Surgical Treatment of Atrial Fibrillation

[fausto.freire]

In the following website: http://www.hsforum.com/stories/storyReader$4071 There are some videos (with an incredible size...) from the symposium: Concepts and Controversies: Surgical Treatment of Atrial Fibrillation

have downloaded and watch some of the videos. Particularly the last one (Question & Answer Session) can be very interesting for those interested in this issue.

Below I have copied the most important contents of the webpage.

Fausto

PS I was not sure if I should post this in the HCMA Announcements and Discussion, but I could not find a better place. sorry!

This symposium was originally presented at the 41st Annual meeting of the Society of Thoracic Surgeons on January 24, 2005, in Tampa, Florida. The symposium was sponsored by the Cardiopulmonary Research Science and Technology Institute (CRSTI) and supported by an educational grant from Guidant.


Developing a Minimally Invasive Surgical Program for the Treatment of Atrial Fibriallation: How Do You Proceed? (33 MB)
J. Crayton Pruitt, Jr., MD
Cardiac Surgical Associates
Tampa, Florida

Surgical Treatment of Atrial Fibrillation (42 MB)
A. Marc Gillinov, MD
Center for Atrial Fibrillation
Cleveland Clinic Heart Center
Cleveland, Ohio

Concomitant Therapy: Who Gets It and Why? (45 MB)
Adam E. Saltman, MD, PhD
University of Massachusetts
Worcestor, Massachusetts

Question & Answer Session (18 MB)

[Tigger1]

Dr Marc Gillinov did my septal myectomy last year at CCF. This is the first time I've seen his named mentioned. I have not heard his name mentioned as having done surgery on anyone else...


Tigger1

[progers]

Fausto,

This is a great resource. Did you notice that one of the speakers mentioned that they would consider a-fib surgery for most people, even those with left atrial dimension of 65mm?

Also, I have emailed you some articles about a-fib.

Take care,

Paul

[fausto.freire]

Hi Paul,

Yes! The videos are a great source of information and they were recorded in the beginning of this year.

Yes! I was very happy to find out that they would do surgery with left atrial dimension of 65mm and they would expect to recover atrial contractility. This is a big issue, since the scars in the atrium reduce the capacity of contraction. In this context, they also said that with a left atrial dimension of 80mm, they would not expect to recover atrial contractility.

Thank you for the papers. I will check my email and send you a reply by email..

Take Care

Fausto

PS concerning the issue of atrial contractility after afib surgery, see below what I have copied from this paper. Joăo Q. Melo, et al (2004) Journal of Cardiac Surgery. Atrial Ablation for the Surgical Treatment of Atrial Fibrillation: Principles and Limitations. Volume 19 Issue 3 Page 207-210

Abstract
(…)
Finally, atrial contractility is addressed, and the authors conclude that the ideal procedure will achieve a balance between conversion to normal sinus rhythm and the preservation of atrial contractility.

[fausto.freire]

Hi Paul (again!):

Thank you very much for the articles. I have read them. In the paper (Watson, C., et al. (1977). 'Effects of Operation on Left Atrial Size
and the Occurrence of Atrial Fibrillation in Patients with Hypertrophic Subaortic Stenosis') it is very interesting to see the difference it makes the age of the patients (less or more than 40 years old). However I could not find in the paper, a patient with such an enlarged left atrium like mine. If myectomy is a option for me I think it should be done together with maze and surgical reduction of the atrium size.

By the way, see the program of this conference, just held a few days ago:

http://www.canalejo.org/IVTeleconfer..._programme.htm

for Tuesday, 14th June 2005, 08.00-13.00 SESION III, SURGICAL TREATMENT OF ATRIAL FIBRILLATION

I am looking forward to receiving news from your meeting tomorrow

Fausto

[progers]

Hi Fausto,

I'm glad the papers were of help to you. Although the paper by Watson et al does not discuss very large atria, it does state:

"Regardless of age, there was a greater likelihood that patients with a preoperative atrial dimension of 50 mm or greater would reduce their left atrial dimension post-operatively by 10% or more, when compared with patients with a smaller preoperative dimension" (page 179).

I met with the EP today for the second time, so here is a report of this meeting:

PULMONARY VEIN ISOLATION/ABLATION

My EP suggested that if a-fib recurs, then they could do a circumferential, wide area, PVI. This would be limited to linear lesions aroung the pulonary veins, and not on the atria itself. He tells me I have a 50% chance of getting rid of the a-fib (last time he told me 60%??).

However, if this failed, they could do a second ablation and possibly a third before recommending surgery. Each of these attempts would stand a 50% chance of eliminating the a-fib. Not great odds, but still a chance.

MAZE PROCEDURE OR ROBOTIC MAZE

The Maze procedure is an option, as is a minimally invasive robotic Maze. A couple of weeks ago I talked with one of the only surgeons in Australia who does robotic Maze procedures. He cautioned, however, that the Maze procedure involves extensive lesions to the atrium and this could have very bad consequences for some people with HCM. This is because the lesions can reduce atrial contractibility; many HCM patients rely on this contractility for their cardiac output. Nevertheless, this is still an option and some centres are doing less extensive Maze procedures (e.g. Mayo). I haven't found out if the less extensive Maze procedure is done here in Australia, but I imagine it is.

ATRIAL PACING and DEFIBRIlLATION

There are two-lead ICD/pacers which have atrial pacing abilities. However, my EP says that are not effective in preventing a-fib. But they do have defibrillation functions. Atrial defibrillation has drawbacks, such as the pacer being unable to determine between v-tach and a-fib. But it is possible to manually do an atrial defibrillation. My EP said that a patient could take a valium, go to bed, and preset the defibrilation for a certain time. I guess if I go ahead and have an ICD put in, I will get the two lead model, which can pace the atrium.

Perhaps in the near future, atrial pacers will become more sophisticated and more effective in preventing a-fib? I think this is likely at some time, because of the huge amount of money being dedicated to atrial fibrillation research right now.

Fausto, perhaps you should consider myectomy and a less extensive Maze? You could find a top HCM specialist, someone who could give you clear, good advice. Perhaps Dr Mckenna in London or someone in Italy? You are lucky in that you are still young and so myectomy etc. would likely result in ventricular and atrial remodeling. This reduction in ventricular mass and atrial size is well documented in recent literature on myectomy and PTSMA. I can give you some references if you need.

Take care,

Paul

[fausto.freire]

Hi Paul!

Thank you very much for the detailed report and your suggestions. I will have an ECO-Doppler in a few weeks followed by a meeting with the cardiologist. Depending on how my mitral valve is working, and the other usual parameters, the doctors will give me their appraisal, deciding what to do next. If I am not very happy with that, I will definitively follow your advice and try to meet an expert win HCM (yes I already thought of Prof Mckenna in London) and/or an expert in afib ablation.

It seems that your EP knows of is job. As you know, different types of ablation lines can be performed and I think your EP prefers doing more than one procedure (if needed) than doing too much ablation at the first tentative with the risk of reducing too much the atrial contractibility. That is more or less what they do in Bordeaux, at least that’s what I have learned after receiving a email from Dr Pierre Jais in reply to a few questions I asked him. In that email and assuming my left atrium was 57mm. He said: “Multiple sessions are likely to be needed. But I think it is worthy to try.”

Just a question: Which left atrium diameter do you have now? I recall it reduced after the myectomy, but I don’t remember the exact value now.

And what is “PTSMA”

Bye for now

Fausto

[progers]

Hi Fausto,

Good luck with your tests coming up. Please let me know how it goes. My left atrium currently measures 56 mm. This measurement was taken just 2 or 3 weeks after my myectomy, so I don't know if it has reduced since then. But I will go in for another stress echo in a week or so, so perhaps my left atrium will be smaller. I certainly hope so. I know that the heart remodels for up to a year after myectomy, so it can take that long for the heart to lose some of its size. I will let you know what the results are when I do the test. It will be a good indication for you if you decide to undergo surgery.

PTSMA is surgical ablation of the septum. I'm sure you are familiar with this, which is then on-invasive catheter procedure to reduce obstruction in HCOM.

Take care,

Paul

[fausto.freire]

Paul: Thanks. I will let you know when I have news from my exams. I hope your atrium reduces further. keep in touch. Fausto