular Therapeutics 28 (2010) 311–326
  39. 39. The Cox maze IV procedure: Predictors of late recurrence. R Damiano Freedom from AF 1y: 89% The Cox maze IV procedure: Predictors of late recurrence Ralph J. Damiano, Jr, MD, Forrest H. Et al. J Thorac Cardiovasc Surg 2011;141:113-2 282pts, prospective data gathering 2002-09: Cox Maze IV: lone (33%) & concomitant procedures (66%) 58% persistent or LS persistent. Median 3.7y
  40. 40. The Cox maze IV procedure: Predictors of late recurrence. R Damiano The Cox maze IV procedure: Predictors of late recurrence Ralph J. Damiano, Jr, MD, Forrest H. Et al. J Thorac Cardiovasc Surg 2011;141:113-2 Risk factors for AF recurrence: • Large LA diameter • Failure to isolate entire posterior LA • Early ATAs
  41. 41. The Cox maze IV procedure: Predictors of late recurrence. R Damiano The Cox maze IV procedure: Predictors of late recurrence Ralph J. Damiano, Jr, MD, Forrest H. Et al. J Thorac Cardiovasc Surg 2011;141:113-2 Procedure: • Lone AF cross clamp time 43min • Mean hospital stay 9days
  42. 42. The Cox maze IV procedure: Predictors of late recurrence. R Damiano The Cox maze IV procedure: Predictors of late recurrence Ralph J. Damiano, Jr, MD, Forrest H. Et al. J Thorac Cardiovasc Surg 2011;141:113-2 Complications 11%: • Reop for bleeding • IABP • Death • PM implantation 9% • Stroke • Renal failure • Mediastinitis • Stroke
  43. 43. The effect of ablation technology on surgical outcomes after the Cox-maze procedure: A propensity analysis The effect of ablation technology on surgical outcomes after the Cox-maze procedure: A propensity analysis Shelly C. Lall, MD, Spencer J. Melby, MD and Ralph J. Damiano, Jr, MD The Journal of Thoracic and Cardiovascular Surgery ! Volume 133, Number 2 389 Cox III: Incisions & cryo Longer cross clamp times Cox IV: RF (Atricure) & cryo Similar outcome at 1y of follow up
  44. 44. Stand alone procedure The Mini invasive way
  45. 45. Types of procedures: • Pulmonary vein isolation • Pulmonary vein isolation plus GP ablation • Pulm vein isolation, GP ablation & additional lines
  46. 46. Pulmonary vein isolation: M. Gillinov, 2006 They reported that ablation procedure did not affect the incidence of ablation failure and thus PV isolation alone may be adequate treatment for patients with paroxysmal AF Gillinov AM, Bakaeen F, McCarthy PM, Blackstone EH, Rajeswaran J, Pettersson G et al. Surgery for paroxysmal atrial fibrillation in the setting of mitral valve disease: a role for pulmonary vein isolation? Ann Thorac Surg 2006; 81:19–26. M. Gillinov, 2013 Gillinov M. Soltesz E Surgical treatment of atrial fibrillation: Today’s questions and answers State of the art paper Semin Thoracic Surg 25:197–205 I 2013.
  47. 47. Pulmonary vein isolation plus GP ablat: • Promising • No randomized data exist to clearly define its potential benefit
  48. 48. Pulm vein isolation, GP ablation & additional lines Krul SPJ, Driessen AHG, van Boven WJ, Linnenbank AC, Geuzebroek GSC et all Thoracoscopic video-assisted pulmonary vein antrum isolation, ganglionated plexus ablation, and periprocedural confirmation of ablation lesions: first results of a hybrid surgical–electrophysiological approach for atrial fibrillation. Circ Arrhythm Electrophysiol 2011;4:262–70.
  49. 49. Pulm vein isolation, GP ablation & additional lines Krul SPJ, Driessen AHG, van Boven WJ, Linnenbank AC, Geuzebroek GSC et all Thoracoscopic video-assisted pulmonary vein antrum isolation, ganglionated plexus ablation, and periprocedural confirmation of ablation lesions: first results of a hybrid surgical–electrophysiological approach for atrial fibrillation. Circ Arrhythm Electrophysiol 2011;4:262–70.
  50. 50. Pulm vein isolation, GP ablation & additional lines Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (fast): a 2- center randomized clinical trial. Circulation; published online ahead of print14 November 2011; doi:10.1161
  51. 51. FAST study Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (fast): a 2-center randomized clinical trial. Circulation; published online ahead of print14 November 2011; 124 pts: • Drug refractory AF, 67% with failed CA • Randomised: C-ablation vs S-ablation CA: Linear antral pulm v isolation and additional lines SA: Bipol RF isolation of bilat pulm v, GA ablation, LAA excision, addit lines
  52. 52. FAST study Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (fast): a 2-center randomized clinical trial. Circulation; published online ahead of print14 November 2011; Primary endpoint: freedom AF 12m without drugs CA: 36,5% SA: 65,6% P=0.0022
  53. 53. FAST study Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M et al. Atrial fibrillation catheter ablation versus surgical ablation treatment (fast): a 2-center randomized clinical trial. Circulation; published online ahead of print14 November 2011; Primary endpoint: freedom AF 12m without drugs CA: 36,5% SA: 65,6% P=0.0022 Safety endpoint: CA: 15,9% SA: 34,4% P=0.027
  54. 54. Ad N, Préparation opératoire • Défibrillateur ext • Intubation double luminaire • ETO • Voie centrale • Ligne artérielle • Saturomètre • EP monitoring • Sonde vésicale • Preparation d’une sterno d’urg • …
  55. 55. En bref: • Thoracoscopie (3 entrées), bilatérale • RF énergie bipolaire (Atricure) • Isolation des veines pulmonaires • Lésions complémentaires OG • Isolation de l’auricule gauche • Section lig of Marchall if possible • Possibilité d’ajout du traitement OD • Possibilité d’ablation des plexi ganglionaires
  56. 56. Lone AF: critèes d’indication
  57. 57. FA: fortement symptomatique
  58. 58. FA: fortement symptomatique Durée de la FA: ?
  59. 59. FA Durée de la FA: ? Dimensions de l’OG • A/P parasternal: < 55mm • 4Ch view: < 60mm
  60. 60. FA Durée de la FA: ? Dimensions de l’OG Fonction respiratoire acceptable • %FVC > 60-70% • %FEV1 > 60-70%
  61. 61. FA Durée de la FA: ? Dimensions de l’OG Fonction respiratoire acceptable Fonction cardiaque acceptable • Pas d’instabilité hémodynamique • FE > 30%
  62. 62. Energy Sources • Bipolar radiofrequency • Bipolar endo/epi application • Ideal for PV isolation & connectin lines • Multi applications without risks • No reports of: PV stenosis, atr perf, cor art injury Ad N, Suri 144: 1051-1060, 2012
  63. 63. Energy Sources • Bipolar radiofrequency • Bipolar endo/epi application • Ideal for PV isolation & connectin lines • Multi applications without risks • No reports of: PV stenosis, atr perf, cor art injury Ad N, Suri 144: 1051-1060, 2012
  64. 64. Traitement de la FA vu par le chirurgien cardiaque: State of the art Dr. Remes Chirurgien Cardiaque 29 nov, 2014 BHC, Bruxelles
  65. 65. Indications for surgical AF: (ESC 2010) • Symptomatic AF patients undergoing cardiac surgery (IIA-A). • Asymptomatic AF patients undergoing cardiac surgery in whom the ablation can be performed with minimal risk (IIB-C). • Patients with stand-alone AF who have failed catheter ablation and in whom minimally invasive surgical ablation is feasible (IIB-C).

×