breast augmentation before and after gold coast

dr. philpott: so this is going to be our surgerypanel and dr. damiano and i are going to talk about the role of surgery and then we'd liketo have a good discussion session. i really encourage you to come to the mikesat the end or if we don't have enough time, come and find us and get us one-on-one andwe will give you the best answers that we can. it is my great pleasure to start off withdr. damiano and frankly this man does not really need an introduction. he'sbeen a huge thought leader. he basically has created the cox maze iv, he's the head ofct surgery at wash. u and that institution itself has been a dramatic leader over the last 20 years in cardiac surgery. he's also the

vice-chair of surgery, i believe.so without further adieu, i give you pretty much the tip of the spear for surgical interventionfor afib, dr. damiano. dr. damiano: thanks, jonathan, andthank you, mellanie, for inviting me to this really wonderful conference and thanks toall of you for attending, you've been a great audience. in fact, your questions have beenexcellent and better than many medical meetings i have been to recently. so you all shouldbe congratulated and really as the cardiologists have said in their panel,the reason we're here is for the joy and satisfaction we get in taking care of patients. so it's really wonderful to be able to addressyou. we're going to have to get

my slides up because this is jonathan's talk.but i would like to actually give you just a wee bit of history of surgery for arrhythmia.as we're waiting to get my slides up, you have to realize first of all many people, and you should know...and you're probably a diverse group of people with atrialfibrillation and most people with atrial fibrillation are treated medically...but as you also know,the symptoms can be severe and can be a major impediment to quality of life. interventional treatment for atrial fibrillationcertainly has become dramatically more common over the last decades. but what you may notknow is that interventional treatment for arrhythmias really started as surgery.some people think, well, how would you...surgery

for atrial fibrillation? that seems prettyextreme. we are at the very bottom or at the very end of the treatment line, i could say.we're not at the bottom, you could say we're at the top of the treatment line, but really the interventional treatment of almost all arrhythmia starting back in 1968 whichis a heck of a long time ago. wolff-parkinson-white was treated first atduke university, which is where i trained, by will sealy and then that ledto the effective catheter treatment of that arrhythmia which now, while i've done onecase in the last five years, wpw really is now a catheter-based procedure. the treatmentof atrial fibrillation, interventional treatment started exactly that way.

and i'll just show you a very little bit ofthe history, but i think it's very interesting because it did show for the first time thatyou could treat atrial fibrillation with a procedure and that flew in the faceof conventional wisdom. you can see how far we've come but really back in the early days,in the early '80s, this was quite a controversial area. so i've entitled my talk a littleprovocatively, "why are most patients not receiving treatment," because i was actuallygoing to be talking about the fact that, and i'll show you some data, a great many patientsare coming for cardiac surgery who have atrial fibrillation and even today, most of themaren't treated, which i think is a shame.

patients with valve disease, infact with mitral valve disease, a third of patients referred for surgery have atrialfibrillation, but still the majority go untreated, which i think really misses a fantastic opportunity. but let's look at afib and i knowthat you've already talked earlier about the fact that the incidence of afib shown in thisgraph is really higher in the u.s. than any other country in the world, which is interestingand there are a lot of reasons for that. but i think it's a very important topic. it isthe most common arrhythmia and particularly common in the u.s. in terms of ablation for atrial fibrillation,really both surgery, and in many respects

catheter ablation, was first developed inthe united states. today there's more surgery for atrial fibrillation proceduresperformed in the u.s. than anywhere else in the world. in fact, probably more than almostall the rest of the world put together. so we played a big role and i'm fortunate...andmaybe you could say i'm just old enough to have lived through much of thisso i guess i'm fortunate to still be around to talk about it, so that's right...but reallyafib surgery started 28 years ago, well preceded catheter ablation like i was saying. it startedat our hospital in st. louis and the gentleman shown in the box is jim cox.and he really, along with a basic scientist, rick schuessler, who still runs our lab, i'llshow you a picture of him and john

boineau, who was a cardiologist, came up withthe idea that since we were already then treating other arrhythmias, atrial fibrillation probablyalso could be treated with a procedure. he came up with a procedure thatturned out to be fairly remarkably successful and this is a cartoon of the first maze procedure.you can see it's a pretty dramatic procedure with lots of incisions on boththe left and right atrium and the idea was that it would prevent these rotors...it'sfunny how dr. narayan is coming back to rotors...but at that time, we did feel that afib was causedby rotors rotating around anatomic obstacles. these incisions, while they lookchaotic, were meant to prevent that. it turned out fortuitously that we also isolatedthe entire posterior left atrium, which you

found out from dr. natale that now with thecatheter-based side, that's also shown to be very, very effective. but thisprocedure was effective and this is sort of the beginning of my journey in 1982. i wasdr. cox's first research fellow. for those of you who can't recognize me, there i am, whichis pretty sad. unfortunately, i haven't stood the test of time very well,but this was a group of...we were a group of young surgeons. dr. cox was brand new onthe faculty. i was actually a medical student when i started with him. we came up really trying to investigatethe arrhythmias and it's interesting. it's been a long journey for me and this actuallyso you can see how...actually we'll go back.

this is how bad the years...there is myselfand dr. cox just earlier this year at a meeting and dr. schuessler is on yourfar left, who deserves a lot of credit. he's one of the unsung heroes and has done a lotof mapping that has really led to some of the advances in catheter ablation also. when you look at surgery for atrialfibrillation, it's really people have been talking about, you know, how do you come upwith these ideas? how do you innovate? how do you develop new procedures that can helppeople in areas that were once felt to be impossible? or as many of you knoweven today, afib, often most people have a fairly nihilistic approach to it, that youshould just rate-control people and give them

anticoagulation and just live with it. well, it's interesting how youtry to change paradigms and the surgical treatment of atrial fibrillation is a fantastic exampleof how that really can happen and how it can be done responsibly. and first what usuallytriggers an advance is someone gets an idea of perhaps a better understandingof the underlying mechanism. then and what was done in this case...and you could seewhen i was working with dr. cox, first i was a research fellow and we were working in animallabs trying to test, "okay we have this idea that maybe it's working by thismechanism and we could maybe stop it if we do this," and those ideas are called hypotheses.

then you test them in a very carefully controlledsituation and then only after that, and now we do a lot of computer modeling, afterthat, bring to the operating room. but then even when you first bring it to the operatingroom, which they did 28 years ago, i'll hope to show you today that we've never stoppedtrying to innovate and to try to continuously improve that operation. that's what happens in many branches of medicinebut this is a fantastic example, one of the best examples i think, of how that happened.it's interesting, back in the early '80s, the improved understanding of the mechanismwas that afib was due to these multiple re-entrant circuits. since we now know that probably,it may be true in very few people, but probably

isn't true. so often the improved understandingof the mechanism may not actually be correct. but it did lead us into the fact that we thoughtwe could cure this arrhythmia. what we did was both map atrial fibrillation, both inhumans and in animals. you can see we built this form-fitting plaques that weput on people who were coming for surgery for other reasons who had atrial fibrillation. we learned a lot and we developed the mapslikes this and you saw maps, but it basically kind of gave you an idea of where the atrialfibrillation was coming. and similar to what you heard earlier, as opposed to itbeing extremely chaotic, there was some organization

and some hope that we could maybe do somethingsurgically for that. the problem really was that, andwe still would tell you that we believe that today, is in most patients and most of you,if you have atrial fibrillation, the mechanism keeps changing. early in your afib, it isoften a very stable mechanism, but we find that most patients with persistentafib or particularly long-standing persistent atrial fibrillation, that mechanism changesover time. even in the shortest time, we mapped people for 10 minutes and in 10minutes, over half the people, the mechanism changed. some people, it went from one atriumto the other. it was dramatic changes. so that led us to say we can't... and we'recoming back i think almost 30 years later

to maybe we can tailor operationsto the individual patient because we have much better understanding now. but in thosedays, we decided we just had to come up with one operation, i showed you that cartoon.this would take care of afib, almost no matter what the mechanism. it would prevent all types of ourunderstanding of the mechanisms that way by creating a set of scars on both the left andright atrium. we tested it in three different animal models in the early 1980s and it wasuniformly effective in curing atrial fibrillation in animals. unfortunately, there'snot a big practice to that, and the animals weren't necessarily that happy with us withthat. but it turns out that was proved also

in our human experience, which i'll show you. but we also showed some importantthings, that you could do this operation and not affect the function of the atrium, thatit still pumped adequately and you didn't cause a big infarction or heart attack ofthe atrium. and we did the first procedure back in 1987 and it's turned outto be very successful. it was the first time anyone had intervened on atrial fibrillationso you have to understand that it was quite a radical development. the success of themaze procedure set the stage for the development of catheter ablation. as inthe case of many arrhythmias, the surgical treatment came first and then it became a catheter-basedprocedure.

while the original cut and sew that i showedyou in that cartoon is almost never performed today because it's very complex,it was very hard to do, it was remarkably efficacious. and we reviewed the series, thisis way back in 2003, i reviewed all those series, many of which were done by dr. cox and a few by myself and dr. sundt, who is now at mass general, but we lookedat how those patients did. and we followed them out at six years andin patients with lone afib, 80% said six years out they were free of atrial fibrillationand off medication, which is pretty amazing. the average duration of atrial fibrillationin these patients was over seven years. so they weren't a simple group of patients. obviouslyat that time, it was a big operation, so they

were really people who'd had along history of afib and were quite desperate to have a cure. so where are we now 30 years later? the goodnews is that there really has been an exponential increase in surgery for atrialfibrillation and i'll explain to you why that's been. i would say up until about 2002, probablyjust a few hundred maze procedures, and that's what we called that original operation, maze procedures were done. when you look now three decades later, that's gonebetween 8,000 and 10,000 cases a year, which is pretty dramatic. still a very small componentof the total population of people with atrial fibrillation, but that's been great.

and this is the data from our big nationaldatabase and before 2004, the numbers were almost too small to measure. you can see itwent up to about, of patients coming to surgery who had atrial fibrillation, about35% to 40% were getting an ablation procedure, which is a dramatic change from less than1% before 2000. i've been charged with talking about peoplewith afib who are coming for other types of cardiac surgery. and still todayabout 95% in the recent data...this was from 2008, but it holds true today...about 95%of people who come for surgical ablation are coming for other types of cardiac surgery,most commonly valve surgery, but also coronary bypass grafting.

so why did it increase so dramatically? well,there's two reasons. one, we borrowed...after showing the cardiologists theyprobably could treat this with catheters also, then we borrowed some of their ablation devicesto try to replace the surgical incisions and decrease the invasiveness of the maze procedure.you hear it called maze. it's been really termed the cox maze, named after jimcox who developed it. we've also developed really less-invasivesurgical approaches. jonathan's going to talk about hybrid approaches and those; i'm goingto really focus on sort of the history of where the maze procedure's gone and end withjust a few things i think as patients you need to know about surgery.

it's interesting. there's been a lot of technologiesused by surgeons to treat atrial fibrillation, to try to simplify the procedure and the listof them are here. we've been funded by the nih to look at these and i cantell you, i am proud of the fact that i've gotten many of these taken off the marketbecause they don't work. we're left now with unipolar and bipolar radiofrequencyand cryoablation as the two energy sources that are used and actually have been shown,particularly bipolar, the ones on your left have been shown to be very effective in theanimal laboratory. we've checked these out and really defined how they work beforebringing them in into the operating room. i think that's really been important to tryto safely...to be able to evolve the procedure

in a safe fashion. this is the lesion sets now andthis is, if you were going to have other surgery and you can see...and i don't really havea pointer, it's the weakest pointer ever...but we make a small little incision. we've actually in the recent iterations have even stopped making that. but in white are theseablation lines so it's a very small incision, or no incision now, and with these ablationdevices we can create the scars of the maze procedure much more quickly and easilythan with surgical incisions. this is a left atrium and i think it's importantthat basically in a maze, you isolate the whole back of the left atrium and as dr. natalepointed out in his talk, we've shown that

if you don't do that...which ireally had a bright idea early in my career that maybe i didn't need to do that...butit was fortunate because we really showed that that really is a big problem, that it'snot just the pulmonary veins. it's the whole back of the left atrium that'sreally important. particularly in patients, most of the patients that have come to ushave had really long-standing atrial fibrillation, but it's really quick in the procedure. we published our results and i'll just showyou, well, what's the difference between doing a cut-and-sew and ablation? andmaybe as a non-cardiac surgeon you would say, "well, that doesn't seem like it's that biga deal," but it turned out to be quite a big

deal because we had an operation that reallywas successful, but no one would do it. so that's not a very good operation.you have to have something that people are willing to do. it can't be so difficult. andwe looked at over 200 consecutive patients we did with just lone atrial fibrillationand how they did. and we compared the maze iii, which is thecut-and-sew procedure to the maze iv with ablation devices, but the most importantthing is to see the time it took really went down, from 90 minutes down to 39 minutes andthe major complication rate significantly dropped because the operationswere easier, patients did well and we didn't have really the complications that we sawwhen we were doing the more complicated maze

iii or cut-and-sew. then most importantlythe success of the procedure was identical because we had to look at that.so you can see we looked at about over 100 and 112 patients in the two groups so prettycomfortable and that data has continued to hold up. but then we went and said, "okaywell, we can replace the ablation devices. can we then do it in a minimally invasivefashion?" and we now do it through about a two to two-and-a-half inch incision, whichis shown in that dotted line and just a small incision in women under the right breastor in men, really under the armpit. you can go in and we don't use any type of spreading.we just use this thing that looks like a giant

rubber band, which really cuts down on thepain. you can see, you can have a very small...this is a patient who had a mitralvalve repair and a maze procedure...you can see it's very nice and really in two weeks,people go back to full activity. now does that make a difference? it's cosmeticallycertainly a lot better than having your whole breastbone divided, but does itreally make a difference? we just recently published at the end of last year, our results in over 350 patients where we compared cutting the breastbone, which is called a medium sternotomy,to that minimally invasive procedure and we'll just show you the results. but basically these are the freedom from alltypes of atrial arrhythmias at one and two

years. you can see really identical at 90,in the mini-thoracotomy which is shown in red, over 90% free of atrial fibrillationat one year. and still 83% at two years. this has held up and i think it's agood success rate and shows you can do it minimally invasive with the same success asthrough a sternotomy and that's really our approach of choice right now. we also showed in this study that the complicationrate continued to go down and also mortality rate seemed to be less. we've nowdone close to 200 of these with really, it really has a very low morbidity andmortality. this way you can do a full maze and you have to remember, this is a complicatedgroup of patients and still our average duration

of atrial fibrillation is close to seven years.and of the people with lone afib right now, over half the patients have failedmultiple catheter ablations. so we're not dealing with easy patients. we're dealingwith the patients that the cardiologists tend to get poor results. you can see this is, while an extensive operation,remains the most single successful intervention for afib really in the worldand as a single intervention, remains quite a bit more successful than a catheter-basedapproach. the bad news that i would say, or the disappointing news to myself despiteall those advances with ablation devices and developing less-invasive approaches, the numberof people getting surgical afib ablation in

the united states has really stayed stablesince 2006. the majority of patients who come for surgeryfor other reasons are still not treated by their surgeons. and this is somedata that niv ad published a couple of years ago and in red is the percent of patientswith afib who get surgical ablation. and you can see while it went up as i showedyou from 2005 to 2006, it's basically gone down, though the overall number continuesto increase. but there's more patients with afib going along with the increasing incidence in the united states. this i think is disappointing, but i thinkif you have a friend who needs cardiac surgery, it's the perfect time to have your afib takencare of. and it's a shame that right now,

only 39% of patients with afib who are alreadycoming for heart surgery so they're going to be in the operating room anyway,only 39% are treated. so that's something we have to do better as surgeons and as patients,you have to really demand the surgeon to do that for you and this is just another wayto look at it. about 60% of patients with mitralvalve surgery are not treated and if you come for just bypass surgery, about 93% of patientsare not treated, they don't receive ablations. that's something we really have to do betterabout. the even worse news, at least in my opinion, is the majority of patients whoget treated aren't treated with the maze procedure, which is the only procedure we really havelong-term data on.

and this is from the european registry ofatrial fibrillation surgery, only 16% of patients who were undergoing ablation hada maze procedure. the other way to look at it, 84% of patients had other operations whicheven to this day, there is very little late data on how well they work. so again it'ssomething that you need to be informed of as patients. why aren't patients treated? i give this talkto surgeons to try to get them to treat it. i think you guys would all say, "why aren'tthey?" the first thing, does it even matter if you afib? and i think the reasonyou're all here is you obviously believe that, but i won't belabor with a lot of data here but...soif you're coming for mitral valve surgery

and you have afib, this is looking at survivalof people following mitral valve surgery who have afib or do not have afib. you can see your survival is much worse, thelower line, and pretty dramatically worse, almost 20% higher death rate at 10 years ifyou have afib as opposed to not having afib. that's been shown also, not quiteas dramatic after coronary bypass surgery, after aortic valve surgery. it is a markerand can lead to really late morbidity and mortality often due to stroke,like we were talking about. so to miss that opportunity is really a shame for the patients. the other thing you could say is, "well, maybesurgery isn't that effective." i showed you

the early results and our results, but maybeother results aren't very good and that's just in st. louis. but really theseare a list of seven randomized studies of looking at people coming for mitral valvesurgery who've either had ablation or the control group just had mitral valve surgery. and then looked at late freedom from atrial fibrillation and absolutely everyrandomized study showed a significantly better freedom from afib with surgical ablation thanwithout. and there's now been two more randomized studies. so this is one of themost studied areas of surgery. so there's very convincing evidence it worksand for those of you, this article got a lot of press, just recently came out in the newengland journal. randomized multicenter trial

looking at surgical ablation ofatrial fibrillation in patients coming for mitral valve surgery and it showed, this isthe freedom from atrial fibrillation at a year basically in patients with ablation. not as good as we were hoping with 63%, andi think part of the reason is they didn't really have a maze procedure, manyof the patients. and 29% of them just had surgery alone. so you can see ablation doesmake a difference and does work in every randomized trial on getting more people out of afib. we've looked at our results with,if you do the maze iv and this is in mitral patients in over 100 patients, and you cansee the success rate is about 84% and it should

be over 80% at a year if you do the procedure correctly. so i think you can get very good results. and again it's a greatopportunity to take care of it. ln almost every sub-group, it's been shownthat the maze procedure's been effective because the afib might be different. andin coronary disease, we published our data and we now we have over 100 patients, butthis is the original report way back in 2003 but we looked at 47 patients and all patientswere free of symptomatic afib at 10 years. so that's pretty darn good. does surgical ablation, why don't surgeonsdo it? does it add to morbidity? and the answer to that, it really doesn't and this is a hugedatabase trial which i was showing of thousands

and thousands of patients and addingablation didn't add to your risk of dying or having a major complication. despite almost three decades of experienceand a ton of publications, the development of less-invasive approaches, surgicalablation's not performed still in the majority of patients who are already coming to cardiacsurgery and we need to do better. that is something that jonathan and i are really dedicatedto making that happen, but there's strong evidence supporting the efficacy ofsurgical ablation and its safety in these patients. and i would just say as a patient, if you'recoming for surgery and even if...we've been

talking about lone atrial fibrillation, whichwe'll switch gears to...you should really make sure your surgeon knows how to do afibablation because it's really the best chance for a cure. after being in thisfield for a long time, i will tell you the best chance of curing afib is if you happento have another procedure, particularly your mitral valve worked on, you can have the surgeon,he's going to be in the left atrium, he's going to be able to see everything. youcan beautifully isolate the posterior left atrium and it's really a shame not to be ableto have that opportunity. i'd like to end just with a couple ofreflections of...because i thought about when mellanie asked me, "what should patients askabout?" and questions to ask your surgeon.

so if either you're being referred for justafib or you have another cardiac problem and have afib...and again particularlymitral valve disease worldwide is the most common cause of atrial fibrillation by far.and in asia, because of the high incidence of rheumatic valve disease, many, many patientswith afib are coming to surgery. so you'd ask your surgeon first of all, "howdo you learn how to do surgical ablation?" many of them did not learn in their trainingso you should ask them how you do it. i think it's a good question and ask them,"how long have you been doing the procedures," because i think you need to know...again ifyour surgeon's not going to do it or is he going to do something that's not quite a completeprocedure, you may want to look for another

surgeon. the other question is, there'sa lot of different surgical procedures for afib. i've shown you the maze, which we developedin st. louis but there's others that have been introduced. but what do you do and why?not everything is a maze but you'll see, it's very confusing on the internet. mostof the surgeons will call whatever they do a something-maze, mini-maze or there's a roboticmaze, but often it's not a maze. the maze is a specific lesion set that forms scars on both the atrium and isolates the whole posterior left atrium. if you performan incomplete maze procedure, it really works poorly. we found that eliminating not isolatingthe back left atrium as you saw

really, we've just looked now at five yeardata and it only worked about thirty percent of the time if you didn't isolate the backof the left atrium, so that's really bad. so you really have to do it well. the other question i would ask your surgeon,which was brought up by the electrophysiologist, but i think it's important for surgery is,ask them how they follow patients after afib ablation. if he or she says, "for one month,"then i would definitely find another surgeon, because that is really not appropriate. similarto it wouldn't be appropriate after catheter ablation. you should remember thatsuccess by all the consensus statements of any ablation procedures is defined as freedomfrom afib and antiarrhythmic drugs at one

year. then you should ask him and youneed to know yourself, what exactly is the surgeon doing? and there's a lot of differentprocedures, but they are not all the same. so surgical pulmonary vein isolation has beencalled a mini-maze but it's certainly not a maze procedure and it's not evena mini-maze procedure. it's just pulmonary vein isolation, which is similar to what theelectrophysiologist told you. and you also heard that if you have long-standing persistentafib or any type of long-standing afib that pulmonary vein isolation alonedoesn't work well. at least, it's been our experience that surgicalpulmonary vein isolation works about as well

as catheter ablation. now you may be a goodcandidate for that and certainly people have been and particularly if you're notcandidates for catheter ablation. there are some advantages to the surgical devices, whichwe could go in in the discussion but it's not a maze and it shouldn't be called one.some people call it a wolf procedure but that's surgical pulmonary vein isolation. that'show you should look at it. we sort of popularize calling isolating thewhole back of the left atrium a box or a box lesion. some people do that and you can dothat also in a very minimally invasive way and that is probably more effectivethan just pulmonary vein isolation. and that's something you should be cognizant of. theother thing which is important, if you have

atrial flutter, neither of those operationswill work at all. so it's important to know what arrhythmia you're going tosee your surgeon or what you have. a left atrial lesion set is the more extensive,which usually involves a line of block to the mitral valve and then the maze is thebi-atrial that i showed you in these cartoons, but not everything is a maze procedure.remember the only real long-term data available are for the maze procedure. that's not tosay this other procedures don't have roles. they do. but you need to know what you'regetting and you need to make sure you understand that when you're having it. this again isa cartoon of what the lesion set of the maze four looks like.

then what do you need to know as a patient?one thing i would do is, if you're going to surgeon and you're not sure he knows how todo it, often just look for his peer-reviewed publications and even as patients, you cansearch those on google scholar or medline. i would pay more attention to that,which means that they've been reviewed by other doctors and we felt them to be credibleand not so much attention to paid advertisements. and generally people who are taking billboardsout, there's usually a reason for that. and usually not a reason why you wouldwant to go to someone who does that. personal websites, some of the internet stuffis really bad in this area and i'd just be wary as a consumer. be carefulof people touting minimally invasive but if

they're not following the patients, they mayalso be minimally effective procedures, which is not so great. so with that, i'll stop andwill be happy to answer any questions. thank you. dr. philpott: as a prefer, kind of a starter formy talk and i've been given the charge of hybrid ablation and really what i see is thefuture of the care for atrial fibrillation, at least from what we've learned from thehybrid experience, which is this heart team model. i certainly hope it is.but kind of as a primer, i wanted to let you know where i was from. this is norfolk, virginia and i'm not a hospitalemployee yet but probably will be in the future

and the hospital that i work in is sentara,the heart hospital. sentara is a large network of hospitals across virginiaand also in north carolina. what you see here is the main complex which is in norfolk andthis is the norfolk general facility which is about a 500 tertiary care facility. right there at the front is theheart hospital. the heart hospital is about 109 specialized heart hospital where we basicallyare trying to be a quaternary care center and take care of anything that's even remotelycomplex in the field of heart surgery. and we're very busy. we do right arounda total of 1,900 open heart cases or cardiac surgical cases a year. about 1,300 to 1,400of those involve the heart-lung machine and

we're very busy in terms of our cardiologyside as well, particularly with electrophysiology. to do this, we've assembled an incrediblyexperienced team. we have four operating rooms, seven surgeons. we're not an academic centerbut we've led nationally. we had one of the past presidents of the society of thoracicsurgeons. probably, the cornerstone of our team are these four electrophysiologistsand they're very dedicated to looking at new and innovative ways to treat atrial fibrillation.and particularly the harder forms like persistent and long-standing persistent atrial fibrillation. if there was a star of the team, it's thislittle lady right here, is lynette and she

has been the cornerstone in all of our trials.she's the one that's allowed us to be a leader in our trials nationally and we've done agood job with that. we were the lead enroller in the ablate trial. we were thesecond lead enroller in the post-approval ablate study and we've been the lead enrollerin both of the hybrid evolutions [deep] which have come along. i want to tell you a little bit about thehybrid procedure and how it came to be. as dr. damiano has already discussed,the maze procedure works beautifully. but its one flaw...well, it actually it has two.one of them is that it's hard to teach surgeons to do it, which i don't completely understandbecause if you spend enough time

with them, it is absolutely something youcan teach. the second one though is that people were just not doing it. in an attempt to come up with an approachthat didn't involve opening the sternum and going on a heart-lung machine, surgeons startedlooking at a minimal access type of way of getting to the left atrium, in particularthe pulmonary veins. you've heard how the wolf procedure started with bilateral pulmonaryvein isolations and so forth. well, the next generation of that was this idea of a totallythorascopic lesion set. i think i'm missingone slide here. but the totally thorascopic lesion set was really driven by a surgeonnamed john sirak and john is an artist. i

think you probably will get this analogy.if you're a professional musician and you go to hear a concert where there's multiplemusicians and there's somebody that really stands out, you can probably pickhim out whereas a lot of other people may not be able to. when i started travelling around trying tofind a platform that was going to work for us, i actually went and saw some people operate.john was one of the ones i went to. dr. edgerton ironically was the other one and of coursehe's not here today but they both created this procedure called, in john's hands,the five-box totally thorascopic maze and with dr. edgerton, the dallas lesion set,but basically they were the same thing.

the idea was to do it, and all of thelines on the left side of the maze procedure, thorascopically. when i saw it,i knew that he could do it but i knew that i was never going to be able to do it. secondlywe had this idea of, wouldn't it be great if we started working together because theelectrophysiologist can do amazing things that we can't do, like test lesions.however, they struggle to make long, complete lines. well, we're good at making long, completelines but we struggle with our testing. so as we started looking around we found that,of all things, holland was a little bit ahead of us. the reason for that is becausein holland, they have socialized medicine and the way that works is each hospital isgiven a certain amount of money and that's

what they have to spend for the year. so inunited states, if you have a catheter ablation or surgical ablation and it's afailure and you come back for another procedure, well, you get paid for both of those. in holland, on the other hand, if the patientcomes back, then that takes money out of the pool that could have been there for somebodyelse. they found out that, by doing a hybrid procedure together, they were saving moneybecause the patients weren't coming back. when i started to learn how to do the mazeprocedure, and i thought that was a great piece of advice, ralph, about going or findingout how it is that you learned how to do this,

so i went to wash. u to learn how to use themaze. we turned around and went to holland to try to find out how to do the hybridprocedure. this is a little cartoon that i'm going touse that shows, kind of in a rough diagram, of what we're trying to get to. these circleshere, those represent the pulmonary veins. this is the left atrial appendage,up at the far left there, and this is the mitral valve. in a hybrid procedure, first the right-sidedveins are isolated and then connecting lesions are drawn over to the other side.then the surgeon switches sides and goes to the left side of the table where the leftveins are isolated and then a line is drawn

to the left atrial appendage. finally a lineis drawn down to the mitral valve. now in an open surgical procedure like a cox maze,we're able to make that line completely down to the annulus and anchor it; but ina hybrid procedure, this is where the team comes in. so now the electrophysiologist will come in andwith a catheter they could come in and complete this lesion down to the mitral valve annulus.then the beauty of it, and i still believe this is the strength of it, isthen they could come back and they could start to check our work. now in norfolk, where yousee these little ablation lines right here this is where they would all be broken onmine. and i would say that in about 30% of

my cases, they would find a break. so we came back and we convinced our hospitalsystem to change the hybrid room that they were building. they were already getting itset to do trans-aortic catheter valves that you hear about, the valves thatgo through the leg. and we got them to ground the room and turned it into pretty much thestate of the art hybrid operating room on the east coast in its day. we found some ofthese crazy nurses to give us a hand and then we started doing the procedures. here we're starting off on theright side. now in the control room they are able to look at all the electrophysiologymonitoring, but they can also watch our camera

work as we're moving along through the case.then we switch to the left side and then once that's over, now i'm talking to my electrophysiologist and he is taking over on the case. he's now getting access and now he's up andrunning. now i'm going to show you some of the results because we're just in the processof reviewing the first trial. we just got access to the data. they're notconfirmed yet and this is going to be sent for publication but this is the rough resultsas they've come through. the first evolution was the deep one and thesewere the six centers that were involved in the trial. and again, this was a trial lookingat safety; how safe is it to do the procedure? and we were the first enrolling center, ithink that's 2010, and the success rates were

okay. now this was a tough type of afib we'retrying to tackle. this is persistent and long-standing persistent. many of the patients had been in afib formany, many years and they had large left atriums. but i wanted better results than this andso did other investigators in the trial. i figured if we were going to this hard, weshould be getting numbers closer to 90. now in time, that may have been toomuch to expect, but that's really kind of what we were shooting for. the green is offdrugs, the blue is on drugs. but the problem with this procedure, as dr.natale has already spoken about, was the complication rate. if you're going to do somethingfor afib, i really believe it's got to be

incredibly safe. it's got to be effective,but it's got to be incredibly safe and the complication rate with this first trial wasdefinitely too high. in fact, the trial was stopped because there was a death in the study at about 30 days after the procedure was performed and nobody knows why the deathoccurred, but in my own mind, i've got to think it had to be somehow related to theprocedure. so people started thinking that maybe we shouldseparate it. so the next evolution was, how about we separate it but we doit at the same hospitalization? and this would have shorter anesthetic times and so forth.well, this is my observation with that. now again, each center can only enroll 10 patients,so we were the lead enroller here and i had

some concerns. the biggest one was, after a couple of daysafter we went to surgery, the whole heart was swollen, particularly where we'd donethis ablations. it was full of edema and swelling and water in the tissue and that was handicappingour electrophysiologist. because then when they would go in and they wouldlook at the lesions, now our lines looked like they were complete but really they wereprobably just stunned and swollen and after time had passed, then we would start to seethe failures. so the next evolution of the trial, whichhas just opened up to a pivotal trial and now this is much bigger, is goingto be hybrid iii and this is going to be separated

by 90 days. so it's still a hybrid trial,but not the same time. you're going to come in, get the surgery and then 90 days is goingto pass, and then you'll have the electrophysiology portion of the procedure. we feelthat by doing it this way, it's going to maximize the testing quality by minimizing the edema. now again there's going to be a bunch of sitesthat're going to come on board right now. here are the sites that are currently enrolling.i'm sorry. the only site that's currently enrolling is pinnacle health, which is upat the top. sentara will be coming in second and the others should be coming in short orderbeyond that. if a hybrid operation is something you're interested in, i think that'sgreat. i frankly would not have a hybrid operation

unless it was in one of the trial centersbecause i believe that's where the best surgeons and electrophysiologists are. and that's probablywhere you're going to have the most experienced providers. so to kind of sum up what i thinkabout hybrid, i think it's promising but it's not for the faint of heart. there's a steeplearning curve here, folks. there will be conversions. what do i mean by conversions?i mean there's going to be a hole in the heart that bleeds and the team has got to be ableto get the chest open and on the heart lung machine and get it repaired very,very quickly. this is going to be something that i think higher volume centers are goingto be able to do because they've seen it and

they have experience with it and so forth. but i think if you go into a hybrid procedure,you've got to know that there's a conversion rate. in our own practice, it'sabout 20% and we convert with a low threshold. if something doesn't look right or we're notcomfortable with it, we open. so every patient that comes to our or for a hybrid procedurehas actually consented for both a hybrid and a full cox maze. now the four people thatwe've ended up opening are all in sinus rhythm and they all did great. butthe reason is because we did not piddle around with this. they all knew exactly what ourgame plan was going to be and we did not hesitate. so what do i think about the hybridcompared to the classic maze? well, the timing's

different. with the classic maze, it's allat one time. the hybrid is staged. the classic maze does involve the sternotomy, but thehybrid involves about six ports on both sides. so the immediate post-op painfor the first couple of days is actually pretty similar. the one-year success rates are differentthough. there's no question that the classic maze i think is significantly better. i amwaiting to see what the hybrid long-term success rate is going to be. i hopeit's as good as the classic maze but i really doubt it. i don't think there's any way it'sgoing to be nearly as close. the biggest thing i want you to focus on hereare the complications. the open maze is an incredibly safe procedure and it'sfast, particularly in experienced hands. if

you have a surgeon that knows what he's doing,this is not a hard operation. it's really not. it's something that takes about two anda half hours to do and it's in-out, completely done. whereas the hybrid, it does take a long timeand there is a steep learning curve and frankly i think it's harder to do. theproblem with the classic maze is getting access to surgeons who are really good at it, who'veperfected it, who've made it a passion. if you have access to somebody like that, i thinkit's a very viable option but it does involve the sternotomy. so what about unintended outcomes? well, thefirst was that it put us on the map and everybody

got interested. i think this was the slidethat wasn't there before, but this is john sirak. he does a beautiful job with this.so how do we handle someone like that at the heart hospital? well, the answer is, we hiredhim. we think that he's going to be great for the hybrid iii and he's going to bringa whole skillset to the table. so he's coming on board with us and he'll sitright next to me and we've already had a good collaboration for the last two weeks. he juststarted. the other thing though is learning from masterslike the man to my left. dr. damiano has really perfected this minimal access or minimallyinvasive right chest procedure and it's safe. it's the full maze and it's usingthe most powerful ablation tools we have to

make these lines. i think that it is somethingwe definitely want to have on the table at norfolk and we're planning to do that. the other part that was the real win withour hybrid experience was this idea of the heart team model, and that i really thinkis the future because it focuses the strengths of multiple specialists all working togetherfor the same goal of trying to do the right thing for the patient and bringing all theoptions to the patient. the biggest thing that it did wasit allowed us to collect data on our outcomes. how were we doing? where were the complications?this was really incredibly helpful because it allowed us to begin to tailor what we wereoffering to different patients based on best

practice design. i want to talk a little bit about this, theheart team model and getting patients to expert centers. the story i'm going to tell, andmellanie's heard this before, but it has to do with this transplant. i do love arrhythmiasurgery but i also do a ton of complex vascular and artery constructionsand i love heart failure. in fact, i'm late to this meeting becausewe were doing a transplant last night and it just is one of these things where wheni get older, i will probably stop because it's a young man's game. but it'sdefinitely something i love but good lord, does it have drama associated with it.

so let me tell you this story. so we're doingthis transplant and i've cut the heart out of a person. now that's a bizarre thing. imean, as many years as i have done it, it's still bizarre. they're right belowyou, you're looking down to this cavity, the cuts are there for you to start sewing thenew heart in, but when the new heart hasn't arrived, it's anxiety-provoking. you're juststaring at it. you keep piddling with instruments and suture because you're ready to go. so my partner comes into the roomand he kicks the cooler with the heart across the floor and goes, "here it is. have fun.it's an appropriate match." he takes the blood type and he slaps it on the side of the cooler.so the team opens the cooler. now remember,

the hearts are almost frozen. they'renot completely at zero but they're very, very, very cold. so as soon as the heart is exposed,it starts thawing out. and this was a heart that we got in our owncenter which meant it didn't have time to really get super-cold in the cooler on theway down. believe it or not, the ones that are right there that don't havea long time sometimes can do worse. so they go, "we can't hand you thisheart, dr. philpott. the coordinator is not here." well, there's this brand new coordinatorand she was having trouble going from one part of the hospital to another. i, you know,"you got to be kidding me. for crying out loud, give me the heart. we'vegot to sew this thing in."

there it is in the bag and it's kind of gettingwarmer and warmer and my stress level is starting to get a little higher and higher and theystill won't hand me the heart. so i said, "you know, this is that thing that went downat duke where they put the wrong [00:50:15] heart in the person." so they're not goingto hand it to me unless i break scrub and go get it. so i did and as i'm coming backwith the heart, one of the team members said something and i thought i handled it reallyprofessionally at the time. [laughter] i think all surgeons probably have a trigger point,ralph, wouldn't you agree to that? i don't remember all the words that were said,but apparently other people did. i was still pretty hot about it the next morning, evenwhen i was sitting in the administrator's

office trying to explain what the deal was.and you've all seen charlie brown, right? you remember like when the parents would talkand it would be kind of like, "blah, blah, blah," you could never hear what they weresaying, right? so as we're sitting there and i'm getting madder and madder, telling thestory. the patient, by the way, did great. i mean, he did fantastic becausei did grab the heart and sewed it right in. of all things, i went into afib and i knewexactly what it was. i mean, she's sitting there talking but she's in charlie brownmode. i don't remember a word she said. i went over and i started taking my pulse, i'mlike, that's about 150 if i'm counting it correctly. and i'm trying to look at my iphoneto time it all out. i said, i wasn't dizzy

or anything like that, but it was kind ofcool at first. i was like, so this is what they're talking about. i get itnow. you know and yeah, it is really fast and it's jumping all over the place and themore i'm thinking about this, it is fairly anxiety-provoking. there's some of my dashboard that i haveinternally that you may not have, but i could get the sensation in the center of my chestof fullness and that had to be the left atrium and just the fact that it wasn't, probablyfilling a little differently. it was a fascinating thing until i started thinking about this [how long does it take for a clot to form?].now that changed. my dashboard is a little different because this is whati was seeing. how long does it take for that

guy to happen? now here i am, i put a lot of work into becomingas good as i am right now. we all have, all cardiac surgeons have. it's about29 years professional work. and as i'm sitting there, i'm thinking, all it's going to takeis one little piece to break off and kaboom, it's all gone. but you know, i'm not justa doctor. i'm a dad. i've got a family. i've got a beautiful wife. i sat therein that chair and i started thinking, my god what if i couldn't talk to them? or how wouldit be if i had a huge limp and i couldn't do all of the things i love doing with them? this is what i was thinking about.it doesn't take much. and it's russian roulette.

if it goes to your toe, great. if it goesto a little part in your brain, you're in big trouble. so the idea of a stroke i foundto be very unnerving and then, this is right...it did break, by the way, so...butbefore it broke, this is where i really kind of hit the wall. who would i trust to do my ablation? now i'ma cardiac surgeon. i don't know a lot of electrophysiologists. i know mine. i'd let haissaguerre do it. iknow what his data is, i kind of trust him. but then i asked this questionand this one was even worse. who would i trust to do my maze? there is one personwho i would allow to do my maze and he's sitting to the left of me. now, i've gotgreat partners. i don't know if i would let

them do my maze. i don't know if they wouldbe complete about it. and i realized that my questions were thesame ones you all have been dealing with. who do you trust? how can you findthem? how can you find the real deal and when you find them, you should get straight answersto this question, what is the real answer to your success? and no bs, whatare the risks? what are my options, without any bias? these are my four guys. they're all greatguys. they're fast, they do a lot of work. i have no idea what their success rates areand neither do they really. the bottom line is, here i am, i'm in the innercircle of experts on afib and i've got no

clue who to go to. guys, this is a huge problemfor both of us. so, what would i want personally?this is what i'd want. i want it to be just like tavr, just like those aortic valves.i want to go to a heart team where all the physicians are incentivized just for one thing,doing the right thing for me. while i'm there, i want them to look at all theoptions and have a very high confidence that their numbers are not propped up, that they'renot shoddy numbers. that they're really hard numbers. that the center is very transparentabout that and honest. and i don't want to go see a dabbler, no dabblers. youcannot go see a dabbler with this. you've got to go see a pro. high volume.

the reality is far from this dream that ihave. without this team, frequently each doctor wants to use their hammer and there'smass confusion. there's this problem with power and success that just gets into thesubconsciousness of many providers. and frankly there's ignorance. ignorance doesn't mean stupidity. it just means lack of knowledge, but there's a lack of knowledgeamongst many physicians who are treating afib because they don't know all the options. in fact, the vast majority of them don't knowthe first thing about them. to make matters worse is the internet. the internet isabsolutely full of very confusing success reports and different treatments and franklya bunch of charlatans that are out there trying

to build a small program. and that's generatedcircles of mistrust. many surgeons don't trust the maze or catheterablations. eps definitely don't trust the maze and frankly they really shouldn'tbecause for the vast majority of our colleagues, they haven't done it correctly, so that'sour problem. general cardiologists crack me up because half the time they don't care andthe other half the time, they don't trust either one of us. and patients ironically, well,they trust just about every doctor they talk to. i can't help but see the irony in thispicture. i envision you on one side and the person you really need to get to onthe other. and our system has made it nothing

but a nightmare to try to get the people whoneed to get to the experts to the real-deal experts. so at a training meeting of all things outin napa, california over a couple of bottles of wine, all the hybrid ablaterswere all there and we started sharing similar stories. we came up with this idea that maybewe needed to try to leave some bread crumbs for patients to try to get to the high-volumecenters. we talked to mellanie about it and she thought it was a very goodidea. so we came up with this idea and this is thefirst one out of the gate, but there should be other alliances. but this is the nationalalliance of integrated af centers, and we

just got this off the ground, so it's brandnew. and it has lots of problems in it because we set the bar so high that evengetting the initial member centers in there to hit the bar has been tough. so there'slike a three-year window where you've got to prove that you can hit these marks or you'reout. but basically these are regional go-to sitesand they have these common mission goals of being patient-centric, using a heartteam with a multidisciplinary approach, you get all the options. it's got to develop thisidea of credibility and trust. otherwise we just missed the mark and we reallywanted to lead, but this is the tough part. we've developed a database which we're betatesting now and this is going to include any

ablations. catheter ablations, surgical ablations.if you have an ablation and you're in the alliance, then the data's going to go intothis and it's going to compare you straight up, head to head. that is goingto be incredibly important. the centers have got to be involved in research, best practices.we want to meet semi-annually and it's got to be easy to get to on the web,but it's the data that's key. so here's the vision. in the beta testingprocess, we've already started looking at this in norfolk. and this has been fascinatingbecause we're learning tremendous amounts already. now remember we don't have thefive box on board yet, nor do we have dr. damiano's procedure here, the minimally invasiveone. but we had everything else and we snapshotted

data so that we could start looking at it.the question we're trying to answer is this, here we are, we're in norfolk. let's lookat persistent afib, at what works in our hands. now we don't have two, five, ten years successrates, but we do have one. and frequently we will have two. we do have the complications,we do have the length of stays, and we do have the hospital costs. that data has beenfascinating. it's been really fascinating looking on the catheter ablationside. now we haven't gotten to our problems yet on the surgery side because we're allover the map. but on the catheter ablation side, it wasvery interesting looking at the four guys

and the other two that also do ablations onthe side to see how their perceived ideas about what was working didn't exactlymatch when we showed them the data. there's a pattern that you can see there where they'vegot some guys in the middle in terms of success, you've got one guy who is incredibly good.we have no idea who he is because it's all blinded. and then you got a couple that arenot as good. well, this kind of data allows you now asa team to sit down and say, wait a minute. this guy is using all these expensive piecesof equipment and he's got terrible success rates. whereas this guy over here has gotgreat success rates at a fraction of the cost. let's go figure out what he's doing.then let's go back to the other guys and train

them up. this is the kind of power this kindof integrated approach suddenly gives you as a system. now i really believe that this outcome datais going to be the cure-all for a lot of afib. it's going to dispel all thesemyths and it's going to guide not only the patients, but it's going to guide the centersabout the best thing to do. the other key is that patients, and you guys know this clearly, i mean, we want the right data. we don't want haissaguerre's and we don'twant cox's. we want the doctor that's going to be doing our procedure. center-specific,actual outcome data relevant to our types of afib.

so if you're a 54 year-old female,you've got long-standing persistent, you've had multiple prior catheter ablations, andyour atrium is 4.5, if we set this up and it goes national and other centers get behindthis, this is the kind of report card you ought to get. individualized for you. nowit's not going to happen in the next year, it's probably not going to happenin the next five. but hopefully in the next 10 years, this kind of data reporting is goingto guide people to what they really ought to get. so early on, this was the vision that we'retrying to lead with. you know, afib occurs. you go to a national website, hopefullya good website like stopafib.org that you

can trust. this brings you to naiac or youjust find naiac on your own. or another organization. it doesn't have to be naiac. just somethingthat is trying to get the best practice groups that are leading in research together. now just to give you an idea of what we wereable to do. this is the naiac site. if you click over on the integrated centers, allfive of the initial sites are up. and then if you click on that, then it getsyou to us, or to the center in your group that you want to check out. there's the contactform that if you click on, suddenly gets you into the clinic where you ought to be talkingto a team. but guys, this is easy to figureout. if you go to a place or you see and you're

just talking to one person, you're not inthe right spot. okay? it's really going to be that easy and they ought to be able toshow you a report card. not tell you, "oh yeah, our results are 90%." mm-hm.it ought to be down on paper or preferably what it really should be is published. becauseat the end of the day, this is kind of what you deserve. now this is what we're aiming on trying toput together in norfolk and in the other sites across the country that are in the naiac alliance.and we're going to be opening it up to other centers. we very much would liketo have big centers like wash. u in it as well and i think that's going to come in time.mark lameir's center over at maastricht

just joined up, but it's this kindof collaboration together as the heart team model that i really see as the future. and that's maui. [laughter] thank you very much. [applause] all right. so i also have the honor ofgiving dr. edgerton's talk and our prayers are with dr. edgerton. he fortunately wasable to go over his slides with me and i'm going to do the best job i can. i think thisis a very good talk. i'll go through the first section maybe a little quicklybecause we've really kind of covered it. but jimmy does a very good job at the endwith a couple of scenarios that i think you'll find interesting and maybe we can solve themtogether. the last part of this talk is going

to be audience participation. again you alreadyknow this, afib increases the stroke rate three to five times, the death rate isprobably a two-fold increase. the longer a patient is in afib, the more difficult itis to treat and eliminate the rhythm. it's classified a couple of different ways.this is one way of looking at it, which is the hrs definition of paroxysmalpersistent or long-standing persistent. but the other way you could look at it is dividedinto lone afib or concomitant afib. as dr. damiano has already said, the concomitantafib side of the story is something that we surgeons have got to take this bullby the horn on and lead and make people start getting up to very high intervention rates.i mean, the newest data is showing much less

complications if you go ahead and do thisprocedure correctly. so the onus is on us surgeons. for you as patients, again if you're goingto see a surgeon and he doesn’t know what he's doing with the maze procedure and ifyou have the time to make the...if you don't have the time, it's critical and it's life-threateningthen you just need to go ahead and get operated on, but if you do have time, itwould probably behoove you to seek out a surgeon that knows exactly what they're doing with the maze procedure and get your concomitant surgery there. the way i kind of like to think about afibthough is paroxysmal versus everything else.

so either they are paroxysmal,which is trigger-based or they are non-paroxysmal, which is probably multi-factorial and rotor-based.notice that chronic afib is not a medical term used anymore because it really doesn'thave a medical definition. so the regular contraction of theupper chambers are followed by the lowers after a little short pause and you get this lubdub. the electrical wave spreads rapidly throughout the atrium and then all the atrial musclefibers contract simultaneously. after the atrial muscle contracts, it's silentfor the next couple of electrical waves and then the atrial electrical wave stimulatesthe av node. the av node has a short delay and then triggers the lower chambersof the heart. and that's the lub dub.

now in atrial fibrillation, you have thesemultiple circular circuits and the atria end up quivering without any effectivemechanical contraction. there's no good pumping action and so you have this decreased cardiacoutput. the av node, when you're in atrial fibrillation,is utterly pummeled by this gigantic number of electrical waves that are hitting it.that's why it's irregularly irregular. you know, it has this short pause and it's tryingto process as many of these beat orders, so to speak, as it can, but it just can't keepup and that's the reason why it's so irregular. less blood is pumped through the heart andwith the stasis of blood in the atria, that's where the clots can form. againif something does form, it's just kind of

russian roulette in terms of where it goes.it can cause a stroke, a blue toe, dead gut. key points to remember, the electricity spreadsfrom cell to cell. it's not like something that's in a voltage wire. it's verymuch the depolarization and the membrane of one cell touching another cell, triggeringit to depolarize. almost like a fire that's moving or rows of dominoes that begin to fall. and the electricity cannot cross a scar. so if you set up a series of scars,then you can direct the flow of the electricity just like the maze procedure in the sundaypaper. problems? well, the biggest one that jimmylikes to talk about is this feeling of impending doom. that may be a little much, but definitelyyou just don't feel well. you really just

don't feel like yourself. palpitations, flutteringin the chest, lethargy, fatigue, feeling washed out – that's probably one of the ones wehear the most. an inability to do much with any exertion. this frequentlyis out of proportion to the activity that is being performed. and again it's probably related to the decreased amount of blood that's flowing. stroke we've already talked about,but this again is one that is interesting to me. and this is one of the reasons whyi got interested in arrhythmia surgery. i would see lots of folks that had afib andsome folks can tolerate afib and others flat can't. their hearts suddenly become very weak.

so treatment options. well, firstthere's cardioversion, which can be pharmacological or electrical. rate control and anticoagulation,where the heart is slowed so that there's more time for adequate filling of the lowerchambers and you prevent stroke from blood clots from the anticoagulation. i would just say the cox maze,either iii or iv. probably iv. open chest procedure. i think he's got eight points downhere. now this again is in my mind still the gold standard. jimmy describes thisas a big operation but i don't completely agree with that. i describe a big operationas one that has a complication. or one that you really struggle to get through. if i do a three vessel bypass or a mitral

valve repair, it's usually two and a half hoursor so, ralph, wouldn't you say? something like that? a maze procedure is less, guys.it's quick in experienced hands. it does involve opening the breastbone, but people tendto tolerate that actually much better than they had thought. so here's dr. edgerton's description of howthese rotors...and they're illustrated by the circles on the diagram that you can see here...that these circles are just spinning around and churning inside the heart.there's usually multiple ones, like four or five of them. and if you just go to wherethe pulmonary veins are, which are right here, and isolate them, that's great. you've takenthe triggers out of the problem, but you haven't

solved anything else. this is why pulmonary vein isolation alonejust traditionally has not done a very good job with persistent or long-standing persistentafib. in other words, non-paroxysmal afib. in other words, non-trigger-based afib. whereasif you are able to put in this ablation lines, then you can break up thesepotential circuits and have a better success rate. then there's catheter ablation and that includesav node ablation and a pacemaker, which is my least favorite and i think all the electrophysiologistswould probably agree with me there in pulmonary vein isolation. now when i firstsaw this slide, i just kind of would freak

out a little bit because it just had too muchgoing on, but don't let it. this is from haissaguerre's initial work and i think this was the onethat was in the paper. this is the heart, kind of schematically drawnout, and let your eyes follow to where the red dots are. just kind of stepback for a second and let your eyes go to the red dots. you can see there's none inthe septum, there's a couple out here on the right atrium, about 10% actually. and there,90% of them are in the pulmonary vein. so naturally if you can isolate those pulmonaryveins, if you can draw an electrical dam around the pulmonary veins, then you should be ableto treat paroxysmal atrial fibrillation very effectively.

so this is pulmonary vein isolation.we've spent tremendous amount of time on this already so i'm going to move a little quicklythrough here. this is a schematic of a heart diagram showing perfectly placed lines whichfrankly, guys, i got to tell you, catheter ablation and getting these thingsto line up this beautifully is incredibly difficult. and i think the same thing appliesto thorascopic complete mazes. there are artists, many of them were in this room earlier, thatcan do it and then there's the masses [01:10:45] that cannot get these dots to line up nearlyremotely closely. it's incredibly difficult to do. and there are some people that cando it and others that really struggle with it.

when we look at the success rates of paroxysmalversus persistent afib after a catheter ablation at a longer term, in theearly period it looks pretty good but long-term you can see the difference. paroxysmal doesmuch better than persistent or long-standing persistent atrial fibrillation. again it'sbecause we really need these additional lines, other than just pulmonary vein isolation,which are accomplished here. that brings us to the closed-chest maze, whichi've already spoken about so i'm going to move a little quickly here but this is theevolution. in 2004, dr. edgerton, and this is actually dr. mike mack who's standingright next to him here, went and spent time with dr. wolf and learned how to do the pulmonaryvein isolations thorascopically.

but then again for persistent, we needed morelesions and for the closed-chest procedure, that meant something like this. and this isthe first iteration of the dallas lesion set, where you can see they've drawn an additionalline up to the aortic valve here to stop a flutter wave that can circle aroundthe aortic valve and the mitral valve. this is the dallas lesion set, completed. thisis also the identical five-box lesion set, which dr. sirak performed. with closed-chest, there is endoscopicvisualization, pulmonary vein isolations are carried out, the left atrial appendage isexcluded and that, by the way, may be one of the best things about any of these thorascopicprocedures, is that the left atrial appendage

is gone. so even if you fail itand you go back into afib, you have a dramatic protection now that that appendage is outof the way. he has a couple of photographs showing here, this is the same set of portplacements that we use in norfolk. this is the left side and now this is detailinghow we've gone through the initial hybrid, the first evolution of the hybrid followedby the staged hybrid. so this is where we're going to move intowhat do we do for what? now remember for surgeons and electrophysiologists, wereally need to be focusing on the risk-benefit ratio. in other words, doing the safest, mostefficacious thing for the right patient, depending on their needs. so for someonewho really has never had any trouble with

their atrial fibrillation, is doing beautifullywith it, they're going to get one set of options. for someone who is having life-threateningcomplications from it, they're going to get another set of options that may bemore risky but they also match the indications for that person's atrial fibrillation. let's go through these kind of one-by-one.this is the first one, and again i invite you to jump up in the audience if you wantto. we'll just kind of make this fun, if you will. first one's a 78 year-oldwoman. now she has long-standing persistent atrial fibrillation and she's had it for 13years. she’s on digoxin, she's on a beta blocker and she's on warfarin and she reallydoesn't have any symptoms. she

has no history of any complications. her primarycare physician though has referred her over for consideration of options because he'sworried about her stroke risk. so what would you do here? who would sendher for a catheter ablation? raise your hands. nobody. who would send her forsurgery? nobody. this lady is doing beautifully just the way she is. she needs to be leftalone. nobody needs to be doing anything to her. all right, so that was thelay-up. they're going to get a little harder. now i didn't come up with these. this is alldr. edgerton. he assures me that they're not actual, but they do have different elementsthat are actual. so this is a 38 year-old man. he's a marathon runner. hisfirst episode of afib was 18 months ago. now

he's really symptomatic with this. he hasepisodes three times a week; they last three to eighteen hours, less if he doesn't run.he's failed sotolol, he's failed a catheter ablation, and he doesn't believein taking drugs. now he's on amiodarone and he has an episodeabout twice a week and they last two to twelve hours. he hates them. they leave him drained.he can't sleep for days after he has one. he's told us his ep told him to quitrunning. that part unfortunately is true. and to have another catheter ablation. nowhe's angry and he's come over for a second opinion, to see what you have tooffer for him. now what do we think about this gentleman?

audience: he needs some help. dr. philpott: he needs some help. now is he life-threatening? dr. philpott: not like i'm thinking. i'm thinkinglife-threatening like he's got a clot in his appendage or his heart has tankedand he's in congestive heart failure, but his life is a mess. his quality of life hasbeen completely blown up by his afib. what kind of afib does he have? he'spersistent, clear cut. now remember if you have an intervention,let's say you're paroxysmal and you go in, you have a catheter ablation...or let's sayyou're persistent, you go and have a catheter ablation, and now you just have afibevery now and then. are you paroxysmal? no,

you're persistent. so he's persistent. sois there a decent chance that pulmonary vein isolation is going to have a dramatic, aredo pulmonary vein isolation is going to have a dramatic improvement? it may have someeffect, but maybe not as much as we would hope. so what are our other options for him? he is a candidate for a mini maze or a hybridmaze. any other options? he is a candidate for an open, if he wanted it. and again thisis where you'd would sit down with him and you give him all the options. and it's prettyamazing to me with the clinic model where we do this because i'll frequently,both of us, me and the electrophysiologist will go in the room and we'll give him allthe options and we're sure they're going to

go one way and they surprise us and go another.ralph, what do you think? what would you do at wash. u? dr. damiano: first i'd just like to correcteverybody because i thought i made the point, but we're still confused now becausefirst of all, a mini maze is not a maze, if the way i think you're trying to refer toit, if you're talking about surgical pulmonary vein isolation, that's what we should say. as far as i know, no one's ever donean off-pump thoracoscopic maze to this date and i know everybody in the world. peoplehave done ablation procedures thoracoscopically but it's wrong to call them a maze and i thinkconfusing for the audience still. so i would

absolutely challenge the terminologyhere. unless they're contraindicated we don't do mazes through sternotomies and haven'tfor many years. so i don't think that's a difference. so if you're talking about a hybridleft atrial ablation which are most of the...or, you know, here are the choices for this guy,are another second catheter ablation, and if dr. natale was here, i think he wouldfavor that in a young guy if he had a small atrium. you could argue and depending, i agreewith what you said completely, it depends on who you're seeing and what theirsuccesses are with the individual procedures. dr. philpott: at wash. u, what do you think hewould get?

dr. damiano: well, since he's had afib for...wewould offer him an option of either a thoracoscopic procedure of a left atrial procedureor minimally invasive, but when i say minimally invasive maze, i mean a full maze. it's dependingon your results. i would tend to agree with dr. natale that, at least in ourinitial, we don't have as big experience as you guys have with hybrids, but our feelingis that the complication rate with hybrids were higher than either catheterablation alone or less invasive maze procedures alone. the fact that he's already failed a catheterablation, we probably would not consider him for a hybrid and would probablyrecommend either some type of a surgical ablation.

usually someone like this, if he had his catheterablation from outside, it depends on who did it. like you said, i think it's a team approach.so we would let the electrophysiologist also see him and see what he thinks. and then i think it's your own success rate.i mean, this is a guy with a heck a lot of his life, he's only 38, really doesn't wantto be on drugs. if you're going to go to surgery, at least it's been our approach to go withthe one operation that we know has the highest success. knowing that it's difficult...certainlyif you do a thoracoscopic procedure first, then you can't do the minimally invasive mazeas a follow-up. you have to go through a sternotomy because of all the scar tissue.

so we'd let the patient make achoice. my own favoring...obviously as you said, everyone has their own hammer...butwe'd probably favor, a guy like this, the minimally invasive maze procedure.in two weeks, they can go back to full activity and the success rates have been good in thispopulation, depending on various different things. but i can't say that i would be adverse,depending on different episodes, different factors. we certainly would lethim talk to an electrophysiologist too about, like you said, it's a team approach. dr. philpott: okay. any other thoughts on thisone? all very good points. all right, we're going to escalate it a little bit. thisone's a little harder. 58 year-old man, unemployed

for four years, now he has a job. so rightoff the bat, guys, we got to do something for him that's going to keep him employed.his first afib episode was four years ago. he's now long-standing persistent.on his monitor, his heart rate is 120. now that's a problem. so this guy doesn't haverate control. he's in the risk of having bigger complications. he's failed sotolol, he's failed an initialcatheter ablation, he's on amiodarone, and he only has episodes of two hours to twelvehours twice a week. these are frequently very symptomatic. these are a little worsethan, "i'm just feeling bad." this is, "i feel like i'm going to pass out." the otherimportant history point here is he's had an

infection. an empyema, in fact, of his leftchest that was drained 12 years ago. he is a smoker with mild copd. oh and yes, on hisechocardiogram, his ejection fraction is 35%. remember, normal is 60%. so theafib and the rate at 120 has knocked his heart down. okay. take a shot at it, guys. you getto play doctor. what are you going to do for him? dr. philpott: who's going to try a catheter ablationon this one? you could think about it. but with him, i don't feel that greatabout a catheter ablation. i mean, this has gotten very serious. he's going to be in congestiveheart failure if you don't get this taken care of. you need to nip this onein the bud. and that thing about the chest

infection. all right, that's actually reallycritical because that means the left chest is fused. hybrid is out. what aboutright chest, minimally invasive, full maze? that's an option. that's a very good option.and in norfolk, we would also offer obviously the open maze. i think once welearn the right maze, we'll probably stop offering that. dr. damiano: yeah, this is a very tough patient. dr. philpott: the final one is, how about an av node ablation and a pacemaker? so any ideas, guys? who thinks that this guyshould get a catheter ablation? raise your hand. how about a hybrid maze? obviously thatone's not on docket. how about the right chest

minimally invasive full maze? here's a couplehands. nobody else? you all are all afraid to put your nickel down. how aboutan av node ablation? all right, the problem with the av node ablationis that it's not the greatest long-term thing and he's pretty young, he's 58. the problemthat can happen with an av node ablation is they can get their own cardiomyopathy, alongwith other things. but it's an option. ralph, what do you think of this one? dr. damiano: well, i mean this is a toughcase. i would definitely, you know, if he was 78, the av node ablation is a good idea.there may be some people who have had av node ablations. the problem, the youngeryou are is, one, you're pacemaker-dependent

for the rest of your life, which is not thegreatest thing. especially at 58, if he lives another 30 years, likely to have some majorcomplications from his pacemaker leads. but you know, maybe not and certainly betterthan where he is. it often does treat the afib-induced cardiomyopathy but you're right,you can get your own cardiomyopathy occasionally. it's rare. and also you're on coumadinfor the rest of your life or one of the other anticoagulants. now we probably would useone of the new drugs which you heard about earlier today. with the chest fused, we would favor...thisguy also has long-standing persistent afib

for years with a poor ejection fraction, wewould favor probably the maze procedure through the right chest. i mean, that wouldn'tbe a problem. i think you have to be careful with this. i think perhaps in somecenters, they might favor a right chest sort of box isolation. one of the problems which we really didn'ttalk about is that when you're on by the heart lung machine, all the ablation deviceswork great. the problem is off the heart lung machine, the ablation devices...the clampswork great but all the others have big problems, so it's hard to complete the lesion set. but there's been advances as, jonathan,you know in this, but we would probably tend

in this guy, who still has a lot of his lifeahead of him, to go in, manage his appendage, and take care of his afib. because you know,as you said, the stakes are pretty high. he's already developed...we assume that hedoesn't have coronary disease or any reason for a poor ejection fraction. dr. philpott: no, that would make it pretty easy. dr. damiano: probably like it's tachycardia-inducedcardiomyopathy. you know, i've been referred patients who were on heart transplantwaiting lists for heart transplant with afib and all we did was a maze and those patientsget back, usually takes about just a few months for the heart to recover.

dr. philpott: all right. that's a good case. we'dbe aggressive about this one in norfolk. okay. last case. this one's interesting. 68year-old man, he's a psychologist in family counseling. he has a daughter who's an epnurse. that may be a little clue. his first episode of afib was 15 years ago. he has episodicafib with general good rate control, i think dr. edgerton wanted to say there. he's been on and off of most drugs. he's now on a new one that he can't remember the name of it. he was afib-free for fouryears since his first catheter ablation twelve years ago. second catheter ablation changedhim from continuous to episodic and improved it for two years. but now when he's in afib,he just feels awful. on echocardiogram,

he has some left ventricular hypertrophy,which is a little thickness of the muscle wall. the left atrium is 5.4 cm. so that'sa bit enlarged. that's a good bit of enlargement. the electrophysiologist wants to do a thirdcatheter ablation, but the electrophysiologist sends him to a surgeon just toget everyone's opinion. now that rarely happens, but that means you've got an electrophysiologistwho is thinking about good options. so he wants to be collaborative and that's good. his daughter is very suspicious of surgery.she says those surgeons don't know how to do a maze and unfortunately she's correctabout many of them. she says, "i want all the doctors working together." so what's theanswer on this one? what do you guys think?

who would do a third catheter ablation?not too many. oh, a couple. okay. how about a hybrid procedure in him? okay. a few more.obviously that's probably the way this one is written to go. sole surgicaltherapies, like our minimal access full maze procedure from the right chest or an openprocedure, probably going to be a little bit too much for this one. so this one was designedto look at the hybrid approach obviously. this is the final slide. dr. edgertonalways likes to end with this one. this is the bridge over the river kwai. apparentlythere's two bridges. one of them is made of bamboo. this is the other one. i think theybombed, they bombed the bamboo one, right? well, they bombed this one, too. and you cansee the center section, it's been rebuilt

there? the take-home message with this is that, theselines in some folks for some reason, they can heal them, every now and then. so particularlywith a big operation like a maze and so forth, we'll get a late failure and we will sendthem back to the lab where electrophysiologists can frequently track down where the breakis and fix it. but it's a good ending and i appreciate jimmy for giving me his slidesto use. [applause] craig: how is the mechanism of forming thatline of lesions in your procedure technically different from the catheter technique?do you use a radio frequency probe and is the difference just that you can lay downa strip, carpet-bomb that line compared to

the poke and prod of the catheterbase? because your results are a lot better. dr. damiano: yeah, well, let me tell you thedifference. that's an excellent question. i didn't really have the time to get intoit, but...so we use different devices that you really can't use in the ep lab. firstof all, we have a really excellent environment. you can imagine, first we cansee everything. so they're just looking at an x-ray, whichcan be...i mean, you've had some of the best electrophysiologists in the world here today and they are very, very good and they get better and there's all types of...imean, the field is changing rapidly and to be honest with you, if i had paroxysmal afib,i would definitely go for a catheter ablation

first, not to surgery. i thinkthey've gotten a lot better. i probably wouldn't have said that 10 years ago, but they've gottena lot better and you saw some of the advances today that are amazing. now the one advantage you have at surgeryand that's why i think it's a shame...like, if you were coming for a mitral valve repairand had afib, make sure you get taken care of because it's your one perfectchance. first of all, we can see what we're doing. so that's a huge advantage. the otherthing is if you're on the heart lung machine, which you are for a valve surgery, there'sno blood in the heart. so that gets in the way and can be a problem with both. it's the reason why

people have strokes after catheter ablationand also why catheter ablation sometimes, even some of the stuff that jonathan was talkingabout, off pump procedure thoracoscopic, don't work. it's even worse in that situation because the circulating blood keeps you from penetrating. so we've studied, so what we can use in theoperating room, two things that are really fantastic. one are clamps. so you can imaginebecause we can see and we can go on both sides, in and out, we just take a clamp and in the jaws of the cramp are embedded the electrodes. so instead of just trying to burn throughwhere...you know, you don't have any idea really when you've gotten all the way through,that's the problem with a catheter. they can

burn, but how do you know it's complete? youdon't. craig: your clamps are bipolar? dr. damiano: they're bipolar. so the clamphas two electrodes in the jaw and you just give electricity between it. it's like a brandingiron. by measuring the impedance of the electrical signal or the conductance between the two electrodes, you can really tell when it's transmural. we were the lab that documentedthat for all ablations, for the bipolar clamps that are presently on the market. and theywork. certainly in ideal situations, they work close to 100% of the time. so it's a fantastic ablation device. the other thing that we have in surgery thata lot of surgeons use are these, like, the

cryoballoons. but the advantage in surgeryis you can see where you are going and you can really see these cryoprobes stick on the heart and we have longer cryoprobes that can do really good ablation. so it'sjust an ideal ablation environment and that's why i think it's better, because we createscars and we can make sure...you heard that they have problems with durablepulmonary vein isolation. well, we can see it. still it's not to say that it's withoutany problems, but that's i think one of the reasons. it's the same type of technologyin terms of energy, but different types of devices that make it more efficient. craig: and then just a comment. i would arguethat the reason you're seeing less surgery

is the gatekeeper, is the person doing thecatheter ablations. that would be my guess, given my field anyway. dr. damiano: yeah, i won't comment. i don'tknow. but i think, you know, a lot of my great friends are electrophysiologists.i think everyone's trying to do the best thing. i think it's true. i mean, i agree with whatjonathan says. you know, this idea of a team approach and to work closely togetherand do what's right for the patient. there's no question still that catheter ablation,all said, is less invasive still. but for some patients, it's not...it become muchmore invasive for those of you, you have a bunch of people who have had catheter ablation,it's no walk in the park. and if you have

a few of them, that's pretty invasive. yourcomplication rate gets up pretty high. shelley: dr. edgerton did my surgery in 2011. i was in normal sinus rhythm for 11 months, but now i have afib every now andagain. what would your advice be for me now that i have afib showing its... dr. philpott: well, let me jump in here becausei do have an answer for that. we're really aggressive in norfolk. when we have a failure,we go back to the lab. because frequently there's one line that has a problem with it that can be tuned up. the bigger problem is when people don't have afib, they haveflutter. now left atrial flutter after any intervention can be a disaster because it'siatrogenic, meaning we did it. we created

a couple of lines of scar and there's a circuitthat's spinning around them and tracking that down can be difficult. but it depends on how it affectsyou. if you can live through it and you're okay with it and your appendage is gone, soyou're in a high safety profile versus the regular population of folks that are in afib.that's a good thing. if it's ruining your life and you are okay with the catheter ablation, i don't think it's wrong to think about that. we've had very good success rates with thatin norfolk. frequently, i can't promise this, but in our own experience, i've been surprisedbecause the electrophysiologist...now you've

got to understand, electrophysiologists donot like treating flutter and i don't really blame them. that means they're going to bein the lab for 10 hours, but they like this because frequently they can go inand in our short experience, they've been lucky in finding out where the break was.