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MicrowaveAblationForChronicAtrialFibrillation LiPoa M D F A C S DirectorofPerioperativeServicesEnloeMedicalCenterChico California TheFutureofCardiacIntervention NationalHealthCouncil Stentandintravascularinterventionexpectedtodoubleovernext3yearsCABGvolumetodeclineabout10 withcardiacsurgeryprimarilyexpandinginEPSandCHFsuchasablativesurgery biventricularpacing LVremodeling andcardiacmuscleaugmentation Valvularvolumetoincreaseabout20 by2005 ChronicAtrialFibrillation Affects2millionpeopleintheUSalonewitha9 5yearmorbidityfromanticoagulationanda5 yearriskofstrokeAshighasan80 riskofstrokeat8yearsintheJapanesestudygroup Kitamura Availabletreatmentmodalitiesincludesurgical Maze cryotherapy radiofrequency irrigatingradiofrequency microwave andlaserSurgicalMazesuccessbestoverallbutMicrowavehastheleastcomplicationsandthebesteaseofuse MicrowaveAblation 3000patients OpenHeart2300patients75 success 0to4yearfollowup BeatingHeart Off Pump700patients80 success 0to2yearfollowup Noadverseevents MIS Off PumpMiniThoracotomy3casesRobotic2casesThoracoscopy2cases 2cm FLEX2TM 4cm FLEX4TM 7cm FLEX7 specimenswerecharacterizedbymyocellulardamageinvolvingthefullthicknessoftheatrialwall wherethicknessrangedfrom4 5mmto1cm ClinicalHistopathologyandUltrastructuralAnalysisofMyocardiumfollowingMicrowaveEnergyAblationEricManasseMD PiergiuseppeColomboMD PaolaBraidottiPhD MassimoRoncalliMD PhD RobertoGallottiMD submittedtotheAnnalsofTh Surg from InVitroandInVivoEvaluationoftheThermalPatternsandLesionsofCatheterAblationwithaMicrowaveMonopoleAntennaDavidKeaneMD Ph D JeremyRuskinMD NancyNorris Pierre AntoineChapelon DanyBerube Ph D Beating HeartSurgery EpicardialablationEndocardialview TransmuralLesion ViableTissue Beating HeartSurgery Dr Maessen Maastricht Netherlands Off pump 40patients 32cAF 8pAF acutedischargeFU40 4026 3932 39 82 10patients8 11months10patients6 8months19patients0 6months PresentedatISMICS 2002 n 31 mitralvalve 26 31 84 insinusrhythm Dr Zembala Zabrze Poland ArrestedHeart PresentedatCTT 2002 29patients concomitantsurgeries 14MV 15CABG92 inNSRFollow up 8patientsmorethan6months21patientsbetween1and5months submittedtotheAnnalsofTh Surg 2002 Prof Schutz Munich Germany ArrestedHeart 14patients beating heartandarrested heart 79 inNSR 11 14 64 withoutAAdrugFollow up mean131days 63 331days Prof Gallotti Dr Manasse Milan Italy ArrestedHeart PresentedatCTT 2002 12patients on pump concomitantsurgeries 75 inNSRFollow up upto3months Dr Gillinov ClevelandClinic ArrestedHeart DresdenExperience 211consecutivepatientswithdocumentedatrialfibrillationforaverageof6 8yearsconcomitantMVR CABG AVR andTVR Survival98 noMWcomplications70 NSRat6months68 NSRat1yearwithnormalatrialtransportfunction23 hadapostopPPMimplant TheInternationalMedicalGroupConference HowtoTreatAtrialFibrillationDuringMitralValveSurgery AnnoDiegeler 21July2001 TheDresdenexperience Dr MichaelKnaut ArrestedHeart PatientPopulation n 120Atleast6monthsofdocumentedchronicAFRefractorytoatleast2AAdrugs1YearResults 70 75 insinusrhythm n 60 Sub PopulationsBypass 60 insinusrhythmMitralreplacement 70 insinusrhythmMitralrepair 71 insinusrhythmTricuspid 75 insinusrhythmAortic 85 insinusrhythm ComparativestudyonConcomitantAtrialFibrillation GroupA 62patientswithnoablationduringsurgerysurvival94 2 NSRin6 ofMVD 9 withCAD and5 withAVDdiseaseprocesses GroupB 88patientsreceivingMWablationwiththeirsurgerysurvival98 NSRin62 ofMVD 70 withCAD and82 withAVDdiseaseprocesses Knaut M etalDresden Germany 10 15patientspersubgroupMicrowave 91 11 12NSR Radiofrequency 65 Cryoablation 55 7to12monthfollow up PresentedatEACTS 2001 Dr Graffigna Trento Italy ArrestedHeart Dr Kshettry Dr SaltmanMinneapolis StonyBrook Off pump 21cAFpatients allMitralValve SubmittedSTS 2003 Acute13 62 NSR5 24 pacedrhythm1 7 JCTrhythm2 10 AF Follow up 1 3months n 20 17 85 NSR3 15 AF Dr DavidKressandDr MuraliDharan 20patients 18epicardial 2endocardial 100 leftORinsinusorpacedrhythm75 freeofAFatdischarge73 ofchronicptsfreeofAFat3months 11 15 80 pfparoxysmalptsfreeofAFat3months 4 5 Noperioperativecomplications deaths orcollateraldamage PresentedatNASPE May2002 PresentedatNASPE May2002 Dr TomMolloyPortland OR 19patients 9off pump 10on pump 100 leftORinsinusorpacedrhythm62 freeofAFatdischarge89 ofptsfreeofAFatlastfollow up 17 19 Only37 7 19 arestillonanti arrhymthicdrug PresentedatNewEra January2003 Dr DonaldThomasChicago IL 22patients 11off pump 11on pump 100 leftORinsinusorpacedrhythm86 ofpts 19 22 freeofAFatlastfollow up SubmittedtoISMICS 2003 CardiologyEPExperience Primaryfociappeartobeatendovascularmuscularsheathsatvascularinsertionpointsinitialattemptsatprimaryablationwithinpulmonaryveinsledtopulmonaryveinstenosis PresentEPtechniqueinvolvesencirclingpulmonaryveinorificesablatingonendocardialsurfaceofatriumbutpresentlytakesanaverageof5 6hoursinexperthandsusingcatheterbasedapproach RSPV RIPV LAA MV LSPV LIPV EndocardialLeftAtrialAblation RAA TV EndocardialRightAtrialAblation CS IVC SVC Septotomy InitialcardiomyoplastytrialsfromSingaporeandFrenchgroupsnowhave15 23 10yearsurvivalrateslargerpopulationnowconsideredinreopenedtrialsgiventhatatrialfibrillationwasaninitialcontraindicationinthefirstgroupswithconcurrentatrialablativesurgerysynchronyisachievable CardiomyopathySupport EnloeExperience Concomitantcardiacsurgeryinpatientwithchronic 3months atrialfibrillationorrecurrentparoxysmalatrialfibrillationFailureofAAdrugpreopIsthmusablationwhenRatrialapproach 37leftatrialablations21epicardial 16endocardial6rightsidedablationsSuccessrates87 successinendocardial85 successinepicardial PreAblationIssues EnsureatriumisfreeofclotespeciallywhencontemplatingepicardialablationIfperformingconcomitant off pump CABG recommendperforminglateralwalldistalanastomosespriortoablationEnsurecomplete detailedidentificationofpulmonaryveinanatomylookingforallpossibleaberrancies TechnicalConsiderations Ensureadequacyofablation takethetimetomakecrossinglesionsTrytokeepablationsurfacesrelativelydryEndocardialablation Ensure1 bloodflowthroughcoronariesand2 TEEprobepulledback Epicardialablation Ensureavoidanceofcoronaryarteries coronarysinus andpulmonaryarteryRememberthatAtrialNatriureticPeptideproductionoccursintheatr