In this episode, I speak with Dr. Vinay Badhwar, an internationally recognized master cardiac valve surgeon, and an expert in complex mitral valve repair, atrial fibrillation surgery, minimally invasive valve surgery, and robotic surgery. The main topic under discussion is Dr. Vinay’s paper, “Robotic-assisted Cryothermic Cox Maze for Persistent Atrial Fibrillation: Longitudinal Follow-up” by Badhwar et al. Key points from the paper: ObjectivesSurgical ablation of atrial fibrillation (AF) is recommended as a stand-alone therapy for patients refractory to medical or catheter-based treatment, or as a concomitant therapy when associated with structural disease. We report a single-therapy robotic approach to the Cox Maze with longitudinal follow-up.MethodsConsecutive patients who underwent robotic biatrial cryothermic Cox Maze for nonparoxysmal AF between November 2016 and January 2022 were examined at 1, 2, 3, 6, 9, 12, 18, 24, 36, 48, and 60 months. Freedom from atrial tachyarrhythmias (ATA) was assessed with 24-hour continuous ECG or pacemaker interrogation in all patients after 6 months. Mean follow-up was 17 ± 14.5 months (Range 1-60 months). Time to event analysis with competing risks was used to determine risk-adjusted associations with late outcomes.ResultsPatients (n=135) had a median AF duration of 4.0 years [IQR 0.8-7.0], with 29.6% failing one or more catheter ablations. Stand-alone Maze was performed in 25.2%, while 61.4% underwent concomitant robotic mitral valve (MV) surgery, 7.4% tricuspid valve repair, and 4.4% aortic valve replacement (AVR). No patients were discharged in AF. There were 3 operative mortalities (2.2%), none in stand-alone patients. One patient required catheter ablation at 8 months postoperatively, and one had a non-embolic stroke at 18 months. There were 9 late deaths. Freedom from ATA and anti-arrhythmic drugs (AAD) at 9, 12, 18, 24, 36, and 48 months was 97.0%, 96.7%, 98.1%, 97.1%, and 100%, respectively. Lower ejection fraction and need for concomitant MV replacement and/or AVR were independently associated with worse survival.ConclusionsFor persistent AF, robotic biatrial cryothermic Cox Maze offered greater than 90% 1-year longitudinal freedom from stroke, oral anticoagulation, repeat ablation, and recurrent AF without the need for AAD.All Things Afib is hosted by me, Dr. Armin Kiankhooy. As a board-certified cardiothoracic surgeon, my focus is on advanced treatments for heart and lung failure and minimally-invasive surgical treatments for atrial fibrillation such as the Hybrid Maze procedure. You can find me on staff at Adventist Health Heart and Vascular Institute in St. Helena California.  Discussion points: ●      How Dr. Badhwar began using robotics●      Robotic surgery has been around for a long time●      The increasingly common “one and done” procedure, patients request●      Some of the patient profiles in the study●      Robotic advantages ●      Patient safety is #1●      Dr. Badhwar takes us through precise step-by-step robotic procedures ●      Phrenic issues can be avoided●      Full flow and drainage●      Is the process for mitral the same?●      Using anti-coags after surgery - the controversy●      Training available for robotics●      LAA and the LAAOS III study●      Level A evidence, the future guidelines, always consider LAA!●      Honor the evidence…. Resources: Dr. Vinay Badhwar LinkedIn Dr. Badhwar’s Paper Dr. Kiankhooy LinkedIn All Things AFib Website All Things AFib Twitter All Things AFib YouTube Channel

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