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| Where Does AF Surgery Fail?: Implications for Increasing AF Surgical Ablation Effectiveness | |||||||||||||||||||||||||||||||||||||
Patrick M. McCarthy, Jane Kruse, Shanaz Shalli, Leonard Ilkhanoff, Jeffrey Goldberger, Alan Kadish, Rishi Arora, Richard Lee; Division of Cardiothoracic Surgery, Northwestern University; Northwerstern Memorial Hospital, Chicago, IL
Methods: From April 2004 to September 2008, 386 pts (216 male; age 65.8 ± 12.4; Table 1) underwent surgical ablation by a single surgeon primarily using bipolar radiofrequency and cryoablation. This included 339 with other procedures (concomitant group), 47 lone AF [31 Classic; 16 High Intensity Focused Ultrasound (HIFU)]. Operative mortality was 1.8% for those with concomitant and 0% for lone AF surgery. Since January 2006 pts were prospectively followed, and all preceding pts were retrospectively followed as well. Results: At the our center 19 pts who developed AF or Atrial Flutter > 3 months after surgery underwent electrophysiology (EP) study with ablation. Of the Classic Maze pts 3/64 were studied and found to have mitral annular flutter. Of the HIFU patients 3/24 were studied (an additional 4 pts had ablation elsewhere) and all 7 had breakdowns in the pulmonary vein isolation (PVI) lines. Need for ablation after HIFU was much higher (7/24, 29%) than after Classic Maze (3/64, 4.7%, p = 0.004). Of the concomitant group the location of arrhythmias was variable and included: RA flutter or RA tachycardia (8), left sided macroreentry around the PV or mitral annulus (7), PV (5), and focal mitral annular atrial tachycardia (1). Conclusion: Failures after HIFU were high and related to breakdown of the PV isolation line. Failures after Classic Maze were infrequent and isolated to the mitral isthmus. Failures after concomitant surgery include right side breakthrough (primarily in pts with just LA lesion sets) and incomplete coronary sinus/mitral isthmus lesions. We now perform more extensive biatrial lesions, and wider cyroablation to the mitral valve annulus and coronary sinus. Identifying the location of failures may lead to higher future success and is being prospectively monitored. Table 1
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