surgical af ablation – where will we be in the next 10 years? · •laa closure and stroke data...

Gan Dunnington M.D.

Cardiothoracic Surgeon

Adventist Heart Institute

St. Helena Hospital

St Helena, Ca

SURGICAL AF ABLATION – WHERE WILL WE

BE IN THE NEXT 10 YEARS?

10 YEARS AGO…..

• Hurricane Katrina

• First Human Face transplant

• Johnny Carson and Pope JPII died

• Pats won Super Bowl……

• White sox won the WS first time since 1917

• Tiger was money leader (10 mil)

• We were at war in the Middle East

• No Facebook, No Uber, No Instagram, No iPhone

(With inflated balls?)

10 YEARS AGO…..

• Damiano was publishing 276 Cox Maze pts, citing as “Gold

standard”

• Gillinov and Wolf reporting 27 pts with bilat thoracotomy (18

paf), 23 in nsr at 3 months

• Chitwood was reporting on robotic MVR with microwave ablation

• “Hybrid” therapy more implied pharmacological and ablative

strategy

NOW….

• Not a whole lot has changed with surgical ablation

• Still only performed by minority of surgeons

• Still evaluating lesions and devices

• Still arguing over safety/efficacy/data

• Still the red-headed stepchild of CT surgery

• Not taught, not practiced, not expected, not followed

• Still probably the largest population of patients with the most to gain in all heart surgery

WHY: INERTIA

ME

EPPATIENTS

WHAT WILL CHANGE IN 10 YEARS?

• Ablation Tools?

• Probably more in the EP/catheter arena

• More power, better feedback, better transmurality

• Still exploring energy sources

• Epicardial ablation?

• Surgical Approach becomes more minimal – smaller

ports, better visualization


• Mapping Tools?

• More in EP arena

• Possibly spill over to surgery bc of hybrid interest

TOPERA EFFECT


• Better prognostication?


• Financials


• Financials –(why it has never taken off)

• What will happen with Reimbursement for

procedures with low chance of cure?

• What will happen with reimbursement for poor

quality or inadequate education?


• Data

• More studies, higher numbers

• DEEP study

• Surgery to appear in guidelines

• No longer “investigational”

• Maturity of existing patient data

• Carrot and the Stick – expecations change as data matures

• IMA use

• Mitral Valve Repair

TOOLS10% MAPPING

10%

PROGNOSTICS20%

DATA/EDUCATION

60%

CHANGE


• LAA closure and stroke data

• 50,000 Atriclips have been applied with only 100 studied short term…none long term

• Lariat in Studies with PVI

• Watchman approved and will be followed

• Consensus


• Hybrid, Hybrid, Hybrid

• More Heart teams, consolidation of care

• TAVR and TMVR will make open valve work less common and on pump work less common

• Currently no way to complete a MAZE off pump, epicardially

• EPS’s will develop epicardial afib ablation tools

• Esophagus protector?


• Education

• Educators more facile with MIS techniques

• I learned ablation from the junior faculty

• TELEMEDICINE


• Education

• Educators more facile with MIS techniques

• I learned ablation from the junior faculty

• TELEMEDICINE

• Mini-Fellowships

• Same model of Endovascular, mini-mitral, TAVR

• Integrated into standard Fellowship

FIRST AFIB MINI(SUPER)FELLOWSHIP

• 3 months – in Napa;)

• In 2 months has done:

• 16 Vats Ablations (planned hybrid)

• 11 Open concomitant Mazes

• Participates in precepting/education of visiting surgeons

• Observation in cath lab

• Attended marketing meeting and leading patient seminar

• Pre-req to have job where EP and hospital interest prior to arrival

Ben Taylor MD

DATA –4/13 – 6/15 HYBRID MAZE DATA -

OBSERVATIONS

• 175 VATS MAZES, 151 completed Hybrid Mazes

• 6 stand alone VATS (1 A FL recurrence)

• Approx 15 AF recurrences

• Approx 20 pending monitors

• 147/151 currently in NSR (97%)

• Mean follow up > 1 year

• 120 men, 35 women

• 10 “redo” VATS after previous open heart surgery

• 54 open concomitant mazes

• Follow up lacking!

2015 HYBRID MAZE DATA - OBSERVATIONS

• LOS approx 4 d

• Second stage cath at 6 weeks (first 50 cases same day)

• Follow up long term Monitor at 3 months, 1 yr, annually

• approx 15 touch up cath ablations

• Two mortalities (intraop CVA, post procedure MOF), One

visual CVA, 1 TIA

• No wound infections

• 1 trach/peg

• 5 returns to OR for bleeding (2 emergent, 1 delayed for chest

wall hematoma, 2 for delayed hemothorax)

• 1 groin hematoma that required re-admit

• 1 sternotomy

2015 HYBRID MAZE DATA - OBSERVATIONS

• VATS ablation consistently 120 min

• 160 min for redo’s

• Cath times 30-60 min less if VATS lesions complete

(75 min vs 120 min procedure time)

• Over 50 Fusion cases

• 34 have completed 2nd stage within 32/34

completely isolated PV and posterior LA box at 6

wks

• Approx 30% required roof or floor touch-ups

pre-Fusion

• Approx 17 hours saved cath lab time


• Future of “arrhythmia surgery” is bright

• Afib

• Lead management

• Leadless pacers

• VT

• LAA management

• Improved Tools

• Education volume Data improvement in technology education…..

• Consensus on LAA management and anticoagulation

• Financial changes

• HYBRID

WHY:

ME

EPPATIENTS

surgical af ablation – where will we be in the next 10 years? · •laa closure and stroke data...

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