M La Meir, L Pison, B. Maessen, C de Asmundis, GB Chierchia

Centre for Heart Disease, University Hospital, Brussels - Maastricht

Surgical perspective:Single-Stage Procedure How I do It

M La Meir, L Pison, B. Maessen, C de Asmundis, GB Chierchia

Centre for Heart Disease, University Hospital, Brussels - Maastricht

The way to all-roundArrhythmia Heart Team cooperation

Potential conflicts of interest

Speaker’s name: Mark La Meir

I have the following potential conflicts of interest to report:

Consultant Atricure

Heart Rhythm - DOI: 10.1016/j.hrthm.2017.05.012

2016 ESC Guidelines for the management of AFdeveloped in collaboration with EACTS

European Heart Journal (2016) 37, 2893–2962

Multidisciplinary Treatment The Arrhythmia Team

Always consists of a arrhythmia surgeon, a EP and a cardiologist

Meeting once a weekClose collaboration with other disciplinesAll cases of concomitant AF are discussed

preoperatively Need for arrhythmia surgery? What kind? Need for LAA closure?

All lone AF patients referred for surgical AF ablation are discussed

Centre for Heart Disease, University Hospital, Brussels - Maastricht

“ AF begets AF “

“ Catheter ablation begets catheter ablation “

Catheter ablation in patients with persistent AF

P. Kirchhof and H. Calkins. European Heart Journal (2017) 38, 20–26

Catheter ablation of asymptomatic LSP AF: impact on quality of life, exercise performance, arrhythmia

perception, and arrhythmia-free survival.J Cardiovasc Electrophysiol. 2014 Oct;25(10):1057-64.

61 consecutive patients (mean age 62 ±13 years, 71% males)

FU 20 ± 5 months

36 (57%) patients SR free off AAD

25 patients AF, 21 (84%) were symptomatic

SF-36 scores improved significantly for patients with successful ablation

The enthusiasm for this “hybrid” ablation strategy must betempered by some important limitations:

It is a logistical nightmare.

It is rare to have tremendous expertise with catheter ablation and surgical AF ablation at the same institution.

Which lesions or lesion sets are needed and what is the best end point for the procedure?

One wonders if it would be preferable to perform the surgical ablation with PVI first and perform the catheter ablation part of the procedure only if AF recurs.

Hybrid ablation for AF: a systematic review.Mindy Vroomen, Laurent Pison.

J Interv Card Electrophysiol (2016) 47:265–274

Hybrid ProcedureTeam Work

What should we try to give the AF patient?

Longlasting PV isolation

Connecting lesions

Excision / exclusion LAA

Line to the mitral annulus

Isolation of the coronary sinus

Lesions in the right atrium

Ganglionated plexi?

This can not be achieved with an epicardial ablation

Certainty in AF surgery

Because AF mapping data was ambiguous and difficult to analyze, the Maze procedure was developed as a salvage procedure. It was designed as an anatomic procedure that eliminated all potential reentrant circuits that could rotate around the thoracic veins and valve annuli, subdivided large areas of contiguous tissue, and left a pathway for the sinus node to activate both atria and the atrioventricular (AV) node.

J Interv Card Electrophysiol (2007) 20:59–64

Pison et al, JCE 2010

Incomplete roofline after epicardial ablation

J. A Armour et. al. Gross and Microscopic Anatomy of the Human Intrinsic Cardiac Nervous System. Anat. Rec. 247: 1997

Cardiac ganglionic plexi - Fat Pads

Step by step: right superior GP ablation

Testing the box

Redo procedures

Gelsomino et al. European Journal of Cardio-Thoracic Surgery 43 (2013) 673–682

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Before Left isthmus After Left isthmus After Left isthmus

*148ms

Right isthmus Right isthmus Right isthmus

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LAAO

Left SVC

Kong et al, Europace 2011

Ablation of complex fractionated atrial electrograms

Repeat Procedures after Hybrid Thoracoscopic Ablation in the setting of LSP AF:

EP Findings and 2 Year Clinical outcome.J Cardiovasc Electrophysiol. 2015 Sep 16.

64 patients, 14 patients underwent repeat CA

AF 43% - AT/Afl 57%

9% of PVs were reconnected, 7% of box lesionswere incomplete.