Drs. Eric Okum and Kathryn O’Keefe of TriHeatlh, Cincy, and Dr. Jonathan Philpott, Sentara Heart, discuss AF patients that may be overlooked by surgeons. They also discuss considerations for patients they may not typically treat and why.
For the hearing impaired members of the AFibSurgeons.org community, we have provided a written transcript below:
Eric Okum: The 80-year-old with a very large atrium and a longstanding persistent afib are the few patients that we don’t do. I think the patients that get left out of this more than anything else are the people that are newly paroxysmal or have just a remote history of afib. I think if you look at our data carefully, those are the patients that get left out the most. Those are the patients that are actually the easiest to cure, frankly. I don’t know if you would agree with that, Dr. Philpott, but those seem like to me those are the patients that get left out.
Jonathan Philpott: Laura and I were just laughing because we just went through some of the data today on the ones that coded in positive. We didn’t do them because they had exactly what you’re talking about, the one single bout of atrial fibrillation three years ago while they had another event, an asthmatic attack or whatever. They never had an atrial fibrillation since or the one who had one brief run and that was three years ago and never had another bit of it. Then you do a mitral and you talk yourself out of the Maze procedure because it was just this one self-terminating event. Then the entire postoperative period she’s in atrial fibrillation and either running fast or running slow, and they’re having discussions about the pacemaker.
The entire time you’re thinking why didn’t I just do the Maze procedure while I was in there? It does make it very hard because you would like to have them lead into that definition. Those people, particularly the ones that have that single episode prior that’s very brief and self-terminates and never had another event are kind of hard to codify.
I wouldn’t say that we stay away from people that have been in it for a long duration. We tend to be pretty aggressive about that. Their success rates are not as good, but they’re still very good. One element that does scare us off is a large left atrium. If it’s 6.5 to 7, we’ll probably think long and hard about not doing a Maze procedure.
Eric Okum: The other situation where I think we struggle with whether to do a Maze or not, and actually in my last patient on this, his afib was really bothersome to him. When I say bothersome, he was very symptomatic in afib, even paroxysmal. He was a redo CABG with an intact IMA. I think those cases people shy away from, but there’s other options that you can do in terms of doing a box lesion in terms of opening the left atrium and doing an intracardiac cryo Maze.
I took the time to dissect out mammary and its full course and get around the left side of pulmonary. Yes, it’s hard. Yes, it added an hour. In him I thought it was worth it. There are other options.
I think those are people that we tend to shy away from the redos with the intact mammaries and the patients that Dr. Zias was describing, the longstanding persistent with the giant left atrium. Besides that, we tend to treat everyone. Katy, would you agree with that?
Kathryn O'Keefe: I would agree. I have two comments on that. One patient population I struggle a bit with is the patient we get in and there’s adhesions that were unexpected. I’m going to be doing a Maze on them. If I can get to the left atrium and open it, in that case I think it’s worthwhile. I may not go around the veins or go around the back side of the heart if there’s a lot of adhesions. My other question was for Dr. Philpott and Dr. Zias. Do you think there’s any benefit in a patient that has longstanding or persistent afib in reducing their afib burden, even if you can’t get them back into sinus rhythm by doing a Maze procedure at the time of their surgery?
Jonathan Philpott: I can probably take that first. I think that sounds really good, but at least in our practice it hasn’t born fruit. It seems that when they fail, they fail. It’s not so much a burden as much as they’re in afib. That’s what we saw in the studies as well.
Having said that, probably a key point out of this Webex, what I hope everybody learns, is that if they fail, don’t shut the book. Call your electrophysiologist. Get them remapped and re-ablated. A lot of times they can take an initial failed Maze or even a late failed Maze and tune it up. Now all of a sudden it’s a success.
Eric Okum: I couldn’t emphasize that anymore. This has been a process for us. It’s been very difficult to get the EPs to take back most Maze patients. What they usually find, and I can think of the last one they did for me, what the EP told me is that a Maze that I did on someone six years ago recurred this year. From an EP standpoint you would have to spend a lot of time mapping and figure out exactly where the break is because it’s a box.
It’s not convergent when you’re covering the whole entire back wall. It was three burns, and the guy was back in sinus rhythm. Without doing that, it would not have been possible. I think it’s really important to involve your EPs in this and really push to have them take them back to the lab to do a touch up ablation if you have any failures, especially late failures.
Jonathan Philpott: I’ve got one for Dr. O’Keefe. What would you say for the fellows that are training currently? What advice would you give them knowing what you know now so maybe they can get a little ahead of the curve and be better prepared when they graduate?
Kathryn O'Keefe: I think that’s a great question. First of all, I would encourage every fellow to go to one of the AtriCure Maze courses that are available and to get as much experience double scrub, triple scrub, stand on the table for any time that a Maze procedure is being done at your institution, even if you’re not going to be the primary operator to be able to get as much exposure and comfort with the anatomy. At the end of the day there may not be that many cases that are done where you’re going to be confident and comfortable.
Dr. Zias: Can I ask you a question, Dr. O’Keefe? Do you think that if we make atrial fibrillation treatment a quality measure just like the IMA, in other words if the STS or other societies measure how we treat these patients, do you think that it would be the adoption of treating atrial fibrillation would be increased?
Kathryn O'Keefe: I think it would be. I think if there’s that expectation as a society that we treat patients with afib, I think you’ll see more adaptation of it. I think the other thing that’s important is that we have the same language and we standardize what we’re doing as surgeons. What one of us calls a Maze may not be a Maze to someone else. Standardizing that lesion set is really important. That was really critical and key in our group so that our cardiologists know that whatever surgeon is operating on that patient, they’re going to get the full lesion set and hopefully the same quality.
Eric Okum: I think that’s very important to emphasize that is standardization of lesion sets so that a Maze is a Maze. We all know that a Maze is not necessarily a Maze in everyone else’s eyes. In our group, no one, no matter how little afib they get, just gets a PVI and a clip. We all feel that’s substandard. At least everyone who gets a left-sided box lesion with pulmonary veins and a left atrial appendage line as well as a right-sided lesion, in all cases, even for paroxysmal or new onset atrial fibrillation, the patients that come in with an acute coronary symptom or non STEMI and have an episode of atrial fibrillation not previously diagnosed, they will even get a full left-sided Maze and right-sided lesions as well.
I think it’s really important to standardize lesion sets because without doing that, it’s a perpetual cycle that if you don’t do it in operation, you’re not going to have good results. You’re not going to have good results, the cardiologists don’t think it works. Then it’s a downward spiral.
In our program it is very important that lesion sets are standard, and we all think that the more you ablate, the more lesions you do, the better results you get. We do have a set protocol for this specifically and specifically for this reason. We look at our Maze patients more like our aneurysm patients that need longer-term follow up and not just a regular coronary bypass patient where we turn over everything to the cardiologist for medical management after a month or six weeks or so. Our current protocol is that the patients are seen in a normal postoperative visit that occur at seven to ten days postoperatively, then an additional three weeks after that.
At three months post procedure we use a two-week monitoring patch. Our particular preference is using the Zio patch because we think it’s easy. There are plenty of things on the market to use. Patients then wear that for 10 to 14 days. It gets read by our EP cardiologists.
Then they get seen back in our office at four months post procedure. Then we have a conversation with them, what we call a shared decision conversation with them about anticoagulation. They also get an EP referral, even if they have a primary cardiologist that’s not an EP. Then we repeat the Zio patch in one year. Depending upon the results, we’ll send them back for additional cardioversions, additional ablations, medical therapy, and do have EPs involved within three months of their Maze procedure.
Dr. Zias: I agree, for following these patients for more than 30 days. I think collaboration with your EPs is the key to success. I think that if you just follow these patients for just a month or a few months, it’s probably not good enough because as we know many of these patients would need additional treatments sometimes by EP. That’s really a great work. I think all programs should adopt this collaborative approach with EPs.
Kathryn O'Keefe: Dr. Philpott, I have a question for you. That was excellent, really phenomenal data. Where do you think your fallouts are coming in terms of the group that you’re treating? Are they the longstanding persistent patients? Is there any sense of who’s not being treated and how you could attack that group?
Jonathan Philpott: This is surgeon specific right now. We’ve got a couple of longer career surgeons who have never really liked the Maze, and they are hesitant to get on that bandwagon. We’ve got one of our most senior surgeons who was able to pick it up overnight and has some of the best results that we have.
The data is that there appears to be no significant increased risk with a Maze procedure, but that’s also with an experienced surgeon. I think a new surgeon coming out, we can tell them that the risks are the same, but in their own mind they don’t completely believe that, and I think they’re actually correct. Any time a young surgeon is going to grab any procedure, no matter what it is, there’s going to be a little bit of a learning curve.
What we’re trying to do is to mentor our young surgeons on how to get this done. Very much like what you went through, I think that is an enviable experience that you had and one that most groups need to really set up. They need to identify a couple of the people that are really good and have the young surgeons pair up with them until they’re comfortable with it.
The other way around it is let them do the case and have the senior surgeon come in and stand across the table from them and just give them pointers as they go through it so it flows smoothly. A lot of it has to do with the sequencing, how you set it up. Personally for me, once I got that sequencing really down and tailored for each case, I thought the procedures went a whole lot quicker and smoother and more efficient.
Eric Okum: Actually, I have two questions. I was very impressed with your surgeon data and the differences between surgeons. We have not looked at our data, but we tended to standardize from the outset. What is your way, specifically on the surgeon that had less efficacy, to bring him up or her up to the equivalent to the rest of the group? That’s question one. I’ll let you answer that.
Jonathan Philpott: The first thing is just to have the conversation. You don’t want it to be just one or two months. I’ve got to show a little bit of a trend there. If they continue to show the trend, that’s where you sit down with them and say if they don’t come to you first – most of them will come to you and say wait a minute.
Eric Okum: Another question I have for you is the means of your left atrial appendage clip. I assume respiratory believes, as I do, these things don’t move. When you have a bad appendage clip, it has nothing to do with the clip. It’s how it was placed. Do you check every one with a CT?
Jonathan Philpott: We do.
Eric Okum: The second is what is your criteria for adequate closer by CT scan at three months down the road?
Jonathan Philpott: The little bit of the troubling part about the TEE was it’s operator-dependent. The flash CT scans take that whole part of did it move or not completely off the table. We do that down the road where if there could have been any movement, it would have already occurred. It’s interesting to see the data on the clip. It’s fantastic. The CT scan protocol is specific for the appendage and not just with the clip. It’s also there for the watchman. Having that standardization in place really takes out the error that you may get from provider to provider with TEE.
Dr. Zias: Dr. Philpott, what is considered a failure of placing the clip, meaning do you have a specific way, meaning you have a pouch of less than a centimeter, that is considered a success? If it’s over a centimeter, it’s a failure.
Jonathan Philpott: We’ve gone by what the advanced imaging physicians are calling for that. It’s actually under that. If there’s any residual pouch at all, they’re calling that a failure. It’s sub one centimeter. When you see the scans, I have found it to be very powerful for the referring doctors. The clip tends to exclude the appendage very flush. It’s almost a smooth taper.
Whereas with staples, the failures that we’ve had when you look at them, they’re a bit concerning. You really want to get these people off drugs. There is data out there to suggest that leaving a pouch may be more dangerous than not doing anything at all to it. A picture says 1,000 words, so to speak.
Dr. Zias: Is there a very specific topic that anybody wants to review or talk about or any questions?
Eric Okum: I saw your last table that showed the bottom one about any atrial fibrillation, that they recommend the point system for left atrial appendage excludes the management. Is there anything that you do in terms of standardization of lesions sets, what most people define as a Maze, and success rates that you follow as well?
Dr. Zias: Yes. Essentially because it is very difficult, I think, to impose surgeons to do specific things for various reasons, initially what we thought we’d do is see what everybody will do, knowing what is the standard of care. What I can tell you is what we have seen is the majority of surgeons will do a box lesion for cases that do not require opening the left atrium. At the same time, I can tell you that we see cases that do not require opening the left atrium. The left atrium gets a full body atrial Maze, depending on how old is the patient, what are the symptoms, etc. I’m not 100% certain that every patient needs to get the same treatment.
We can discuss this. For example, if you have an 80-year-old patient who had atrial fibrillation for the last 30 years and a left atrial that is more than 6.5 centimeters, I am not sure that I would treat this patient with more than just a left atrial appendage exclusion with a left atrial appendage clip. I don’t think that in a patient such as this that they can get an extra 30 or 45 minutes to do a full Maze with anything. I would like to hear your views on that.
The question that I have for pretty much everybody, have you instituted specific guidelines to try to capture atrial fibrillation diagnosis in the patients that you see who will not necessarily come and tell you I have atrial fibrillation? For example, we have noticed that by putting smart phrases as part of the history and physical, you can’t complete the history and physical unless you ask the question do you have palpitations? Do you feel tired, sleepy, etc.? There’s a whole slew of questions. We have seen that we have captured patients that we never know that they have a history of afib if we do not ask these specific questions. Have you instituted programs to increase the chance of getting that diagnosis of atrial fibrillation so you can treat during surgery?
Kathryn O'Keefe: I can answer that for our program. Our APPs are really good about asking those kind of questions and digging through the charts. Obviously, we look at any EKGs. The other thing I started doing is looking at the stress test. Sometimes patients while they’re being stressed will have an episode of afib. That may have been their only episode. That will be enough for me to offer them a Maze procedure.