mitral repair/af ablation sternotomy approach · the bluhm cardiovascular institute northwestern...

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Patrick M. McCarthy MD, FACCExecutive Director of the Bluhm Cardiovascular Institute

Chief of Cardiac Surgery DivisionHeller-Sacks Professor of Surgery in the Feinberg School of Medicine

November 17, 2017Session IV: Concomitant Ablation—How I Do it and Why

Nobu Eden Roc HotelMiami Beach, Florida

Mitral Repair/AF AblationSternotomy Approach

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Disclosures

• None

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

MVR/AF AblationIssues to Consider

• MV: TV/RA Involvement; Reop; Mechanical?• AF: Type; Duration; Stroke Hx; Symptoms• Decision: Technology and Lesion Set

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

What Technology and Lesion Set?

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Cox Maze Procedure

• Pulmonary Vein “Box” Lesion• MV Annulus to Box Lesion• SVC-IVC• TV Annulus flutter

lines X2• Excision of LAA

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

What I Don’t Like about Bi Polar Clamps

• Multiple applications (7-10)• Awkward (Left atrium); esp w small incision• “Thin” tissue next to “thick” tissue; e.g. svc• Need a second device (cost and footprint)

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Last 3 Years Almost Exclusively Cryo

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

MV Repair; LA Maze; Atriclip

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Reoperations: MV Annulus Lesion

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Tips/Pitfalls of Cryo

• Mind the Gapunfold the tissuepush from outside

• 2 min freeze LA, 1 min RA and Epicardial CS • Release the retractor blade• Don’t “poke” anything (like your mv repair!)• Don’t freeze the coronaries

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Lesion Set: Left vs. Biatrial

Not PVI; Do the MV and CS

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Cox Maze Procedure

• Pulmonary Vein “Box” Lesion• MV Annulus to Box Lesion• SVC-IVC• TV Annulus flutter

lines X2• Excision of LAA

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Ann Thorac Surg, 103(6):1858-65.

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Box Lesion Across LAAFreeze Endo and Epicardial to C.S.

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Propensity matched groups

0%

20%

40%

60%

80%

FFAF at last FU, p=0.10

LA BA

70% 89/127

79%98/124

0%

20%

40%

60%

80%

FFAF at last FU off AA, p=.09

LA BA

0%

5%

10%

15%

Pre-discharge PPM, p=0.57

LA BA 0

0.02

0.04

0.06

0.08

Annualized Stroke rate per 10 person/year, p=1.00

LA BA

69%82/119

79%86/109

0.080.0712%

17/14710%

14/147

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Patient Population and Late Outcomes Impact Success

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

NMH: DMR ’04-’1597% of AF Treated

97% of Valves Repaired

Variable NAge 912 60.8± 12.7 Gender (female) 912 311 34%NYHA Class I / II 904 759 84%NYHA Class III / IV 904 145 16%Repeat Sternotomy 912 29 3%

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Operative Characteristics

VariableEntire Cohort

(N=892)Class I

(N=390)Class II(N=370)

Class III / IV(N=132)

P-value

Perfusion 89(74, 111) 84(71, 103) 92(77, 113) 96(73, 126) <.001Cross Clamp 74(62, 92) 72(60, 87) 78(66, 96) 75(62, 97) <.001Elective Surgery 875 (98%) 388 (99%) 363 (98%) 124 (94%) <.001CABG 133 (15%) 47 (12%) 58 (16%) 28 (21%) 0.033Aortic Valve 42 (5%) 15 (4%) 17 (5%) 10 (8%) 0.21Tricuspid Valve 99 (11%) 38 (10%) 34 (9%) 27 (20%) 0.001AF Ablation 217 (24%) 76 (19%) 100 (27%) 41 (31%) 0.008Mitral Surgery <.001. Repair 865 (97%) 382 (98%) 363 (98%) 120 (91%). Replacement 27 (3%) 8 (2%) 7 (2%) 12 (9%)MV Leaflet 0.20. Anterior 49 (6%) 20 (5%) 22 (6%) 7 (6%). Posterior 659 (79%) 306 (83%) 268 (77%) 85 (77%). Bileaflet 121 (15%) 42 (11%) 60 (17%) 19 (17%)

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

NMH ‘04-’15Freedom from MV

Reoperation for DMRFreedom from MR 3+

(No 4+ MR)

Year1 Year2 Year4 Year6 Year8 Year10 Follow-up(Years)

MV Repair 99.8% 99.4% 98.3% 97.3% 96.5% 96.5% 3.4±2.8

MV Replacement

100% 100% 100% 100% 100% 100% 3.7±3.1

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Pacemaker Thoughts(Not Party Line)

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

NMH Incidence of PPM by AF Lesion Type

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Pacemaker

• Retractor on SA Node• SA Node Artery Divided• SSS Occurs without AF Surgery

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

MV/Maze Opinions

• Cryo is Easier; Faster; Cheaper; More Flexible than RF

• Early in The Course of The Mitral Disease Little RA Involvement: LA Only

• Always Do LA and Isthmus Lesions• Pacemakers are from SA Node Trauma, not

SSS, not from the Maze

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Freedom from MV Reoperation for DMRNMH ‘04-’15; Single Surgeon

Year1 Year2 Year4 Year6 Year8 Year10

99.6% 99.6% 99.6% 99.6% 99.6% 99.6%

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Freedom from MR 3+ (No 4+ MR)by MV Surgery Type

Year1 Year2 Year4 Year6 Year8 Year10 Follow-up(Years)

MV Repair 99.8% 99.4% 98.3% 97.3% 96.5% 96.5% 3.4±2.8

MV Replacement

100% 100% 100% 100% 100% 100% 3.7±3.1

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

• Need new HRS quotes• 10 minutes of video• 5 min discussion

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

MV Annulus Lesion

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Key points

• Have to do mitral ring or replace before mitral annular line

• Cut SA node; retractor on SA node; we see SSS in non-Maze surgery

• I don’t use a separate LAA line. Excision or cryo goes to LAA

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Why LA onlybring slides from the 900+ DMR

• 84% FC I or II• Only % had mod or more TR• Combined free from 3-4+ MR and free from

reop….so no recurrence leading to late AF• 97% of AF is treated (some maybe others

wouldn’t because too advanced, others only 1 or 2 episodes

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Valve Inspection24 seconds

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Valve Measurements21 seconds

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Mitral Repair4 minutes

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

Cryoablation: Not Just for Reops Anymore

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital

• For next slide need to animate with some red arrows to TV surgery and AF ablation

• Box around Class I N=390• Do we have data on type and duration of AF?