AATS Mini Theater: “Restoration of Clinical Pathway”

Video Categories: Surgical Ablation, Mitral Valve, AATS
4 YouTube Views - Published June 30, 2020
Featured Speaker: Dr. Armin Kiankhooy




Video Overview

Watch as Dr. Armin Kiankhooy presents on the long-term data relating to the safety and efficacy of surgical ablation in concomitant mitral valve surgery procedures. Occurrences of pre-op and post-op complications, various anatomic factors and pertinent comorbidities are among the considered factors as he shares his perspective on AF burden reduction and success.


Video Transcript

For the hearing impaired members of the AFibSurgeons.org community, we have provided a written transcript below: 

Armin Kiankoohy: Now we're going to jump into the safety and the efficacy of surgical ablation, especially in the concomitant maze procedure setting. Dr. Niv Ad has published a lot of papers on the Cox maze IV, but one thing that's been great is that he's really got into the safety of the procedure in different settings. I think that that really speaks to a lot of surgeons. Often, we're not treating afib in the isolated setting. Most of the time, we're taking patients to the operating room for another diagnosis, whether it's coronary valve disease.

The slides that are coming up are going to speak to is it safe to perform surgical ablation in that concomitant setting. Here's one slide that really tackles that issue when you're talking about mitral valve disease. Is the mitral valve concomitant maze a safe operation? What are the long-term outcomes? This is a paper that was published back in 2018. First and foremost what you can see is you really have restoration of normal sinus rhythm in 90% of folks at one year.

The Cox maze IV in this setting is effective, and it's safe. Less than 5% complication rate. You can see the numbers for yourself. Very low stroke risk, very low risk for reop for bleeding, low risk of dialysis, 2%. Then perioperative complications, pneumonia, UTI, things like that are really small. I think one thing that surgeons often talk about is will they increase clamp time lead to clear complications down the road or perioperative complications?

This is one of those studies, and Niv Ad even mentions in this study that yeah, he acknowledges that there's an increased clamp time even up to 60 minutes in some patients. That does not necessarily lead to complications. Quite the contrary, the patients tend to - sometimes tend to do better because these patients are normal sinus rhythm post-operative as opposed to afib.

Here's another study coming up through Niv Ad's group. This study, again, is looking at the mitral surgical patient population and the maze procedure. What's nice about this study is he really demonstrates AF burden over time. Looking at this table here on the left, what you can see is on the Y axis is percent AF burden. On the X axis is years of follow-up and so long follow-up, seven years.

What you can focus on is in the blue lines here. That's 100% normal sinus rhythm. That's an absolutely fantastic result. What's also a very good result is if you combine the gray, the white, the yellow, and the blue, these are folks who have very low AF burdens, so less than one hour of AF. That's significant restoration of normal sinus rhythm. The black is really just continuous AF. You're looking at less than 10% continuous AF. This is in the mitral valve surgical population with the maze procedure, really nice results. Patients are doing well.

Here's another study. This is Dr. Rankin out of his group, and Dr. Badhwar out of West Virginia. They're looking at the association between surgical ablation and mitral valve procedures. Again, the big take-home point of this study was they had four groups. Group one is no prior diagnosis of afib. Obviously, they did not undergo surgical ablation, 50,000 patients in the SDS database.

What's really compelling is when you compare those patients to this Group 4. These are patients who had a preoperative diagnosis of atrial fibrillation, underwent surgical ablation, 16,000 patients. What you actually saw is similar operative mortality, similar complications, similar permanent stroke risk. In other words, if you have a patient with afib, and you treat it with a surgical ablation, you're going to reestablish, basically, the same clinical trajectory of somebody who had no preoperative afib and did not undergo a surgical ablation. Again, really compelling data that treating somebody with afib can really restore a normal clinical pathway for them.