Anti-Thrombotic Therapy after Surgical MAZE for Atrial Fibrillation

Patrick T. O’Gara, MD

BWH Heart and Vascular CenterProfessor of Medicine, Harvard Medical School

Disclosures• NHLBI CTSN Co-chair• Medtronic Apollo Exec Cmte

Question 1• For patients receiving MV repair for primary MR

+ Maze for persistent AF who are in SR at discharge, indicate below the post-operative strategy that best characterizes your current practice.A. Warfarin (INR 2-3) for 3 months, then ASA.B. DOAC for 6 months, then ASAC. ASA + clopidogrel for 3 months, then ASA alone.D. ASA aloneE. None of the above. I treat each patient differently

Question 2• In your mind, which of the following best

characterizes the current state of affairs with respect to management after AF ablation?

A. ACC/AHA, ESC, HRS, STS and AATS guidelines are concordant and provide explicit recommendations.

B. Observational studies suggest a variety of anti-thrombotic approaches.

C. If the LAA has been excised, anything would suffice.D. Surveillance for post-operative AF is uniform across surgical

centers. E. There is high variability in practice.

ACC/AHA/HRS 2014 AF Guideline

Recommendations COR LOEAn AF surgical ablation procedure is reasonable for selected patients with AF undergoing cardiac surgery for other indications.

IIa C

A stand-alone AF surgical ablation procedure may be reasonable for selected patients with highly symptomatic AF not well managed with other approaches.

IIb B

Surgical excision of the LAA may be considered in patients undergoing cardiac surgery.

IIb C

Recommendations COR LOEAF catheter ablation to restore sinus rhythm should not be performed with the sole intent of obviating the need for anticoagulation.

III:Harm

C

No specific recommendations provided for post-Maze antithrombotic therapy

ACC/AHA/HRS 2014 AF Guideline

2016 ESC AF Guideline

No specific recommendations provided for post-Maze antithrombotic therapy

2017 HRS AF Guideline

2017 HRS AF Guideline

2017 STS Guideline

No specific recommendations provided for post-Maze antithrombotic therapy

...Anticoagulation is routinely continued for 2-6 months post-opertaively until a stable rhyhm has been established as

verified by ECG monitoring. TTE is often done to ensure adequate atrial emptying as suggested by the absence of SEC...

2017 AATS AF Statement

No specific recommendations provided for post-Maze antithrombotic therapy

Oral Anticoagulation May Not Be Necessary for Patients Discharged in Sinus

Rhythm Following the Cox Maze IV Procedure

Takashi Murashita, Lawrence Wei, J. Scott Rankin, Harold Roberts, Mohamad Alkhouli, and Vinay Badhwar

West Virginia UniversityMorgantown, WV

MethodsBi-atrial Cox-Maze IV for persistent AF

between 10/11 and 04/16

(n=239)

Study group; (n=176)Patients discharged in NSR

with aspirin only

Exclusions (n=57)- Mechanical prostheses, venous thrombotic disease, low LVEEF < 20%, atrial calcification or thrombus, concomitant tricuspid replacement, or known hypercoagulable state.

6-month Follow-up OutcomesNo OAC(n = 176)

OAC(n = 57) P value

Preoperative CHADS2 score 2 [2-3] 2 [2-3] 0.914

Stroke 1 (0.6) 0 >0.999

Major bleeding events 4 (2) 3 (5) 0.366

Any AF recurrence 22 (13) 8 (14) 0.764

OAC restarted 12 (7) — —

OAC discontinued — 20 (35) —

Cumulative Freedom From Stroke Without OAC

MONTHS OF FOLLOW-UP483624120

FREE

DO

M F

RO

M S

TRO

KE

1.0

0.8

0.6

0.4

0.2

0.0

97.5%

At Risk

130 101 76 40 12

Anti-thrombotic Therapy After Catheter Ablation or Surgical Maze

• Inadequately studied…• Optimal screening methods for post-

operative AF• Presence of electrocardiographic P

waves does not always equate with either sinus rhythm or atrial mechanical systole

• A clinical problem that lends itself to multi-dimensional research