This document summarizes a presentation given by Dr. Remes on the surgical treatment of atrial fibrillation. It discusses the pathophysiology of AF and reviews studies on the Cox Maze procedure. Dr. Remes presents data on success rates of different Cox Maze variations and predictors of recurrence. Minimally invasive surgical approaches for AF ablation including pulmonary vein isolation are discussed. Energy sources for ablation like bipolar radiofrequency are highlighted. Guidelines for lone AF surgery are reviewed. In conclusion, the document provides an overview of the state of the art in surgical treatment of AF.

1. Traitement de la FA vu par le
chirurgien cardiaque:
State of the art
Dr. Remes
Chirurgien Cardiaque
29 nov, 2014
BHC, Bruxelles

2. FA: Physiopathologie
Physiopathologie

3. FA: Physiopathologie

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. 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. • Symptomes génants
• Risques d’AVC x 5
• Risque de mortalité élevé
La Clinique:

7. Traitement chirugicale
• Concomitant Procedures
• Stand alone Therapy

8. Stand alone
procedure

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. 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. Concomitant
procedures

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. 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. 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. Left sided lesion set: Cox Maze IV

16. Left sided lesion set: Cox Maze IV

17. Left sided lesion set: Cox Maze IV

18. Left sided lesion set: Cox Maze IV

19. Left sided lesion set: Cox Maze IV

20. Left sided lesion set: Cox Maze IV

21. Left sided lesion set: Cox Maze IV

23. Right sided lesion set: Cox Maze IV

24. Right sided lesion set: Cox Maze IV

25. Right sided lesion set: Cox Maze IV

26. Right sided lesion set: Cox Maze IV

27. Right sided lesion set: Cox Maze IV

28. Right sided lesion set: Cox Maze IV

30. Closure of the LAA
Excision or exclusion of left atrial appendage
Sans Sievers
European Journal of Cardio Thoracic Surgery 1 (2012)136-37

31. Closure of the LAA
• Endocardial – epicardial
• Multiple pursstrings
• Closure vs resection
• The problem of a residual stump

32. 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

33. 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

34. 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).

35. 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).

37. Energy Sources: Unipolar
• Cryothermy
• Radiofrequency
• Microwave
• …
,

38. Energy Sources
• Cryothermy
• -20° -30°, 2minutes
• Disadv: Only on the arrested heart

39. Energy Sources: Bipolar
• Bipolar radiofrequency

40. Bipolar radiofrequency
Adv:
• Energy delivered between 2close electrodes
• Tissue conductance -> transmurality
Disadv:
• Limited lesion sets (jaws epi & jaws endo)
!!! COMBINE !!!

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. Stand alone
procedure
The Mini invasive way

48. Types of procedures:
• Pulmonary vein isolation
• Pulmonary vein isolation plus GP ablation
• Pulm vein isolation, GP ablation &
additional lines

49. 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.

50. Pulmonary vein isolation plus GP ablat:
• Promising
• No randomized data exist to clearly
define its potential benefit

51. 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.

52. 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.

53. 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

54. 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

55. 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

56. 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

57. 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
• …

58. 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

59. Lone AF: critèes d’indication

60. FA: fortement symptomatique

61. FA: fortement symptomatique
Durée de la FA: ?

62. FA
Durée de la FA: ?
Dimensions de l’OG
• A/P parasternal: < 55mm
• 4Ch view: < 60mm

63. FA
Durée de la FA: ?
Dimensions de l’OG
Fonction respiratoire acceptable
• %FVC > 60-70%
• %FEV1 > 60-70%

64. FA
Durée de la FA: ?
Dimensions de l’OG
Fonction respiratoire acceptable
Fonction cardiaque acceptable
• Pas d’instabilité hémodynamique
• FE > 30%

65. 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

66. 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

67. Traitement de la FA vu par le
chirurgien cardiaque:
State of the art
Dr. Remes
Chirurgien Cardiaque
29 nov, 2014
BHC, Bruxelles

68. 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).