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