mitral repair/af ablation sternotomy approach · the bluhm cardiovascular institute northwestern...
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![Page 1: Mitral Repair/AF Ablation Sternotomy Approach · The Bluhm Cardiovascular Institute Northwestern Memorial Hospital Patrick M. McCarthy MD, FACC Executive Director of the Bluhm Cardiovascular](https://reader030.vdocuments.us/reader030/viewer/2022020304/5ba07fc209d3f2c2598cdbf1/html5/thumbnails/1.jpg)
The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Patrick M. McCarthy MD, FACCExecutive Director of the Bluhm Cardiovascular Institute
Chief of Cardiac Surgery DivisionHeller-Sacks Professor of Surgery in the Feinberg School of Medicine
November 17, 2017Session IV: Concomitant Ablation—How I Do it and Why
Nobu Eden Roc HotelMiami Beach, Florida
Mitral Repair/AF AblationSternotomy Approach
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Disclosures
• None
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MVR/AF AblationIssues to Consider
• MV: TV/RA Involvement; Reop; Mechanical?• AF: Type; Duration; Stroke Hx; Symptoms• Decision: Technology and Lesion Set
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What Technology and Lesion Set?
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
• Pulmonary Vein “Box” Lesion• MV Annulus to Box Lesion• SVC-IVC• TV Annulus flutter
lines X2• Excision of LAA
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
What I Don’t Like about Bi Polar Clamps
• Multiple applications (7-10)• Awkward (Left atrium); esp w small incision• “Thin” tissue next to “thick” tissue; e.g. svc• Need a second device (cost and footprint)
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Last 3 Years Almost Exclusively Cryo
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Repair; LA Maze; Atriclip
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Reoperations: MV Annulus Lesion
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Tips/Pitfalls of Cryo
• Mind the Gapunfold the tissuepush from outside
• 2 min freeze LA, 1 min RA and Epicardial CS • Release the retractor blade• Don’t “poke” anything (like your mv repair!)• Don’t freeze the coronaries
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Lesion Set: Left vs. Biatrial
Not PVI; Do the MV and CS
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cox Maze Procedure
• Pulmonary Vein “Box” Lesion• MV Annulus to Box Lesion• SVC-IVC• TV Annulus flutter
lines X2• Excision of LAA
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Ann Thorac Surg, 103(6):1858-65.
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Box Lesion Across LAAFreeze Endo and Epicardial to C.S.
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Propensity matched groups
0%
20%
40%
60%
80%
FFAF at last FU, p=0.10
LA BA
70% 89/127
79%98/124
0%
20%
40%
60%
80%
FFAF at last FU off AA, p=.09
LA BA
0%
5%
10%
15%
Pre-discharge PPM, p=0.57
LA BA 0
0.02
0.04
0.06
0.08
Annualized Stroke rate per 10 person/year, p=1.00
LA BA
69%82/119
79%86/109
0.080.0712%
17/14710%
14/147
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Patient Population and Late Outcomes Impact Success
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH: DMR ’04-’1597% of AF Treated
97% of Valves Repaired
Variable NAge 912 60.8± 12.7 Gender (female) 912 311 34%NYHA Class I / II 904 759 84%NYHA Class III / IV 904 145 16%Repeat Sternotomy 912 29 3%
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Operative Characteristics
VariableEntire Cohort
(N=892)Class I
(N=390)Class II(N=370)
Class III / IV(N=132)
P-value
Perfusion 89(74, 111) 84(71, 103) 92(77, 113) 96(73, 126) <.001Cross Clamp 74(62, 92) 72(60, 87) 78(66, 96) 75(62, 97) <.001Elective Surgery 875 (98%) 388 (99%) 363 (98%) 124 (94%) <.001CABG 133 (15%) 47 (12%) 58 (16%) 28 (21%) 0.033Aortic Valve 42 (5%) 15 (4%) 17 (5%) 10 (8%) 0.21Tricuspid Valve 99 (11%) 38 (10%) 34 (9%) 27 (20%) 0.001AF Ablation 217 (24%) 76 (19%) 100 (27%) 41 (31%) 0.008Mitral Surgery <.001. Repair 865 (97%) 382 (98%) 363 (98%) 120 (91%). Replacement 27 (3%) 8 (2%) 7 (2%) 12 (9%)MV Leaflet 0.20. Anterior 49 (6%) 20 (5%) 22 (6%) 7 (6%). Posterior 659 (79%) 306 (83%) 268 (77%) 85 (77%). Bileaflet 121 (15%) 42 (11%) 60 (17%) 19 (17%)
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH ‘04-’15Freedom from MV
Reoperation for DMRFreedom from MR 3+
(No 4+ MR)
Year1 Year2 Year4 Year6 Year8 Year10 Follow-up(Years)
MV Repair 99.8% 99.4% 98.3% 97.3% 96.5% 96.5% 3.4±2.8
MV Replacement
100% 100% 100% 100% 100% 100% 3.7±3.1
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Pacemaker Thoughts(Not Party Line)
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
NMH Incidence of PPM by AF Lesion Type
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Pacemaker
• Retractor on SA Node• SA Node Artery Divided• SSS Occurs without AF Surgery
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV/Maze Opinions
• Cryo is Easier; Faster; Cheaper; More Flexible than RF
• Early in The Course of The Mitral Disease Little RA Involvement: LA Only
• Always Do LA and Isthmus Lesions• Pacemakers are from SA Node Trauma, not
SSS, not from the Maze
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Freedom from MV Reoperation for DMRNMH ‘04-’15; Single Surgeon
Year1 Year2 Year4 Year6 Year8 Year10
99.6% 99.6% 99.6% 99.6% 99.6% 99.6%
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Freedom from MR 3+ (No 4+ MR)by MV Surgery Type
Year1 Year2 Year4 Year6 Year8 Year10 Follow-up(Years)
MV Repair 99.8% 99.4% 98.3% 97.3% 96.5% 96.5% 3.4±2.8
MV Replacement
100% 100% 100% 100% 100% 100% 3.7±3.1
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
• Need new HRS quotes• 10 minutes of video• 5 min discussion
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
MV Annulus Lesion
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Key points
• Have to do mitral ring or replace before mitral annular line
• Cut SA node; retractor on SA node; we see SSS in non-Maze surgery
• I don’t use a separate LAA line. Excision or cryo goes to LAA
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Why LA onlybring slides from the 900+ DMR
• 84% FC I or II• Only % had mod or more TR• Combined free from 3-4+ MR and free from
reop….so no recurrence leading to late AF• 97% of AF is treated (some maybe others
wouldn’t because too advanced, others only 1 or 2 episodes
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Valve Inspection24 seconds
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Valve Measurements21 seconds
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Mitral Repair4 minutes
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
Cryoablation: Not Just for Reops Anymore
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
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The Bluhm Cardiovascular InstituteNorthwestern Memorial Hospital
• For next slide need to animate with some red arrows to TV surgery and AF ablation
• Box around Class I N=390• Do we have data on type and duration of AF?