Marc Gillinov: Why Don’t You Treat? Debunking Cox Maze IV Myths

Video Categories: Why Treat, Lesion Set
3 YouTube Views - Published July 30, 2020
Featured Speaker: Dr. Marc Gillinov




Video Overview

Dr. Marc Gillinov reviews and counters the often used reasons for undertreatment of A-Fib.


Video Transcript

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

Dr. Marc Gillinov:  This said to a survey to at the AATS where they asked all the participants, why do you ignore a-fib? What's the deal with that? These were the four reasons. They said there's safety concerns; they're unsure if it worked, of the advantages; they thought there's a lack of consensus, the societies, their statements, their papers don't tell us what to do; then some said I'm uncomfortable with it. I grew up when the Cox Maze III was all there was, this gigantic cut-and-sew operation and that was enough to make me just stop right there. If you look at each one of these, you find that there are definitely today answers about treating a-fib or not treating a-fib. 

First, the safety concerns. A-fib surgery is safe. There are a whole bunch of papers that say it's safe no matter what you're doing. The addition of a Cox Maze procedure did not increase morbidity or mortality. What about if I'm doing CABG or aortic valve replacement different study? Is it only true that it's safe in one center versus another? The answer was no, it's safe everywhere. It was safe in this study as well, meaning no increased risk of adding an ablation. Adding the Maze procedure did not hurt the patient. 

Ralph Damiano recently looked at the same thing with mitral patients. He's got another paper coming out that shows this. Adding a Cox Maze procedure did not increase the procedural risk. It is definitely safe. This was the largest study from my friend, Vinny Badhwar. He looked at the entire US and said, what is the risk of adding surgical ablation? He found across the US – this is STS database stuff – that performing the ablation was accompanied by improved risk, by a reduction in mortality and stroke. This is the first study, the largest, so maybe he needed these numbers to show this. This is the first study to show that adding an ablation actually improved patient safety. That was 87,000 patients 

Where did that leave the guidelines in terms of safety? The STS guidelines said adding AF surgery did not increase morbidity or mortality and the AATS, not to be left behind and even to outdo it, said adding ablation did not increase morbidity and actually improved mortality based on that STS database study. 

Other surgeons argued alright, maybe it's safe but are there advantages? I mean, why bother? I'm here for the CABG. I'm here for the AVR or mitral valve. What – just let them live with a-fib. Plenty of people have a-fib. Well, if we restore sinus rhythm, there are advantages There are definitely advantages. I mean, the first advantage to doing the procedure is just that; you restore sinus rhythm. If you treat the a-fib, they're more likely long-term to have sinus rhythm, which is better. 

It also improves quality of life. Couple studies showed this. This one study just showed in the red rectangle that people who had a successful ablation were more likely to have a good quality of life. From the same study, left atrial ablation, so not a complete Cox Maze IV, good quality of life more common in those who had a left atrial ablation than those who did not. 

This is one interesting study, but it's been borne out elsewhere. In mitral patients – this is mitral patients. In mitral patients, treating the a-fib reduces the percent of patients who wind up with late tricuspid regurgitation It's good for the right atrium; it's good for your tricuspid valve. The biggest thing to me is freedom from long-term stoke, treating the appendage, treating the ablation, restoring sinus rhythm. You have a greater freedom from stroke if you're' treated successfully 

This is yet another study that showed that, and this all translates as well as we can estimate into improved long-term survival if we get a successful ablation, get the patient into sinus rhythm. Now admittedly, there is no randomized controlled study showing improved survival, but we've got a ton of data showing excellent safety, better restoration of sinus rhythm, greater freedom from stroke and other thrombobolic event, higher quality of life, less tricuspid regurgitation, and it just makes sense that people who have sinus rhythm and are free from all these events live longer.  

I think this is from Pat McCarthy and Rick Levy. This is the best controlled study. It's a retrospective site for propensity matched really well with controlled to an extent we can showing that people with treated a-fib, successfully treated a-fib, have survival that is as good as if they never had a-fib.  

This study from Ralph Damiano shows the same thing. Successful, emphasis on successful, Cox Maze IV leads to better long-term survival. This led to the guidelines saying surgery for a-fib improves quality of life, decreases stroke, decreases long-time stroke and TIA, and the AATS didn't want to go so far as to say anything about survival, but the STS did, improved survival. 

Now the societies actually now do agree, which makes sense that the AATS and the STS should agree since it's all the same people anyway. This consensus statement from ISMICS, which is a very good paper, pretty quick read, basically says here are the reasons for concomitant surgical ablations. Here's why you do it. Then here's a broader consensus statement on surgical treatment of a-fib in concomitant procedures, which has been endorsed, basically, by everyone. Therefore, the STS guidelines say concomitant of surgery recommended, recommended, recommended, and doesn't hurt operative mortality at all, doesn't hurt operative morbidity. AATS, same kind of thing, recommended. Do you ablation. If you've got somebody who's coming into the operating room with a-fib, do an ablation. It improves operative mortality, doesn't affect morbidity, decreases peri-operative stroke, improves quality of life, decreases long-term risk, so just do it. the European societies, same thing; if you come to the OR and you've got a-fib, you should get an ablation. To put that the other way, we should do an ablation. 

Still, there are some surgeons who are uncomfortable with it, just don't want to do it. that gets to the idea that successful surgery's important. The difference between successful and unsuccessful a-fib surgery is for the patient a difference from freedom from stroke, for the patient, a difference in freedom from death, difference in survival, but for the surgeon, the difference between success and failure is often just really paying attention, staying away from that atrial pacemaker complex, making sure you get a complete lesion or every lesion and particular for the lesions that go to the annulus, mitral and tricuspid. It's not that you've got to be the next Stanton Cooley to get this right. Just like anything else we do, you got to know how to do it and then execute appropriately. 

This gets to the idea of training. No one just goes out and does a new operation without ever seeing one or being proctored on one. Just make sure that you know how to do it because we are all 100% capable of doing this right. If you can do a LIMA to LAD, which we all can, LIMA to LAD is way harder than this operation. It's microsurgery, and there's a lot riding on it. This is far easier. 

The summary of this is in 2020, there's got to be a good reason not to do an ablation in someone having concomitant surgery because it really is the center of fair. Now what would be a good reason not to do an ablation? Well, if you're doing a third-time redo triple valve in an 85 year old with a low EF, I mean, first you have to ask why am I doing this operation? Can I actually get the patient to survive? Maybe you say in that person, if I can, I'll treat the appendage but 20 minutes in that person might actually make a difference. Duration of a-fib isn't a reason. If you've got someone who's been in a-fib for 15 years, don't say it's never going to work. It very well might work. Fifteen years of a-fib, maybe you've got a 50, 60% chance of getting rid of a-fib, getting that person off Coumadin or Delac, so it's definitely worth doing it almost always.