Nice discussion about merits and demerits of hybrid procedure

A hybrid procedure combines minimally invasive surgical isolation of PV followed by catheter mapping and ablation of non-PV substrate.

[www.theheart.org]

Murray, are you reading this? "...Calkins said the study should include more patients with longstanding persistent AF who have dilated left atria, since these are patients who have had limited success with catheter ablation. "

Murray, i think you fit that description quite recently. Here's hoping you resemble it a little less as time goes on. Best of luck to you.

PeggyM

Remember that Natale's and 3 other groups in the US tried the same thing and found that they weren't anymore successful and that serious adverse events went up slightly and they presented their findings 2 years ago if recollection serves. I think what the Dutch study suggest is that you need to have a dedicated group of surgeons and ablationists that are willing to work well together - something that may more difficult to achieve in the US with the way specialties are set up in different silos. The latter is my interpretation of Calkins' comments.

Dr. John Sirak's five box TTM procedure has a 94% success rate and a high percentage of his patients are persistant. Serious adverse effects have been neglible.

I am prejudiced of course, but if you are persistant I don't know why you would consider any other procedure. It essentially is a COX Maze done through keyholes on a beating heart.

ohioafib.com

EB

Dr. Sirak is probably a very good surgeon. Problem is nobody has replicated his results. It is also not possible for any surgical procedure including the 5-bos to map substrate so any additional lesion sets or focal points required to address non-PV triggers would be missed. I am very doubtful that the 5-box alone can better open heart cut and sew cox maze III which has around 90% success long term with a very extensive lesion set. Sirak's claimed 94% may refer to acute success and not long term success. Anyway, it is up to Dr. Sirak to provide refereed results to prove what he claims. So far, I haven't seen any. If you know of refereed papers, please share. Thanks.



Edited 1 time(s). Last edit at 06/27/2012 05:40PM by researcher.

Researcher,

I am speaking as a patient, not as a surgeon, although my 3 plus years of reading on this site gives me some small degree of understanding regarding various procedures.

Dr. Sirak's lesion set is essentially the same lesion set as the Cox Maze; he verifies each line electrically as he goes. Regarding mapping, his procedure isolates the entire left atrium with multiple boxes; I believe the idea is that non-PV triggers in the LA would be handled by these multiple lesion sets. On his website there is a detailed anatomical drawing of the surgery (as well as a video of an actual procedure).

I hear your skepticism about his high success rate but is it really such a stretch that a procedure based on the COX Maze could not approach the COX Maze 90% rate (or even better it slightly)? I believe I was the 351st patient that he performed the procedure on; it is pretty unlikely that he is going to see something that he hasn't already seen.

I am not aware of research papers but there is quite a bit of information on the ohioafib.com site. There is also information regarding setting up a telephone consultation with Dr. Sirak. I spoke with him by telephone for about 45 minutes prior to scheduling my surgery; I had 2 pages of questions and he answered every question I had.

Also regarding research papers and studies: this website promotes lots of supplemental remedies, homopathic remedies, nutritional strategies, and the like which are not backed up by any formal structured studies. I guess I am concerned that some patients here might cling to dreams of being cured by an enzyme while your post questions a legitimate and effective surgical remedy performed by a professional like Dr. Sirak. Did I misunderstand your concern?

I want to repeat what I said earlier- if you are a persistent afibber considering a procedure, you really should consider Dr. Sirak.

I appreciate the opportunity to express my opinion and share my experience.

EB

Thanks EB for detailing your experience. Dr. Sirak doesn't count atrial flutter or tachycardia as failures so we may be comparing apples and oranges when it comes to quoted success rates. If the Dutch researchers use the same criteria, then their success rate would also be in the 90's. The cox Maze lesion set would be very difficult if not impossible without open heart surgery. If I can find it again, I will post a link with the lesion set diagram. It looks like a puzzle with rectangular polygons.

Researcher,

You are incorrect about Dr. Sirak counting flutter or tachycardia; he told me that many of his failures were flutter cases that were solved with a simple flutter ablation.

Regarding your comment about the Cox Maze lesion set being difficult if not impossible to replicate; yes it is difficult but Dr. Sirak has repeatedly demonstrated his ability to do so, with excellent results.

You obviously have some problem about either Dr Sirak or his procedure. I can tell you that Dr. Sirak is not popular with some EPs (because he takes their patients away and cures them).

The following is taken from a post by DickI, who posts frequently on this site and reflects his thoughts on the Five Box:

I think the question of the sequence of non pharmacological treatements (CA & surgery) for different kinds of patients with different kinds of AF is an important one, since the landscape had changed and there are now more possibilities than before (more expert EPs, better equipment, less extreme alternatives to the MAZE, both with improving and potentially excellent results and safety.

(Thanks for bringing it up.)

I do not want to get into a full discussion of how this might work, except simply to bring up the following:...

Invasiveness is a tricky concept. It relates to both complications which could have lifetime impact and to recovery unpleasantness -- which doesn't. IMO recovery (temporary) discomfort and inconvenience should not be a significant factor in choosing treatment.

But what about more substantial invaseness effects? Is a CA with extensive burning (Dr Cox called it "carpet bombing" less invasive than a 5-box with its lines, even though the latter's access takes more incisions -- resulting in more pain and longer healing -- but presumably heals as completely as a CA. And there is radiation that is part of the picture, as Dennis mentioned.

The total invasiveness impact will depend partly on the chances of the need for two procedures. A figure given for CA is 20-30%. If there is significant probability of a second procedure there will be a significant chance that you would be subjecting yourself to two invasions, so why not do the procedure with the best chance of success first?

BTW the trial convergent approach DEEP-AF was stopped because the experimental procedure of having the surgical and CA parts in one session was not considered to represent current practice. The reason could be that a patient's AF may stop after surgery alone and/or undegoing two consecutive procedures will be dangerously stessful(?)

I know we will be hearing more about this question in the future.


-- Dick

I thinks Dick's post brings up thoughtful and important points for potential patients trying to determine the best course of treatment. (BTW thanks Dick for letting me quote you).

EB

Cox maze cut and sew schematic shown in the following link. I am sure that Dr. Sirak does not imply that he has only encountered right atrial flutter failures in his results. That would be quite remarkable. Sounds like more statistics and long term followup is needed. We can discuss further later. I will be back online tomorrow,

[cardiovascres.oxfordjournals.org]

Correct, he did not imply that his only failures were flutter.

Here is a link to a publication by Dr. Sirak; interesting to compare his diagram (near bottom of page) with the Cox Max diagrams in your Oxford Journals publication


[www.ohioafib.com]

He is very skilled with the laparoscopic tools. I think the main difference between his approach is the lesion sonnecting mitral annulus to the SVC and another conneting to the main PV box. In the video, it is hard to tell when and how he did that. Bordeaux group and others call their lesion line mitral isthmus ablation and attempts to do the same thing. With visual access, Dr Sirak should do better. As he said repeatedly throughout his video. He is "meticulous" when removing the layers of connecting tissue and fat to gain access. I think there is only one person in the world I would trust in doing the approach laparoscopically and that would be Dr. Sirak. Using lap tools skillfully and accurately is an art so I can see why he hasn't been able to spread his approach.

Yes,I agree regarding his skill. He fixed my problem-

Thanks

EB

Hopefully Dr SIrac is making progress with his procedure, I have little doubt he will with continued experience with it. However, there is nothign simple about fixing an atypical left atrial flutter as opposed to the "simple flutter ablation' he apparently mentioned to you as some of his failures.

Im with researcher on this, that as much as we all hope his track record is as good as he claims, I would like to see more independently verified results regarding the number of patients experiencing periodic a-typical left flutter/tachycardia after his 5 Box method?

I believe it was Cox who witnessed one of these Minimally invasive maze docs doing their procedure a few years ago and the whole surgical team doing teh mini-maze ( It may not have been strictly the 5Box) ... all broke into celebration when the patient's AFIB was converted into left flutter as if they had finished the job, when in fact, they had not fully recognized the conversion to flutter which in some cases is asymptomatic... No doubt EB, 94% success on one procedure is great and if Sirac can, at some point, produce verifiable statistical and clinical evidence of Long term success rates anywhere near that high with no left flutter issues to speak of, then we are talking turkey.

Nevertheless EB, I'm thrilled it has worked so well for you so far and wish you continued unbroken NSR. Just as there are many here who have been one and done with a good CA using a skilled EP. Were you in persistent AFIB when you started or paroxysmal? How many years and how many 5 Boxes has he done so far?? It would be a miracle indeed if he has done any where nearly as many as other long term top of the line EPs have done ablations, without having any issues to speak of with left atrial flutter when dealing mostly with the persistent AFIB population!?

In any event claims of 94% with one procedure will simply need better independent verification and replication at some point, than most of us have seen in our review of his technique, before it will can become widely accepted as valid and long lasting, and this is so no matter how good the experience may be of any one person ... or small group ... of anecdotal reports may reflect.

I really hope he does have such long term success and can make his case more convincingly with regard to his long term results as that really would be a breakthrough, time will tell.

Cheers! Shannon

Thanks for the link to the Dutch study on hybrid ablation Researcher.

I can imagine in that setting with skilled surgerical and EP ablation teams working together they can get better outcomes, than most typical ablation only operators.

Certainly the bipolar and quadripolar clamp ablation tools used epicardially are a plus for transmural PVI and isolation of the CS and SVC, particularly when compared to the more typical ablation EP with less skill than the handful of elites. And anything that can improve the success rate on the overall number of procedures done is a positive contribution.

Having the EP mapping and ability to address left flutter issues is a plus for the hybrid approach as well even though a good number of left flutters don't rear their head until sometime after the initial PVI ablation.

With Dr Sirac, he has an impressive procedure and as you noted he does seem very skilled with the lap tools and I can imagine he does get excellent success in dealing with AFIB itself. My question still stands as to the veracity of the 94% claim and if, as you noted, that related to initial success over the first 6 months or so, or if that is truly long term and includes no left atrial flutter/tachycardias which I too would find a bit hard to believe without the ability to thoroughly map the atrium during his procedure?

Nevertheless, I can believe he does gets better results with AFIB the first time than is the case with most typical CA operators. And I do hope he publishes more data backing up his impressive claims and better clarifies his experience with left atrial flutter after his 5Box procedure, as opposed to just 'simple flutters' that are mostly right atrium in nature.

BTW, you mentioned in another thread a recent study by Marchlinski on LAA isolation .. do you have a link to that artilce? I would appreciate reading it .. thanks!

Shannon

Shannon,

You asked about my history- I was paroxymal for 3 1/2 years. Had a PVI approximately 2 years in that was unsuccessful. I was a mixed mostly vagal afibber with all the classic vagal triggers plus occaisionally would go into it during a run. I fit the tall male lifetime runner profile; I was 52 years old at my first episode. I took flecainide PIP and usually converted in less than a hour. My afib burden varied a lot- went through periods where it was a couple of times a month but when I scheduled my 5 Box I had a run of 12 episodes in 30 days (that sucked). In my surgical report, Dr. Sirak noted extensive myocardial fibrosis in my atria; he told me later that this is not uncommon in people who have done a lot of cardiovascular exercise. The fibrotic tissue conducts electricity in an erratic manner (ergo afib) and the challenge to the EP or surgeon is that isolating a small area doesn't necessarily fix the problem, it just moves to another area. The 5 Box addresses this by providing multiple lines of isolation. An EP doing mapping could accomplish a similar result but it would indeed be challenging.

Most of Dr Sirak's patients are persistant; he doesn't get many easy cases. You asked how many he has done- I was number 351 (5 months ago).

If you haven't already done so, look at the video on ohioafib.com. Warning- it is graphic.

The surgery is much more rigorous than an ablation; recovery time varies pretty significantly. I went back to work after 10 days but my energy level didn't really come back for over a month. From talking to other 5 Box alumni it can take longer, or be shorter (kind of all over the map).

There is a 5 Box support group on Yahoo or patients who have scheduled or completed the surgery. It is a good group-

Thanks

Thanks EB for the outline of your experience, I can well imagine why you would be a particularly good candidate for Dr. Sirak with the added atrial fibrosis.

Had his technigue been more developed and with a longer track record 4 years ago, i mgiht well have interviewed with him as well, in addition to Dr. Haissaguerre and Dr. Natale, and possibly would have gone that route too, but I think I would have tried at least one good ablation with a top EP first in case I got a good result as I did with Dr Natale, but if not, as in your ablation experience, then I would likely have called Dr. Sirac too.

I have zero regrets about my decision to go to Dr. Natale and often thank my lucky stars. My case was quite complex from the beginning having gone persistent three months prior to the 2008 ablation with very difficult to control rate and highly symptomatic AFIB/Flutter that had me in and out of Amsterdam hospitals every week the last couple of months before flying to Austin to get the first one done with Dr. N.

I have had not had one blip of AFIB itself since leaving Natale's table the first time which to me is a true miracle, considering only Haissaguerre other than Natale was willing to consider an ablation for me at that time.

From the beginning, prior to the first ablation Dr. N told me I would likely need two procedures, with possibly a third short 'touch up' to boot, in order to fully get the whole thing done for good. And yet, I had basically 3 years of total quiet except for two short flutters that were ECVed the same day,, the first a year after the ablation and the second one 15 months after the first ECV.

This latest 4th year since ablation is when the atypical left flutters have jumped the fence, as Dr N predicted would happen at some point and signal the time to come in again, as I've now had 13 ECVs (and counting) in the last 14 months ... so its definitely time to go for round two on August 6 with Dr. Natale.

He knows exactly where to go in my heart and what the story is being so familiar with my case. Due to the nature of these left flutters with no AFIB at all (which he also predicted right after my ablation that I would never have AFIB again), its very unlikely there has been any PVI reconnection...and in Natale's overall experience he finds very little PVI reconnection on redo's as he tends to very skillfully and thoroughly zap those the first time in over 90% of the cases.

My left flutter is exascerbated by the fact that Dr, N wasn't able to finish my first ablation and had to ECV me back into NSR on the table while he was just starting to work around the LAA when my blood pressure crashed from a left bundle branch block that triggered. I Ne effect he had to leave a left flutter circuit open and hope that it would have a good period before it became a nuisance and reguired round two. So we knew this flutter issue was almost certainly going to bring me back for a repeat all along.

In my case, its clear I got as good an outcome as I could possibly have expected on the first one, and hopefully we can wrap up this business for good on this next fast approaching date on the ablation table ..

Thanks too for the tip about Dr. Sirac's 5Box video! Ive watched it twice previouly and it is a very informative and as you noted a 'colorful ' video! I can imagine after seeing it why the recovery is a good deal more demanding than most ablations. Though if it's really one and done with no flutters or anything else showing its head for the long term, then it could well be worth it.

Anyway, its great to hear you are having such a good result with your 5 Box results and it's refreshing to hear of such progress being made on all fronts, both with improved ablation successes and in new surgical approaches to deal with this frustrating problem.

All the best,
Shannon