The Role of Surgery in Advanced Arrhythmia Care
Originally Broadcast: Wednesday, May 17, 2023 at 6pm ET
Objectives:
Review of current guidelines for directed therapy for Afib
Identify the role surgeons have in advanced/hybrid ablation for Afib
Describe the role of surgery for treatment of complex arrhythmias
Good evening. I'm Tara Lo with Baptist Health and I am here today to help moderate and introduce to you to our speaker, Dr Stephen Hall. So now I would like to introduce you to Doctor Steven Hall. He is the associate chief of uh cardiac surgery and the director of Arrhythmia Surgery at the Baptist Health Miami Cardiac and Vascular Institute, Doctor Hall Sarah. Thank you. Uh I appreciate the opportunity to speak with you tonight. We're gonna talk about the role of surgery in advanced arrhythmia care. What we'll do is start by discussing mechanisms of atrial fibrillation generation. As a fib is the most common arrhythmia that we deal with. We'll talk about initial treatment strategies for atrial fibrillation, which will give us a context for the role of surgery. And then we'll discuss guideline indications for surgical ablation for atrial fibrillation, including concomitant at fibrillation. Uh that is at the time of other heart surgery and for stand-alone applications uh for patients with without structural uh disease. Uh We'll then move to a discussion of the development of the cox maze procedure. Um the original surgical treatment for atrial fibrillation and then move to a discussion of um how that led to the development of minimally invasive and hybrid uh techniques for uh a fib generation. And we'll spend a few minutes at the end of the talk talking a little bit about hybrid ablation for inappropriate sinus sinus tachycardia and ventricular techy cardia as other complex arrhythmias that we deal with. So to begin with, I'd like to start with some definitions. The Heart Rhythm Society is the Guiding Organization for Electrophysi uh Electro Physiology and they have published a guidelines that we prefer to use in talking about uh a fib. Um When we talk about Permal a fib, we're talking about self terminating uh arrhythmia uh with or without intervention that occurs with uh less than seven days period of time. So brief parax system of a fib, when we say persistent atrial fibrillation, we're talking about continuous a fib that has lasted at least seven days. Longstanding, persistent atrial fibrillation is defined as continuous a fib for at least 12 months duration. And when we talk about non paroxysmal a fib, we're talking about persistent and longstanding persistent a fib together as a more complex form of the disease. Uh permanent atrial fibrillation is an arrhythmia that the patient and the treating physician have agreed. No further additional attempts will be made to try to restore or maintain science rhythm in terms like chronic a fib or loan a fib have variable definitions. And the HR S has advised that we try to avoid using those. So I'll do the best I can there as well. I'd like to talk a little bit about mechanisms for the development of atrial fibrillation because this is gonna help us, I think, understand the basis for uh treatment, whether that be uh cathode based treatment or surgical treatment. And I like to think of those mechanisms as mechanisms that uh lead to the initiation of atrial fibrillation and the propagation of atrial fibrillation. Um Michelle has um in Paris in 1998 published in the New England Journal of Medicine. Arguably the landmark paper about uh mechanisms of initiation of atrial fibrillation where he first really described the majority of uh initiation of atrial fibrillation, humans occurring in my sites in the pulmonary veins or in the uh uh early cuff of the left atrium at the juncture of the pulmonary veins. Um And really everything that we do with regard to ablation fray them has to do with electrically isolating these P D triggers. Uh Doctor Jim Cox, who we'll talk about at some length later. Um uh was really the first to identify um re entrance circuits of the left atrium as the etiology and mechanism for the propagation of atrial fibrillation. So, I I like to think about this is if you have pulmon triggers alone. Um And what you'll have at that point is parasal a fib alone if as the disease progresses and you later develop these reentrant circuits in the left atrium. Uh you then have substrate for both these mechanisms and you will have non parasal atrial fibrillation as that pertains to ablation that we're going to do to treat this. I like to discuss this in terms of burden specific specific lesion sets that is the burden of atrial fibrillation and what it requires to successfully treat it. So, as I mentioned, pulmonary vein isolation, electrically isolating those pulmonary vein triggers from the rest of the heart is the basis of what we do um in a fib ablation. And if you have Permal at fibrillation alone, that is generally sufficient in um uh treating that if you have non Permal attra fibrillation, it will require a more robust lesion set and there the maze lesion set that we're going to discuss is really um the basis for successful treatment. So when I talk to patients about treatment paradigms for atrial fibrillation, I tell them that you know, the initial treatment for atrial fibrillation, especially if you have parasal atrial fibrillation is medical. Um the goal is generally initially rhythm control and patients may go through multiple drugs or even cardioversions um to try to maintain sinus rhythm if that's not successful or if the medical therapy isn't tolerated or not desired. Then I tell patients there's or the disease process progresses, then I tell them they really have two options. The first is to continue medical therapy with a different goal. And that is really a goal of rate control and lifetime anticoagulation to reduce stroke risk if indicated. The other option is to consider a more advanced ablation procedure. And I tell patients ablation, um technology comes in two flavors. Uh you know, we can um uh perform those procedures endocardial, either with catheters or theory with open surgery or ecard with some of the minimal invasive techniques that we'll talk about tonight for parasal atrial fibrillation. Each has excellent results. And generally, I refer those patients for cat fibrillation because it's a much more straightforward, um much easier to recover from procedure. And there has to be a reason why um that would, you know, the success rate of that wouldn't be optimal. Um for us not to refer those patients to our E P college for non Permal atrial fibrillation. Each of those technologies um has poor results alone. Um And so, what we've found is that combining those technologies, epicardial uh and endocardial procedures significantly improves the results in patients who have non parasal atrial fibrillation. So, in 2017, this uh group of distinguished surgeons published in the abso thre surgery to the society, thas Surgeons Clinical Practice guidelines for surgical treatment of atrial fibrillation. This is the most uh uh recent um guidelines that have been um published with regard to surgical ablation. And in that uh study, what they said is that in patients who have symptomatic and medically refractory atrial fibrillation, they described indications for surgery in two groups. And that is patients who have a history of atrial fibrillation and require another cardiac surgical procedure. Um That is they uh would be candidates for concomitant ablation at the time of other heart surgery. And what's uh uh subsequent studies have shown is that this can be performed with no increase in morbidity mortality. And in these guidelines, um the treatment of atrial fibrillation during mitral valve surgery, mit valve repair replacement is a class one a indication um during aortic valve replacement or bypass surgery. It's a class one B recommendation. So those are significantly upgraded from previous guidelines in patients who have atrial fibrillation in the absence of structural heart disease. Um or um uh our candidates for a potential stand-alone surgical ablation. Those would be performed in patients who are intolerant of medical therapy or antic coagulation and who have failed or are likely to fail catheter ablation. And in those guidelines, uh a standalone surgical ablation is class two a indication. So I'd like to talk for a few minutes about concomitant ablation. And um how we've done with that and the paper published by Doctor Boar and Doctor Cox in 2017 is arguably the best day that we have most recent day that we have about um a large cohort of patients undergoing surgical ablation for atrial fibrillation. And what they did is they queried the S T S database, arguably one of the most robust medical databases in the world for patients from 2011, 2014 and found nearly 87,000 patients with a history of atrial fibrillation that had undergone non emergent heart surgery in the United States. And what they saw is that less than a half of those patients actually had their a fib treated. Now, that's a significant improvement over a paper, similar paper that was published five years before. Um, but still, I think, um, is a little bit alarming in some ways and, um, leaves us uh room for improvement. Now, they further broke that down into um specific uh surgical procedures and uh we've gotten significantly better when it comes to the treatment of atrial fibrillation of patients who are having micro valve surgery. Um And what they showed is over two thirds of those patients got a concomitant ab not quite as well um penetrated when it comes to uh aortic valve surgery where less than 40% of those patients, uh got an ablation and bypass surgery where less than a third got ablation. Now, at the same time, this very robust uh uh data set showed us that ablation for atrial fibrillation in those patients was associated with a significant reduction in 30 day mortality and 30 day stroke rate. So, why wouldn't you wanna do more treatment of a fib in that, that concomitant case? Well, that was um, a question that the American Association of Thoracic surgery asked a little bit later in that year. And um put out a survey to its memberships uh asking what they thought some of the barriers to concomitant ablation were. And the more common uh responses were that surgeons were concerned about increasing the complexity of the surgery or whether it be cross plant time or time on the heart lung machine. They didn't want to increase the risk of the operation in patients who are older or sicker had comorbidities. They didn't want to open the left atrium, particularly in the case of um uh it valve surgery or bypass surgery, potentially increase additional uh air risks and things like that. They were skeptical regarding the success of surgical ablation for atrial fibrillation. And um the there was an apparent um concern about inexperience with surgical ablation. Now, what we've subsequently seen is that indeed there have been papers published not only in the microvalve literature, but also in surgical ablation literature saying that with increased surgeon experience the rate of micro valve repair, for instance, uh improves similarly, with increased surgical experience, the rate of surgical ablation goes up. So um these are for those of us that uh are interested in this uh uh opportunities for um uh improving the penetrance of concomitant ablation at the time of heart surgery. So, I'd like to take a step back now and talk a little bit about the surgical, the history of the surgical treatment of atrial fibrillation. And this really revolves around the work um of Doctor Jim Cox and his colleagues um at Washington University in Saint Louis. And interestingly, it didn't start with a fib. So what Doctor Cox and his colleagues learned, actually, they started with um uh an interest in treating a wolf Parkinson white syndrome and 80 node reentry tachycardia. And this um stemmed from work that began in the mid and late seventies uh initially in their dog lab and then in the operating room, and this group developed a very sophisticated, if not uh bulky eic cardial mapping system um uh by um modern modern standards which um help them understand the nature of these reenter arrhythmias and to better um move toward effective therapies what they did then. And in fact, if you talk to Doctor Cox, he'll tell you that um he believes that his work with W P W is arguably his most important contribution to arrhythmia surgery, not a fib. So, what they did is they took these same concepts and they um shown that light on a fib beginning in the mid and late eighties. Um uh using this similar sort of um mapping and corridor ablation um uh techniques um uh for the treatment of atrial fibrillation. Doctor Cox performed uh the first cox maze procedure in September of 1987. Um interestingly, um about 19 months after his mother died from a fatal stroke from atrial fibrillation and continued to make improvements not only in the operating room but also in the lab. Um such that in 1991 he published his first experience with the first seven patients of the then the uh most common iteration, which was the cox maze three or what we now call the cut. And so maze procedure. Additional improvements continued per uh predominantly in the lab at WASU but also at uh other sites that um started doing this uh early on. Um and uh those improvements led to the Cox Ma four operation, which was described for the first time in 2002 by Ralph Damiano, who was Doctor Cox's uh heir at WASU, um where they described uh an approach through a right mini Thoro um and added a radio frequency and cryoablation we had, which had been developed in the years prior to this paper. This is a picture of the good Doctor Cox. Um And this is um a diagram from his uh early description of the maze three procedure that shows, you know, the importance of poster update wall ablation. Their um uh idea about where these reentrant rotors were and where all these cuts were to interrupt those. This is a little bit um prettier uh artist depiction of the same thing. But what you can see is the extensive um uh cuts um and repairs of those to um to create lines of ablation to fix these a um arrhythmias. So, the results uh were excellent and they have showed a very high freedom from, uh, recurred atrial fibrillation. The downside was, this was a real heart surgery, right? This required a sternotomy. It required a time on the heart lung machine. It was a complex operation that was associated with a risk of uh real complications. And so, uh, it therefore was performed by only a handful of centers on a very few patients. Um, and, uh, you know, so, uh effective but not very popular. And so what's happened over the last probably 12 or 15 years is we've moved toward trying to figure out ways to create the same sort of effective ablation less invasively. So the idea was we want to try to create the same lines of ablation that were equally effective. But in a procedure that was easier on patients less invasive, utilize these new different energy sources to create the scars that Doctor Cox had started with a, a knife cut and suture. Um and do that either from the inside with catheters or from the outside with surgery. And the way I describe this to patients, the analogy I use is uh this is a little bit, these creating these lines of ovation is a little bit like building a corral for wild horses. Um If you leave a gate open or leave a few pen fence posts too low, ultimately, the little buggers will get out. And so the same is true with lines of ablation. If you leave a gap in those that line of ablation, whether it's transmural or not, ultimately, though that line of ablation will fail. Um And so, um uh as particularly in um in uh complex forms of atrial fibrillation, they really demand complete um and trans lines of the complete from one end to the other and all the way through the thickness of the my party. Um So, as we became the idea of hybrid ablation became more robust, we realized this was really a combination of sort of best of both technologies. We know that the surgical lesions that uh we can create are robust. We know that management left atrial appendage is a must. And that was an important part of the maze procedure as developed by Dr Cox, we know that rigorous epicardial testing with follow-up endocardial testing, ablation can ensure these full thickness and complete lines of ablation. We also know anatomically that the uh lines to the tricuspid and uh Mitr Annuus can be anatomically challenging if not impossible epicardial but are relatively simple for our E P colleagues. And that this seemed to be a uh an ideal approach for symptomatic non peral at fibrillation. So, um as it turns out, Doctor Cox uh put this to uh pen to paper and uh and published this paper in 2019 that um espoused those same things. So he and Doctor mccarthy, I think did a wonderful job in doing that. And here's what they taught us they learned several lessons from their early ablation experience that included the maze pattern of lesions is the most effective way uh for the treatment of longstanding persistent at fibrillation. They also realized that the surgical maze procedures were too invasive for first line therapy. For a fib even for longstanding percy at fibrillation, a full maze lesion set cannot be performed thoro cop nor can it be performed and accordingly with a catheter. We know that our electrophysiology colleagues are excellent at localizing and closing gaps in the surgical lesions. Uh um Given the sophisticated um mapping systems they have. And we're gonna show that in just a little bit and we know that they're also excellent at creating conduction block and narrow and combined spaces in the atrium. So the open maze procedure, if that was too invasive to be widely adopted as initial therapy, um what happened was even some of the less invasive surgical procedures that Doctor Damiano talked about that were developed in the late nineties did seem to alter that perception. Now, the development of off pump thos cop a fib surgery in the late two thousands did dramatically change that perception. And hybrid ablation procedures. Combining thor scopic surgery and catheter ablation are now first line therapy at multiple centers around the world. So this is a um uh a depiction from Doctor Cox of uh when they figured out all the different macro entrance circuits and non parasal at fibrillation that are in the left atrium. Um What they said is OK, what is it gonna take to interrupt these? And so that's where um this lesion set was developed, where we see that again, the basis of surgical ablation is electrical isolation of the pulmonary veins from the heart. Um This allows creation of additional um connecting lines to create a complete poster elect wall ab remember that looked like the um the diagram that doctor Cox published in the early nineties. And with that, um what that'll do is interrupt all these abnormal re entrance cycles. Now, when we add a line of ablation from there to the left atrial appendage, which is part of the mare procedure, we get rid of that um uh re entrance circuit uh at the base of left atrial appendage. And when we ligate the appendage, um that creates not only a mechanical ablation, but also um should create an electrical ablation that interrupts uh left atrial appendage flutters and that sort of thing. So when we add clips, um you know, at the uh at the edges of the ablation to guide our E P colleagues, we end up with a complete initial surgical procedure. Um and independently, it's really very robust um but has a few gaps. So what this leaves out is um re entrance cycles around the base of the left, a little appendage um near the ad valve um uh annu and that's where our E P colleagues then can come in and create a line of ablation that uh it interrupts those as well. So that leaves us with a final uh lesion set, which I'll show a little bit more um uh in a, in a bit. So this thoro procedure is performed through 3, 12 millimeter port incisions performed on a beating heart without the heart lung machine, utilizing radio frequency energy delivered epoc cardial with really excellent visualization. Um We initially started performing this in a hybrid operator on the same day. But uh our early experience showed us that if we can actually separate those two procedures, um the results are superior. Um So the surgical portion is performed under general anesthesia with a double interrelate tube to allow us to inflate and deflate the lungs to uh be able to see the heart start on the right side to create uh initial uh our initial lines of ablation, then move to the left side to finish the lines. As we just showed, uh we'll manage left a appendage and then the patient will come back for endocardial testing and follow up ablation. And these are just some um some uh diagrams of how that looks. So we start on the right side again with these uh thor scopic incisions. Uh the we open the um uh the pericordium anterior to the uh to the tic nerve on the right side. Um Then utilizing this um bipolar bidirectional radio frequency clamp can make a circumferential um injury um in the cuff of the left atrium that uh once healed and scarred creates electrical isolation from the pulmonary veins. Then we have a unidirectional uh uh bipolar device that allows us to make these linear connecting lines that we um showed that. So we'll begin those on the uh right side. Then we move to the left side again, similar thoro access. This time, we opened the para cardi and posterior to the front nerve. And um uh we do uh point of isolation with this bipolar clamp. Again. On the left side, the linear device completes the linear lines of ablation as well as a line of ablation to left appendage and then ligate the appendage. So I have to talk just for a second about managing the left atrial appendage. Um uh as is commonly known in a fib sluggish atrial blood flow and endothelial factors lead to blood clots. Patients aren't anticoagulated. Um These are the source of the stroke risk and a fib and because of the anatomy of the left atrial appendage and it's multiple trabecule, it itself is the source of at least 90% of thrombi that are formed uh during atrial fibrillation. So, removing the left atl appendage um is critical to the procedural management of atrial fibrillation and should significantly lower stroke risk. Um This is a potential advantage of a surgical approach and in those guidelines that we discussed um managing left atrial appendage is a class two a recommendation. So this is the device that we use for um uh for applying the um uh epi cardial uh uh left a pen lag device. This is the device that we use. Um Thos cop goes through a 12 millimeter port. Um This uh clip device comes in multiple sizes. So we measure the size, the base of the left arial appendage and then can choose an appropriately sized clip. And so this is a video that shows this done thoracoscopic. I think the most important take home message here is the left a pen in its anatomy is highly variable. I've described it as the uh cardiac fingerprint. I've never seen two the same and it has multiple, sometimes has multiple lobes. And if you don't get all those lobes, you're not gonna be able to affect. And so like there's one right there just pop, right, not gonna be able to affect um uh an appropriate ligation. Uh So similarly, then what we'll do is once the appendage is within the clip, we'll grasp it with a soft tip grasper to make sure that we've got the entire appendage pulled up all the way down to the base and then deploy the device. And that gives us a very effective ligation of the appendage. And this is uh um just some data from an animal model and from humans at 90 days that shows the endothelial remodeling um of this device. And as you can see it's extremely effective at um eliminating any potential leaks or gaps that could be um uh thrombogenic um when applied correctly. Now, let's talk a little bit about the endocardial libation as part of this hybrid ablation. So this is a uh cardo uh voltage map of the poster wall of the left atrium. And what this shows is this, these red areas here are basically areas of no electrical conduction. So what this shows is um after someone's had this ablation, um this has been very effective at uh eliminating um electric flow except for right here. These green and blue areas here are actually uh and uh show an incomplete line of ablation, a superior that superior connecting line that um that um is a failure of um complete coaster le wall um ablation. So what our E PC lakes can do then with their um fancy GPS driven catheters is actually these little uh what I call red tennis balls are areas of ablation that have successfully closed that gap and comp shown and led to complete electrical isolation. Um the posterior left a trail wall and this is actually uh showing us where they've put a um my this line as well. So uh uh graphically what this looks like. So this is basically an artist rendition of the poster left control wall. Now, what we have is these pulmonary vein isolation uh lesions as the basis of our ablation, a superior inferior connecting line that gives us complete post your left, a trail wall um isolation uh aligning to the left a appendage, a clip applied on the appendage, which not only is competent, mechanically but also electrically and um performs basically our electrical isolation or left take app. And then these little red tennis balls that show us areas where the electrophysiologists have come in and uh uh perhaps close the gap in the superior line here. And this is uh a lesion set to the micro valve, uh annuus um that they've created as well. And similarly, we can create right sided um uh atrial lines if desired as well. Um In a meeting that I was in with Doctor Cox in 2016 for the first time, I actually heard the words out of his mouth that he described this as complete may lesion set. I thought it was so important. I wrote it down and I actually, it's the first time I think I made that slide. Um subsequently, the good Doctor Cox published that paper that I showed you earlier in 2019. And this is the conclusion from the abstract and it says that it is possible to create the complete lesion pattern of a maze or procedure with a staged thoro cop and catheter hybrid procedure. The success of this hybrid maze procedure in patients with longstanding pre atrial fibrillation should be the same as that obtained with an open surgical maze. Four procedure, strong words coming from Doctor Cox. So one of the other things that I think is really important about success rates for ablation procedures. Any ablation procedure is how closely we look so monitoring for success. Um It is an important thing and there are a couple of caveats. I'd like to go over the first is that uh heart rhythm is a side definition of failure. So what that definition says, it, it's pretty strict. Is that any recurrent atrial fibrillation for more than 30 seconds after a 90 day healing or blanking period um is technically a failure of an ablation procedure. So if you don't look, you won't find it. And with every in incremental length of monitoring, efficacy can go down to these procedures. And obviously, there's a, a great variety of ways that we can monitor for atrial fibrillation. Um You know, in the old days, Doctor Cox uh admits that the way they followed patients is with phone call, they had a nurse in the office, call a patient. They said, are you in a fib? They said, nope, I'm fine doc. And so they said, you know, you're fixed, we've done um EKG monitoring. We've done hater monitoring. There are now long term event monitors that can be um uh worn by patients. And our favorite um mode of monitoring is actually an implantable uh internal loop recorder. Um Because as we've talked before in a year of follow-up, which would you rather miss which is most important or uh to patients. A couple of 32nd episodes of a fib that define a failure. Yet, you know, the rest of the year was free of a fib with a continuous monitor or you miss a couple of 30 day episodes of atrial fibrillation with a 24 hour halter obtained every 3 to 6 months. That looks ok. Currently, the HR S guidelines, a ablation procedure say that a 24 hour halter is all that's recommended. And uh our thoughts have been that these guidelines may need to be modified to fit the available technology that exists to allow us to more accurately and closely monitor our patients to be sure we're doing uh treating them safely. So this is an old slide but I think it gives you the sense for comparing results and monitoring strategies in pa uh patients that were described after a cox maze four operation and after the thoro hybrid ablation procedure uh about the same time frame, about the same number of patients. Um And what you can see is that the hyper delation results are at least as good as the maze results as doctor cox predicted with a uh at least uh as good if not better monitoring. So sometimes we can't do this procedure for patients. And um I uh I tell a lot of patients that there are several large groups of patients and then then go underserved um in the ability to offer them some sort of uh additional hybrid uh procedure for a fib um if patients who have have pul pulmonary function and can't tolerate single lung ventilation, they're not candidates for that thos cop strategy. Uh It's challenging in patients who are very obese, who have poor lefton tri function. And this is a bit of an older slide. So it, it used to say moderate M R that no longer exists because in those recent guidelines, the presence of moderate mitt is actually a class three indication. We now know that that's something that probably those patients shouldn't undergo um standalone uh at fibrillation, they should be considered for microvalve intervention as well. So um what we have is a second procedure that we can perform in some of these higher risk patient populations that is um a little bit less impactful to them and better tolerated. So this is um a, a an approach uh from the sub space requires basically a parac card window incision. And through that incision, we place this cannula which then gives us really very good visualization of the post to your left at your wallet. Um And then using a suction based bipolar radio frequency uh device, we can create very robust ablations across the uh uh poster left through the wall. This is uh another diagram of that. And basically what it shows is what we'll do is we'll create these um multiple areas of ablation. Basically creating uh uh what we tried to achieve before with the thoro procedure. And that is complete poster left atrial wall ablation that's um uh uh added to by the addition of our uh little red tennis balls with our um uh electro physiology colleagues. Now coming in to complete a bit more robust um ablation around pulmonary veins to create the pulmonary vein isolation. Then we have um uh the poster wall ablation and then they can create um micro lines as well. So there are pluses and minuses to this procedure. I think um among the advantages are this is lower impact to patients, it's a little bit better tolerated. Um It provides a very robust. The potential downsides are that the lesion sets, particularly the surgical lesion sets are less robust and that's probably led to results that are a bit inferior to the thos cop procedure, particularly in patients with um more uh complex forms of atrial fibrillation. Those patients with longstanding percy atrial fibrillation. Um Gaul plexi is a controversial term in uh uh in atrial fibrillation ablation. I'm not gonna get into that right now. And um the other limitation in the past has been the inability to manage electrical penn. Though a lot of surgeons including myself recently have moved to uh adding this Suby procedure with a left thoro copy procedure to ligate the electrical pen at the same time. So when you put all this together, then in sort of an integrated approach to symptomatic non Permal at formulation. If you have persistent a fib, there are a lot of options, you know, a lot of those patients get treated medically. Um um often they'll go for catheter ablation, one or multiple. And um if those treatments have failed or if there are patient characteristics that would suggest that they may fail, then um evaluating those patients as well as patients with long stay percy atrial fibrillation for candidacy for a thos cop hybrid ablation is reasonable. And if they're candidates, then that's one treatment strategy. What if they're not candidates? Well, if they have pulp perry function or pore cardiac function, we've just described this Peric cardios cop hybrid ablation with or without left Oren. That's another treatment option for us. Um If they have um other reasons why they wouldn't be candidates. So, for instance, in patients that I've seen who've had persistent later appendage clots despite changing and a coagulation strategies um were required reoperation or by a patient's choice. Um We've performed basically am invasive uh mini thoracotomy cryo cuts may four. Um And so the that's kind of the um uh approach with all these different errors in our quiver for managing symptomatic non parasal a fit. So, for the last few minutes, what I'd like to do is talk a bit about a couple of other kind of complex arrhythmias um that are have emerging hybrid um uh applications. So, inappropriate sinus tachycardia is a prevalent and debilitating condition resulting in a baseline elevation of heart rate with often sudden and profound episodes of inappropriate sinus tachycardia. This can lead to common symptoms including fatigue, dizziness, pre syncopy, and even Frank syncopy. It's diagnosed commonly in young healthy women and interestingly, um as many as half of those uh are health care workers. It's often misdiagnosed as panic attacks or mental or emotional disorders and the symptoms um can result in significant loss of quality of life. I tell people that these patients often cry twice in my office. The first time they do is when they come in and they tell me how crumby their lives are. Uh And the second time is when they're back with a successful ablation. So the abnormality is mapped to the crystal terminalis low in the sinoatrial node complex, which is an epicardial structure. So attempts to map and ablate. Um This focus endocardial have been associated with poor results, often a high failure rate and often complications included including Freni nerve palsy because the fre nerve sits right next to the upper cordial surface uh where the crystal term mouse often lies as well as uh injury to the sinus node complex which can require permanent pacing. So now you have these young women with front nerve palsy or permanent pacing requirements for the rest of their lives. So what's happened is a group in Belgium has developed a hybrid epicardial and endocardial mapping and ablation strategy with excellent success and extremely low complication rates. This is performed through right cos very similar to the technique I showed you for a uh and at the same time in a hybrid lab, um they get um simultaneous endocardial mapping of the S A node complex with chemical induction of inappropriate sinus tech cardia usually with isopro. So then we can not only mark where the S A node complex is, that's our no go zone as well as the crystal term. Now, which is our target for ablation, we then perform an epicardial ablation uh as we showed before with pulmonary vein isolation, as well as um uh ablation of the crystal terminals and repeat endocardial mapping with attempts to reinduce I S T to give us our best chance of making sure that this is a one and done procedure. And if we need to go back and read until we're confident of success and our, our experience with this in a limited setting has been extremely positive. And in fact, we hope to begin enrolling in a international clinical trial um looking at um safety and effectiveness of this sort of procedure in the near future. In addition, we've had experience with hybrid emulation for ventricular tachycardia. Now V T is often mapped to single and occasionally multiple sites um in uh both ventricles. Um Those uh sites are usually in a cardio and often associated with prior score or other uh infiltrative um uh pathologies endocardial ablation has been actually really pretty effective um in treating that al although it often requires pretty extensive um uh uh ablation. Now, occasionally the uh the site is up cardio and in that case, it can often avoid even extensive um endocardial ablation procedures. So what we've done is use some of these similar technologies. For instance, this is a common one that we've used. We've used that sub Zoid approach that we talked about for a fib um and created simultaneous endocar epi cardial mas um looking for this V T focus. And then using some of the ablation strides that used, we've often used this section based bipolar R F uh device to create um uh ablation of that focus and then remapping to assure that we've been successful. So that's really um the gist of what I wanted to talk about. Um I hope that helps as far as uh helping to identify the surgical role of uh a care of these complex arrhythmia patients. And I'd be happy to answer any questions. Hi, doctor. Um First of all, I do know that some people are asking if this uh webinar was going to be available. Um I will let everybody know we will put this on our position resources dot back to self dot net. So it will be available there and then we'll make sure it gets sent out via email as well. So um doctor Hoff a couple of questions that I I've seen is, uh, one, um, what's the usual post, of course and care for, uh, Thor, uh, Thoro ab procedure, um, that you described in your talk? Ok. So, um, usually, uh, we send most of those patients to our IC U overnight. It's not that they're sick but they're sore. And that way they've got, um, a good, uh, careful nursing care because these patients have a combination of ploy that we've given them when we inflated and deflated their lungs, as well as pericarditis from opening their pericordium on both sides. Um uh Typically, uh a regimen of uh non steroidal anti inflammatories tends to be very effective. In fact, our eras protocol for cardiac surgery works extremely well for these patients. So we watch them overnight in the IC U. Um They have a chest tube in bilaterally to um be sure that they have full um expansion of lungs by the, they're excavated on the table. And um and by the first post op morning, we remove their lines and tubes and they're feeling much better and they go to the floor and usually they'll spend another day or more often two in the hospital. And that's usually about reinitiating their antiarrhythmic therapy and their anti coagulation. And so patients will go wait a minute doc, I just went through this procedure for a why do I have to be back on my medicines and keep in mind that's about um the what um uh interrupts those abnormal electrical pathways. It's not the injury that we create. It's the scar that they develop. And that's why the HR S has this 90 day healing or blanking period. And so in order to make sure that they don't have recurrent arrhythmic, we put them back on their antiarrhythmics and to protect them from uh uh thrombolic events, even though they have a ligated dependence, we generally put them back on their anti. So they stay on those for that 90 day blanking period and then we'll start monitoring them. And um, you know, if after that 90 day blinding period, they remain in sinus rhythm. Uh And um we start throwing away medicines, we start with uh anti ays, we usually leave them on their anti coagulant just in, since they've had, you know, transmit ab just to be on the safe side. Um to be sure that they don't have arrhythmic, that's unmask as their antiarrhythmics wash out and once their anti RMS have washed out, if they maintain the sign's rhythm and they have a ligated dependence, we can believe they can safely be alpa coagulation. So it's usually a uh a pattern over the next uh you know, several months they get off those drugs. We tell most people, you know, lay low for a few days a week or so until you're feeling better and then they're really back to normal activities without restriction. Thank you. Um We have a question here. And, and you'll have to excuse me if I do not get this completely right. Um It says it says, is a patient with severe, is it M I T incompetence a contra indication or is it mix incompetence a contra indication? You know, um I don't know if that has to do with the uh micro valving competence or if that might, I'm, I'm, I'm assuming that might be. Yeah. So as we talked about, there's data in the literature to suggest that with reverse remodeling, if you can maintain sinus rhythm in patients who have had a fib that um associated um problems like micro regurgitation from angular dili actually can improve. Uh However, what we've seen is if, if you have more than mild mit regurgitation, um it's not gonna improve enough. And so that's why uh patients, for instance, with moderate micro where we might have treated them years ago for a F alone, we now know um those patients probably need to be watched. Um uh And ultimately, uh end up with an intervention both for their MIT valve as well as for their A fib if they have severe M R, um they're gonna be candidates for microvalve surgery. Um The next question I think it might be a follow-up is, can you redo this after the first attempt? Yeah, usually it's one and done. Usually what happens with these patients is they'll develop pericardial adhesions such that we probably can't fully access the pericardial space that is repeating their epicardial surgery, um is um generally not possible. Now, it's usually not necessary. As I said, the devices for the surgical epicardial ablation are very robust. It has we have seen patients in whom they'll uh get both a epicardial surgical procedure and an endocardial Cathy procedure and come back with recurrent a fib, this was common actually in our experience when we first started doing this, when we did it as a uh combined procedure, you know, same day in the hybrid O R. And what I think was happening was um uh our E P doctors were fooled because they said, oh, look, these surgical lines of ablation are pretty good. And I think what they were seeing was edema rather than true transmural injury. And um so I don't think that they were, had the opportunity to create a, as robust ablation as they needed. And so when we separated those procedures, let the surgery heal and then came back, we got a much more accurate picture of what needed to happen, endocardial and the results were better. But we certainly have had patients in whom uh their catheter procedure say or even surgery procedure. Um uh reconnected, that's the uh common E P term that's used. Um whether it's uh a gate opens somewhere or a couple of fence posts don't heal quite right. Um And we've had a few patients in whom a second catheter procedure has been able to identify those defects in the lines and fix them. And so it is possible to redo the catheter ablation but not usually the surgery. Ok. Uh The next question is, uh what is the success rate? Um, in 12, 24 36 months? Yeah. So, uh a there's emerging data that, um you know, uh is giving us longer term results now that we're having more and more experience with this most studies in uh E P literature, look at really, you know, uh one year follow up. Um there's now emergency uh emerging data in the surgical literature, about longer term, five year, seven year follow up. And a lot of this depends on the burden and to be sure that they have burden specific uh lesions. But um these surgical or hybrid ablation procedures for per fibrillation like say have success rates similar to catheter based procedures in the upwards of 90% success um for um non paroxysmal life. That has to do I tell patients with some of the, you know, either good or bad patient characteristics. So what would lead to less robust outcomes? Well, we typically will see that in patients who have extremely large left atrium, um uh the bigger the atrium, the more extensive the uh ablations are the more substrate there is for reentry. Um uh We can see this um we often will see higher failure rates in patients who had a longer duration of atrial fibrillation. So, you know, uh, if someone has persistent atrial fibrillation or long staying persistent atrial fibrillation of only, you know, a year or two, uh, with a left atrial uh, size, that's, um, you know, less than 4.5 or five centimeters of volume index of under 30 or 35 I'll often quote them upwards of 80 to 90% success if they have been in a, for 15 years and have a left atrium of 5.5 centimeters. Um, you know, I'll sometimes quote them success rate as low as maybe 60% beyond 5.5 to 6 centimeters. We generally don't offer this procedure because the let a room is so deranged that we just don't think the success rate is worth it. Ok, thank you. Um, I think I have one more question here. Um, as patients are living longer to like their mid nineties is age itself, the contra education for this minimally invasive surgery procedure through the, through the scope. Yeah, that's a great question. Um, you know, 80 is the new 60. And so, uh, um, uh, you know, I don't, uh, I, I think, uh, the physiologic age of the patient is probably more important than the chronic chronologic age. Um, I've done this in eight year olds but I've not done it in 90 year olds yet. Um, uh, though I think that really has more to do with symptoms, um, the likelihood of success and impact of the procedure. And so as we've talked about, you know, we have lots of arrows in our quiver. And so I think this is where individualizing care is a really important thing. And I don't know that a self for me, um, obviates uh appropriate surgical therapy, whether it's for a fib or coronary disease or anything else. I think it's really about, um, you know, the likelihood of success and the um uh negative impacts on patients. So, uh um I think, you know, we're, we're always um uh you know, pushing the envelope as it's appropriate um to provide the best care for our patients. OK. I think we have time for at least uh one more. Um Tell me more about um the multidisciplinary a of a arrhythmia clinic that you were discussing in your presentation. Yeah. So, um this is something that we've had experience with for many years. Um There are a few places in the country that uh other places in the country that do this as well. Um It's been um a really gratifying experience for us. Um What we do is um uh have a uh multidisciplinary clinic for, you know, initially for a fib but ultimately for other arhythmical. And for us, it's created um a lot of really important advantages. The first is actually interaction among the surgeons and the electro physiologists. Um uh You know, when we first started doing this, this was about kind of being able to speak to each other, right? Uh be learning the lingo understanding um the options that we all have and knowing what arrows we had in our quiver. What uh the um what were the strengths and weaknesses of the electro physiology procedures and the strengths and weaknesses of surgical procedures? Um It also uh provided sort of a one stop shop for patients was very convenient. So we used to say that patients would come in with a diagnosis and leave with the plan. Um And if that diagnosis was a fib, they may leave the plan that includes medical therapy or could it involve catheter therapy or surgical therapy or hybrid therapy? Um And so, um it a across the board, we felt like it was a really good experience for not only the practitioners but also the patients. And so, um that's something that we're uh getting ready to roll out here at Baptist. We're very excited about that a possibility. Um And um excited to, you know, see um what that uh allows us to do as far as helping to manage these complex patients. One of the things that we learned about this before and I think will be an important thing in rolling it out here is the realization that we're here to help a very small portion of that patient's overall medical care, right? We're talking about providing expertise for a uh often a very complex um uh diagnosis, but we're taking over the care of that patient. And so the idea here is to have those patients come with these, um, arrhythmias, um, to, uh, uh, help get state of the art guideline directed therapy and then get them back to their doctors and get them back to their, um, their locations. And, um, uh, and then we move on. So this is entirely about really creating, um, a consult, a consulting service for high end, um, isolated, um, uh, problems. I'm actually gonna ask one more because I'm seeing a conversation kind of be being chatted and I think I, I, I know we've been starting to do some of this at Baptist as well. Um, a couple were asking, you know, if this would be something that they could watch in person, um, being surgeons themselves and they think it's pretty fascinating. So, is that something, um, I think that we're trying to do it? Yeah. Sure. So, you know, this is a sort of, uh, so I have, um, you know, by means of disclosure, um, been a consultant and a peer trainer for the primary, um, manufacturer of these surgical devices for many, many years. And, uh, and, you know, we, we've commonly had, uh, people come observe, um, cases, um, uh, and answer questions, that sort of thing. And so whether we do that now with the ability to, you know, do some of these training and, um, uh, type of, um, uh, events virtually or whether we do can do that live. We've certainly, um, you know, been happy to, you know, try to, um, try to share that with people and, and help as far as that goes. So, uh, yeah, uh, I would think that that would be the sort of thing that, uh, we could help with. Yes. And for those that were coming to chat, I have captured your name. So I will make sure we have your email and um I will try and see if we can get you some more information on that as well. So I think that is the end of our uh webinar today. Thank you so much, Doctor Hoff. This was really, really great and um I do look forward to possibly one day doing another one of these with you. Um Thank you to our audience for being there. Thank you all so much for attending. That is.
