RECENT REPORTS OF SUCCESS RATES FOR SURGICAL TREATMENT OF AF (MAY 2007)

Here is a summary of some recent reports on surgery for atrial fibrillation from the AATS Convention in Washington DC in May 2007. Its purpose is to give you an very general idea of the outcomes to be expected from surgical approaches. Details such as subject characteristics, invasiveness,  lesions sets and whether they were done as "stand-alone" or concomitant procedures are left out.  Remember that rates for surgeons will vary, so you should always get data on success- and complication rates for the surgeon you are considering -- for your type of AF and physical status,  taking into account the way success is measured and length of follow-up (see the af-ideas.com web site for more on choosing a treatment for your AF and  selecting a surgeon or EP to do it).

Not every well-known surgeon was at the convention. Absent were such notables Dr Dale Geiss and Dr Patrick McCarthy, both of whom reportedly have excellent success rates.

Surgeons treating AF are obviously keeping track of the accomplishments of their EP colleagues, as evidenced by the title of one of the presentations by Ralph Damiano, entitled "Surgery for Lone Atrial Fibrillation: How do we become competitive with catheter ablation?". They are working hard  to develop approaches that are less invasive while retaining the potentially excellent success rates of the Maze procedure.

You will notice that the follow-up periods, with one exception, are very short. Several presenters stressed that what is needed are long-term, randomized studies on various techniques on large groups of patients differing on characteristics that affect prognosis.

The first section presents rates from two top Catheter Ablation ("CA") centers for comparison purposes. This is followed by a section on surgical outcomes. At the end is a brief description of the criteria for recommending surgery vs. CA provided by Dr Niv Ad.

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Catheter Ablation Success-Rate Examples

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Surgery Success-Rate Examples

PAF=Paroxysmal/Intermittent AF;    

CAF=Permanent/Persistent/Continuous AF;   

FU=Follow-up; NA=not available;

PVI=Pulmonary vein isolation

If the % of Ss that are off medications or other information is not indicated, it was not reported. (Of course being off medication rate is very important to most prospective patients...)

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These two reports on the Cox Maze III are presented for the purposes of comparison with newer modifications and other "minimaze" approaches.

http://jtcs.ctsnetjournals.org/cgi/content/full/126/6/1822

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*Dr Gillanov is a well-known surgeon from the Cleveland Clinic (CCF).    Here are rates from a descriptive article he wrote for patients at the CCF web site:

"The Maze procedure has been very successful with a 98% success rate in "lone AF" patients and a 90% success rate overall. Post procedure freedom from stroke has been over 90%."

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Here are the reports from the AATS Convention:

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***This is a high percentage of complications. It must be noted that: 1) Some other presenters did not report complications; and, 2) This sample was very small. The complications reported by Dr Ad are: One re-operation for bleeding, and two permanent pacemakers .

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PVI-Centered "Minimazes"

**The endocardial approach and energy source are the same as that of Dr Adam Saltman who developed the totally endoscopic "micromaze". He does important additional lesions, however. He almost certainly has more experience than the surgeons in this study and would be expected to have more success isolating the PVs. The only report of success rates I have been able to find was contained in a 2005 Personal Communication: "Success of 82% with all comers at 12 months follow up so far. That has been with spot ECGs and patient questions. We are starting to do 24-hour Holter recordings to look at that too."

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This "hybrid" approach was not presented at the 2007 AATS meetings, but will be described in the April 2008 convention.

http://www.nmh.org/nmh/heart/inthenews.htm?year=2008&cid=2522

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The new epicardial approach below -- of which the Wolf and Saltman procedures are other examples-- was not presented at AATS, but may be of some interest because of its ambitious steps for maximizing the probability of success by specifying restrictive endpoints, because of the use of a new instrument for making lesions, and because of the pattern of lesions. The "comprehensive bi-atrial lesion pattern" is designed to be as effective as the Cox III Maze using a different pattern of lesions:

http://www.ex-maze.com/

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Brief List of Criteria for Choosing Surgery over CA

"Based on the new 2007 Heart Rhythm Society Guidelines that are just being released the indications for a maze procedure are: 1. Symptomatic AF patients undergoing other cardiac surgery, 2. Selected asymptomatic AF patients undergoing cardiac surgery in whom the ablation can be performed with minimal risk. 3. Stand alone AF surgery should be considered for symptomatic AF patients who prefer a surgical approach, have failed one or more attempts at catheter ablation or are not candidates for catheter ablation." -- Dr Niv Ad 2007 Personal communication to LAF Forum (http://www.afibbers.org/lafforum.html) and a-fibcures ( http://health.groups.yahoo.com/group/A-fibcures/ )  Bulletin Boards.

[I would add that another reason for considering surgery would be if the person cannot  -- or will not -- take Coumadin. Virtually all surgical procedures will remove the Left Atrial Appendage, which is the source of the great majority of clots formed while in AF.]

There are other reasons for choosing surgery over CA, one of them being that the Maze procedure is designed not only to stop AF as currently triggered and sustained  in a given patient but to prevent AF that might occur in the future. More EPs, however, are including Maze-like lines in their procedures, although they are relatively difficult to do. For more on these issues, please see the af-ideas.com web site.