Surgical Aspects of Cardiopulmonary Bypass Ppt Powerpoint Presentation slides-Medical Slideshow Single, Percutaneous, Femoral Venous Cannulation for Cardiopulmonary Bypass

Surgical Aspects of Cardiopulmonary Bypass

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Slide 1 :

6/16/2009 1 Thoracoscopically Assisted LIMITED Thoracotomy for Radiofrequency Ablation of Atrial Fibrillation Michael Gibson M.D., Justin Fanning M.D., Benjamin Sherlag M.D., Deborah Lockwood M.D., Warren Jackman M.D., Marvin Peyton M.D. Cardiac Arrhythmia Research Institute Thoracic & Cardiovascular Surgery University of Oklahoma Health Sciences Center

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6/16/2009 2 Introduction Atrial Fibrillation 1% general population 6% population over 65y/o 1.4 million hospital visits per year 227,000 hospitalization annually 50% as emergencies 6.6 billion healthcare dollars annually Morbidity and mortality of atrial fibrillation Irregularity of heartbeat-discomfort and anxiety Compromises cardiac hemodymics-CHF Vulnerability to thrombembolism-stroke

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6/16/2009 3 1960’S - Catheter based mapping and ablation of tachyarrhythmias 1967 - first WPW ablation 1968 - first surgical procedure for elimination of accessory pathway after catheter mapping 1973 - resection of atrial focus resulted in cure of atrial tachycardia 1981 - first closed chest ablation for afib by direct current (dc) 1987 - introduction of radiofrequency ablation catheter History

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6/16/2009 4 History (continued) Surgical ablation became more refined and precise as mapping techniques improved. 1988 - Surgical dissection was performed to treat av nodal reentrant tachycardia without causing av block. Although surgical ablation was therapeutic, there was a significant morbidity and mortality associated with the surgery. The surgical risk was not justified for most patients at this time and was reserved as a last resort for highly symptomatic patients.

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6/16/2009 5 1980- (Cox) left atrial isolation 1985 – (Guiraudon) corridor procedure, isolated a strip of atrial septum 1987-92 - (Cox) Maze-I, Maze-II 1992 - (Cox) Maze-III 2002 - Epicardial Radiofrequency Ablation 2003 – Wolf Mini-Maze Procedure History (continued)

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6/16/2009 6 Background Paroxysmal Atrial Fibrillation - From discrete atrial sites at the base of the pulmonary veins. -Surgical ablation results ? 90%. - Catheter ablation success rate ? 60% - Less invasive than Cox Maze III procedure - Remains suboptimal compared to surgical ablations. Chronic Atrial fibrillation - Catheter ablation success rate < 30% - Surgical ablation success rate 15-25%

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6/16/2009 7 Background Catheter Ablation - Complications - Pulmonary Vein Stenosis, incidence ? 2-4 % - Thromboembolism from the endocardium - esp in left atrial appendage

Slide 8 :

6/16/2009 8 Background Thoracoscopic Radio Frequency Ablation - external clamping device - reduces incidence of pulmonary vein stenosis - more limited transmural lesion - reduced area of endocardial injury - less foci for thrombus formation Excision of LA appendage further reduces potential for thrombus and embolism

Slide 9 :

6/16/2009 9 Background Atrial Fibrillation - Autonomic ganglii in pulmonary vein and atrial interface initiate and maintain a-fib - In animals, stimulation of epicardial fat pads by rapid pacing allows identification of ganglionic plexus - Interruption of these ganglia by ablation may further improve surgical ablation results for a-fib

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6/16/2009 12 Surgical Procedure

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6/16/2009 13 Hypothesis The epicardial delivery of radiofrequency current for ablating conductance at the pulmonary vein -atrial interface as well as autonomic ganglii as a source of stimulation for atrial fibrillation may improve the rate of success for conversion of atrial fibrillation. Adding intraoperative verification of the epicardial ablation areas may improve results.

Slide 14 :

6/16/2009 14 Patient Profile 18 cases Age Range: 32 – 76 yrs (median 56) (8 > 65yrs) Ht. Range: 5 ft 5 in – 6 ft 5 in (median 5 ft 11 in) Wt. Range: 136 lb – 311 lb (median 225 lb) (7 > 250 lb) (2 > 300 lb)

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6/16/2009 15 Presenting History Chronic atrial fibrillation 8 Paroxysmal atrial fibrillation 10 Previous catheter ablation 7 Medical management 18

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6/16/2009 16 Hospital Course Hospital days Range 1 – 33 days (1 pt. 33 days) 3 patients 5 days 2 patient 7 days Average 3.9 days (excl. pt. 33 days) ICU days Range 1 – 21 days 3 patients 2 days 1 patient 3 days 1 patient 21 days Average 1.3 days (excl. pt. 21 days)

Slide 17 :

6/16/2009 17 Rhythm at Discharge Sinus Rhythm 13 patients Atrial Fibrillation 4 patients (+ 1 death) Current Rhythm Sinus Rhythm 15 patients Atrial Fibrillation 2 patients 1 chronic 1 paroxysmal Atrial Flutter 1 patient

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6/16/2009 18 Thoracoscopic RF Ablation Results Chronic atrial fibrillation 8 patients Converted to sinus rhythm 7 patients (88%) Paroxysmal atrial fibrillation 10 patients (1 death) Converted to sinus rhythm 8 patients (80%)

Slide 19 :

6/16/2009 19 Conclusion Thoracoscopically assisted limited axillary thoracotomy for isolation of the pulmonary veins by radiofrequency ablation allows a directed surgical approach for correction of both chronic and paroxysmal atrial fibrillation. Excision of the left atrial appendage may reduce the risk of embolic sequelae. Interruption of autonomic ganglia seems to enhance conversion in patients with chronic atrial fibrillation.

Slide 20 :

6/16/2009 20 References Haissaguere M, Jais P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med 1998;339:659-666. Chen SA, Hsieh MH, Tai CT, et al. Initiation of atrial fibrillation by ectopic beats originating from the pulmonary veins: Electrophysiological characteristics, pharmacological responses, and effects of radiofrequency ablation. Circulation 1999;100:1879-1886. Haissaguerre M, Shah DC, Jais P, et al. Electrophysiological breakthrough from the left atrium to the pulmonary veins. Circulation 2000;102:2463-2465. Pappone C, Rosanio S, Oreto G, et al. Circumferential radiofrequency ablation of pulmonary vein ostia: A new anatomical approach for curing atrial fibrillation. Circulation 2000;102:2619-2628.

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6/16/2009 21 References Robbins IM, Colvin EV, Doyle TP, et al. Pulmonary vein stenosis after catheter ablation of atrial fibrillation. Circulation 1998;98:1769-1775. Bettoni M, Zimmermann M. Autonomic tones variation before the onset of paroxysmal atrial fibrillation. Circulation 2002;105:2753-2759. Schauerte P, Scherlag BJ, Patterson E, et al. Focal atrial fibrillation: Experimental evidence for a pathophysiologic role of the autonomic nervous system. J Cardiovasc Electrophysiol 2001;12:592-599. Tsai CF, Chen SA, Tai CT, et al. Bezold-Jarisch-Like reflex during radiofrequency ablation of the pulmonary vein tissues in patients with paroxysmal focal atrial fibrillation. J Cardiovas Electrophysiol 1999;10:27-35.

Slide 22 :

6/16/2009 22 References Gillinov AM, McCarthy PM. AtriCure bipolar radiofrequency clamp for intra-operative ablation of atrial fibrillation. Ann Thorac Surg 2002;74:2165-2168. Damiano RJ, Jr, Gaynor SL, Moon MR, et al. Initial clinical trial of pulmonary vein isolation with bipolar radiofrequency ablation for the surgical treatment of atrial fibrillation. AATS Meeting Oral Presentation. April 2004.

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