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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EAnswering the question posed by his session (\u201cCuring AF: Ablation or Surgery\u2014Who and Why?), professor Douglas A. Packer, MD, co-director of the Mayo Clinic, Rochester, MN, electrophysiology laboratory said, \u201cBecause the drugs don\u0027t work all the time.\u201d\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Earrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECuring AF: Ablation or Surgery\u2014For Who and Why?\u003C\/h2\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/5\/1\/8\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1952801482\u0022 data-figure-caption=\u0022\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure1\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/5\/1\/8\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/5\/1\/8\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure1\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/5\/1\/8\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16082\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003E\n               \u003Cem\u003ECredit: Jim Dowdalls\/Photo Researchers, Inc.\u003C\/em\u003E\n            \u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EAnswering the question posed by his session (\u201cCuring AF: Ablation or Surgery\u2014Who and Why?), professor Douglas A. Packer, MD, co-director of the Mayo Clinic, Rochester, MN, electrophysiology laboratory said, \u201cBecause the drugs don\u0027t work all the time.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EAddressing success with ablative and surgical techniques, Packer reviewed the development of surgical procedures, stating that while the success rate for the surgical MAZE III procedure (Cox JL: \u003Cem\u003EAnn Surg\u003C\/em\u003E 224: 267, 1996) in eliminating atrial fibrillation (AF) was 94%, other series have had rates ranging from 78\u201397%. Surgical outcomes, Packer said, may depend on the underlying AF cause. Patients with chronic AF, for example, haven\u0027t done as well as those with paroxysmal or intermittent AF. Also, larger trial size predicts worse outcome. Stroke rates over 10\u201315 years after Maze surgery do decline, he added.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003ENew surgical techniques, including bipolar, cryo and ultrasound devices, have made procedures shorter, but harder from the point of view that they introduce procedural changes. The general trend has been a decline in invasive surgical procedures, with growth in both new, more costly techniques and ablative interventions overall. Surgeons moving towards minimally invasive routes lose one of the advantages that has been inherent to surgery: less invasive strategies tend to impair the surgeon\u0027s ability to completely visualize the heart. Whether or not these new strategies represent less risk and higher success rates (and thus, lower cost) remains to be seen.\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EComplication rates (e.g., mortality of 1\u201315%), Packer said, are mostly a function of the underlying disease. \u201cAdding a Maze procedure to a valve repair or bypass graft surgery doesn\u0027t really change the morbidity and mortality.\u201d On the catheter side, while early use of radiofrequency ablation with hand-held probes led to lethal esophageal perforations or other damage, the newer bipolar approach with clamps has nearly eliminated such complications. Risk for the need for a pacemaker following either surgical Maze or catheter ablation (2.6%\u201319%) is also a function of underlying disease. The most recent look at ablation procedures success rates in clinical trial places them in the 75\u201385% range.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EPatients with paroxysmal AF, which is more initiation substrate- and trigger-dependent, are good ablative candidates, Packer pointed out. Success rates for those with more permanent AF with more substrate-mediated arrhythmias are reduced to 60\u201370%. \u201cIt takes a lot bigger procedure,\u201d Packer said. Catheter ablation for heart failure patients successfully boosts ejection fraction and lowers heart failure class.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003ETreatment by either means is warranted when patients are highly symptomatic or when drugs simply don\u0027t work. Stroke prevention, he emphasized, however, is not a valid stimulus for surgical or ablative approaches because coumadin is effective. Does ablation make life longer? Hypothetically. Data are not there yet.\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThe balance tips in favor of surgery when patients need bypass grafting or valve repair or replacement. In overall terms of success rates and complications, ablation and surgery compare favorably. Cost favors ablation, preservation of left atrial function may be similar in both approaches, but a catheter- based procedure is substantially less invasive and the recovery period is significantly shorter than with surgery.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003E\u201cI think there\u0027s going to be enough AF to keep both surgeons and ablation doctors busy for a long, long time. We will get more interventional and more aggressive and surgeons will become less invasive. We\u0027re going to meet someplace in the pericardial space,\u201d Packer concluded.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EStroke Prevention in Atrial Fibrillation\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003ETo the question, \u201cis the AF paradigm shifting away from warfarin anticoagulation for stroke prevention?\u201d professor A. John Camm, St. George\u0027s Hospital Medical School, London, said: \u201cShifting, yes, but changed, not yet.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003ETrends include an increasing prevalence of difficult-to-treat \u201csilent\u201d AF, with greater stress on \u201cupstream\u201d therapies, rate control, non-pharmaceutical strategies, and reduced use of pharmaceutical rhythm control.\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EFor stroke prevention, meta-analyses show that warfarin dose-adjusted to an INR between 2\u20133 is outstandingly effective compared with placebo or low-dose warfarin, and somewhat better than aspirin. Between compliance problems and extensive drug-drug interactions, INR control is considered \u201cgood\u201d when 70% of tests fall within therapeutic range. Despite compelling evidence, many appropriate AF patients are not treated, especially younger (\u0026lt;55 years) and elderly patients (\u0026gt;85 years). Only 62.1% of \u201cideal\u201d candidates are treated, Camm stated. Other groups typically undertreated include those with paroxysmal AF and asymptomatic AF, despite the fact that their stroke, TIA and death risks are at least as high as in those with chronic AF. Also, in those with pacemakers, AF may be masked and risks increased.\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EWill new agents such as direct thrombin inhibitors allow us to discard warfarin? Some, like ximelagatran showed promise with easier administration, but approval has been denied by the US FDA and the approval process has been severely slowed in Europe as well due to liver toxicity. Other new agents, including heparin analogues and direct factor Xa inhibitors are not yet adequately studied.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EWill rhythm control obviate the need for warfarin? Will pulmonary vein isolation? Studies do not support that patients so-treated can safely skip warfarin anticoagulation, Camm said. What about stroke risk reductions with Maze procedures? \u201cIt is far too early to say that warfarin is not needed in these patients.\u201d\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EAre there no cases where warfarin anticoagulation can be discarded? Several devices, including some placed in the left atrial appendage, and carotid diverters placed in the external carotid bifurcation, show promise in early human trials. The same is true for strategies involving left atrial appendage occlusion and appendagectomy. \u201cWe have to wait for results,\u201d Camm stated. He concluded: \u201cThe paradigm may be about to shift, but it has not yet shifted.\u201d\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2005 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/5\/1\/8.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlz4d\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlz4d\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}