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MCG map-guide personalized minimal AF surgery; new approach to treat AF with a F-wave Action Potential Activity Map in 3D heart model

Doosang Kim1*, Kiwoong Kim2, Yong-Ho Lee2 and Hyuk Ahn3
  • 1 Seoul Veterans Hospital, Republic of Korea
  • 2 Korea Research Institute of Standards and Science, Republic of Korea
  • 3 Seoul National University Hospital, Republic of Korea

Atrial Fibrillation (AF) is a supraventricular tachyarrhythmia characterized by uncoordinated atrial activation with consequent deterioration of atrial mechanical function. On the electrocardiogram (ECG), AF is described by the replacement of consistent P waves by rapid oscillations or fibrillatory F waves that vary in size, shape and timing, associated with an irregular, frequently rapid ventricular response. AF is the most common clinically significant cardiac arrhythmia, accounted for 34.5 % of patients hospitalized with a cardiac rhythm disturbance. The prevalence is estimated at 1 % of general population, but increasing rapidly with age. Two million Americans and 4.5 million Europeans are suffered now, and the projected number of patients will reach double within 30 years. However, millions of patients remained untreated. Only 3 % of the AF patients are treated by EP (Electro Physiologic study) ablation or Maze operation, and 97 % remained with/without anticoagulation medications. So, millions of AF patients are at risk for stroke and embolism. AF classified as paroxysmal, persistent and longstanding persistent according to the duration and self-termination. Conventional ECG is insufficient to localize AF focus in atrium, only give whether AF or not. Therefore, now we conduct AF treatment without map in surgery or very limited map in EP ablation. EP study is very invasive, one and more hours needed to conduct, moderate x-ray hazard, hard to both patient and physician, so only the patient who have normal size heart and tolerable LV function endures the total EP procedures. Success rate of EP ablation remains at 70-80 % in paroxysmal, 50-70 % in long standing persistent AF. In 1990s, Cox et al developed a surgical procedure that controls AF in more than 90 % of selected patients. Although the Maze procedure is effective, the complexity, long incision length, prolonged CPB time, and bleeding risk prevented widespread application. AF surgery is now conducted as an adjuvant combined procedure when the patient underwent main operation for structural heart disease, such as valvular replacement or coronary bypass. Still lone AF surgery for normal heart condition is not accepted yet because of its burden of full lesion set of Maze procedure. Basically, Maze is not a map-guide surgery, so it might have unnecessary incisions. If we make a personalized F-wave map, we minimize the lesion set and conduct easily. Magnetocardiography is very sensitive method to detect F-wave with high accuracy and much information from 64 channels. It is non-contact, non-invasive, x-ray hazard free, easy and physiologic tool. Home-made KRISSMCG64 software algorithm helps localize F-wave action potential activity in spatio-temoral scale. Combining individual CT image with MCG records, we make a personalized F-wave map in 3D heart surface model. By this, we tested 28 patients’ F-wave including paroxysmal, longstanding persistent, wandering pacemaker patients. Among them, 15 cases were successfully analyzed to make F-wave map. 12 patients were enrolled for personalized minimal AF surgery; 9 patients are open cardiac surgical candidate having structural cardiac disease to be corrected, 2 are non-cardiac disease patients (esophageal diverticulum and diaphragmatic eventration), and one is standalone AF. According to the type of AF classification, 10 patients are long-standing persistent and 2 patients are paroxysmal. Mean age is 65 years old (range; 46-77), AF duration is 16 months, AF burden is 1.0, LA size is 56 mm, LVEF is 55 %. We use cut-and-sew only in 3 patients, cryo ablation only in 5 and both in 4. Transmural ablation under cardiopulmonary bypass was in 9 and epicardial ablation under beating heart condition was in 3. We have three op mortalities, one rhythm-related death (stroke), and two non-rhythm-related deaths (CRF sepsis and heart failure due to arrest during anesthesia). AF free rate is 83% at their last follow-up (10/12). According to the period, AF free rates are 75% at postoperative time (9/12), 44% at discharge (4/9), 71% at 3 months (5/7) and at 6 months (5/7), 83% at 9 months (5/6) and 1 year (5/6), 100% at 1.5 year (5/5), 2 year (4/4), 2.5 year (2/2) and 3 year (1/1). Follow up duration is 18.4 months with range 1 to 39 months. There are no sick sinus syndrome, no permanent pacemaker insertion. Using MCG map-guide, we can conduct personalized minimal AF surgery instead of full Maze procedure, and their late rhythm (more than 1.5 years) converted all sinus rhythm successfully. It might be a new method to treat AF with feasible results.

References

1. Doosang Kim, Kiwoong Kim, Yong-Ho Lee, Hyuk Ahn. Detection of atrial arrhythmia in superconducting quantum interference device magnetocardiography; preliminary result of a totally-noninvasive localization method for atrial current mapping. Interact CardioVasc Thorac Surg 2007; 6:274-279.

2. Doosang Kim, Kiwoong Kim, Yong-Ho Lee, Hyuk Ahn. Clinical application of magnetocardiography for map-guided minimal atrial fibrillation surgery. International Journal of Vascular Biomedical Engineering 2007; 5(1): 28-34.

3. Lee YH, Kwon H, Kim JM, Park YK, Park JC. Double relaxation oscillation SQUID with high flux-to-voltage transfer and its application to a biomagnetic multichannel system. J Korean Phys Soc 1998; 32(4): 600.

4. Kim K, Lee YH, Kwon H, Kim JM, Kim IS, Park YK. Optimal sensor distribution for measuring the tangential field components in MCG. Neurol Clin Neurophysiol 2004; 1:60.

Conference: Biomag 2010 - 17th International Conference on Biomagnetism , Dubrovnik, Croatia, 28 Mar - 1 Apr, 2010.

Presentation Type: Oral Presentation

Topic: MCG: Instrumentation, Modeling, Basic and Clinical Studies

Citation: Kim D, Kim K, Lee Y and Ahn H (2010). MCG map-guide personalized minimal AF surgery; new approach to treat AF with a F-wave Action Potential Activity Map in 3D heart model. Front. Neurosci. Conference Abstract: Biomag 2010 - 17th International Conference on Biomagnetism . doi: 10.3389/conf.fnins.2010.06.00312

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Received: 06 Apr 2010; Published Online: 06 Apr 2010.

* Correspondence: Doosang Kim, Seoul Veterans Hospital, Seoul, Republic of Korea, mdksr@paran.com