Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And today, we're highlighting undertreatment of AFib and recent outcomes from the Robotic Cardiac Surgery Program. Joining me is Dr. Kevin Hodges. He's an Assistant Professor of Cardiac Surgery at Northwestern Medicine.

Dr. Hodges, thank you so much for joining us today. At the Society of Thoracic Surgeons, at STS 2026, you presented on the persistent undertreatment of atrial fibrillation in surgical patients. From your perspective, Dr. Hodges, what are the most significant barriers contributing to the gap? Why do you think it's proven so difficult to close despite guideline-based recommendations that we hear about?

Kevin E. Hodges, MD: Thanks so much for having me. And thanks for that great question to start. This is a really tough one and one that we talk a lot about at Northwestern and talk a lot about among those of us who are really passionate about treating AFib. There's been a wealth of data as you alluded to that treatment of AFib improves long-term outcomes, potentially even including survival. And that it's safe and effective for treating AFib at the time of cardiac surgery. In fact, even in complex patients, treating AFib with a Cox Maze procedure doesn't contribute significantly to increased morbidity or mortality.

Nevertheless, we've seen very limited progress in terms of treatment of AFib during cardiac surgery with the Cox Maze procedure. We think that this could be due to a number of potential barriers. Some are the perceived complexity of the Cox Maze procedure. There are a number of providers or surgeons who don't do a lot of surgery that involves opening the left atrium. And we suspect that maybe in certain centers or among providers who aren't familiar with that anatomy, opening the atrium to perform a biatrial Cox Maze procedure may be perceived as complex or potentially risky.

The other issue that we need to continue to address as surgeons, as societies and as expert centers, is to really disseminate data about the effectiveness of this procedure. We've known that the Cox Maze procedure is effective for some time. But I think that when we talk to other providers, when we survey other providers, there's a persistent belief that it may not be as effective as the data shows. And I think that's really incumbent on us and incumbent on our professional societies to dispel that belief.

Melanie Cole, MS: I agree with you. That's really interesting. So, can you describe a little bit about what Bluhm Cardiovascular Institute is currently doing to optimize AFib treatment as an institution? Tell us a little bit about the models and processes or the innovations, you talked about Cox Maize, but some other ones that are helping drive that more consistent and comprehensive AFib treatment that we're looking for.

Kevin E. Hodges, MD: Yeah. Thank you. We're really blessed here at Northwestern Medicine and the Bluhm Cardiovascular Institute to have not only the leadership of Dr. Pat McCarthy, who has been a long time leader in this space, but also to have the presence of Dr. James Cox, who, as everybody will recognize, is the inventor of the Cox Maze procedure and the preeminent expert on this in our field. And so, here at Northwestern, we have historically done a very, very good job of treating essentially all patients who have AFib, who undergo cardiac surgery with a Cox Maze procedure, or at least some concomitant surgical ablation.

And so, I think what our progress has really been in terms of offering Cox Maze to patients that we might have not otherwise thought about. And so, that means concomitant maze procedure during minimally invasive or robotic mitral valve surgery or Cox Maze procedure as a standalone operation for people who have very difficult-to-treat AFib. And we've really utilized robotic and minimally invasive techniques to expand the population that we can offer this operation to.

Historically, there have been a lot of people who have had difficult-to-treat, longstanding persistent atrial fibrillation, where a surgical ablation procedure like a Cox Maze may be the most effective therapy, but for whom something like a median sternotomy was considered to be prohibitively invasive or prohibitively risky.

With the advent of robotic surgical techniques in cardiac surgery, we're able to do that same operation in a less invasive way and expand access to more patients. And it's still cardiac surgery. It's not an outpatient procedure. It's not the same as a procedure in the EP lab, but it's a procedure that's much more easily tolerated, I think, physically and psychologically by patients who may be looking for something to cure their AFib, beyond what can be done with a catheter or with medication.

Melanie Cole, MS: Yeah. So along those lines then, what would you say is some of the most compelling evidence-based benefits of concomitant AFib ablation? How have you seen it impact postoperative outcomes in your own practice, Dr. Hodges?

Kevin E. Hodges, MD: I think what we've seen is a couple of really important things. One is that patients who undergo Cox Maze procedure during cardiac surgery certainly have less postoperative AFib in the hospital. We always occlude the left atrial appendage. And so, the requirements for early aggressive anticoagulation in those patients is less.

And, you know, anecdotally, what we've seen is that treating AFib aggressively at the time of surgery makes people have a smoother postoperative course in the hospital and in the first 30 days after surgery.

I think the strongest data and the most compelling literature on this has been done by a number of centers including ours, data from WashU and St. Louis in particular, looking at The long-term benefits and a number of studies have actually shown improved long-term survival when you treat AFib with a Cox Maze procedure.

If you listen to James Cox, who I mentioned again is one of my, you know, most cherished colleagues here in Northwestern, long-term survival benefit for a Cox Maze procedure for a patient with AFib is at least as strong as what's been shown historically with the use of a left internal memory artery for coronary bypass surgery. And it's very interesting that use of internal mammary is the gold standard in coronary bypass surgery and is sort of the gospel that we all live by as cardiac surgeons. And we haven't seen that same adoption with AFib despite similar benefits, similar survival benefit over the long-term.

Melanie Cole, MS: So Dr. Hodges, the Northwestern Medicine Robotic Cardiac Surgery Program was implemented two years ago. Tell us a little bit about the program's two-year outcomes as you're talking about outcomes and what you feel is the most important for the surgical community to understand, and particularly as we think of safety, durability, and recovery metrics.

Kevin E. Hodges, MD: That's a great question. And let me just start by saying that we're extremely proud of the program that we're building in Northwestern. We're extremely proud of our team and all of those providers that contribute to our success and our growth.

If you look at our program, we began by focusing on mitral valve surgery, which is a well-established procedure for robotic cardiac surgery. And the goal with that program is always to essentially recreate the tremendous outcomes that Northwestern has had in the mitral valve program historically, which means no mortality and very low rates of complication, and very high rates of mitral valve repair as opposed to replacement in the degenerative population.

And we've been able to achieve that. Our outcomes for our robotic program match exactly what the outcomes have historically been for the traditional open procedure. With the exception of what I would say is the expected benefits of a robotic program, which is lower lengths of stay, less blood transfusion, less rates of postop atrial fibrillation and earlier return to work for patients.

And so, that's really been the foundation of our program. And I think that will continue to be the case well into the future, as we've continued to grow in response primarily to patient demand and collaboration with our referring cardiologists. We've begun offering a lot more standalone atrial fibrillation procedures, whether that's a Cox Maze procedure or an epicardial ablation, like a convergent procedure or even standalone left atrial appendage management.

We've also started to offer a lot more robotic coronary bypass operations in the form of a robotic left internal mammary artery harvest and a MIDCAP procedure. And so, what we've taken is basically a stepwise, somewhat conservative approach to expanding the program so that we really focus on maintaining safety and outcomes along the way.

Melanie Cole, MS: Dr. Hodges, you mentioned your team just briefly there. What elements of that team structure training workflow at Bluhm Cardiovascular Institute have been most instrumental? We know how important that multidisciplinary team approach is when we think of delivering the outcomes, the lessons that would be transferable to other centers looking to scale robotic programs is paramount to understanding those great outcomes.

Kevin E. Hodges, MD: You know, we've been very, very proud of our team and our growth. And I think it's a testament to the leadership of the division in some ways. What we really did was spend several months before we even did our first robotic cardiac case back in 2023. Training the team and training with simulation, practice cases, trips to observe other centers so that the other key elements of the team, the bedside assistants, the APPs, the nurses who are participating in these cases in the operating room felt comfortable that they knew the next steps, they knew the sequence, they knew how to troubleshoot, things that came up. I was fortunate to come from a place in my training and in my practice before coming to Northwestern, where I had extensive exposure to robotic cardiac surgery, but we knew that we were coming into a place where that wasn't true for every team member. And so, we spent a long time practicing and learning before we even did our first robotic cardiac case.

And I think that's really been what's been so valuable to our success. And you mentioned that, for other centers, what are the keys? And we've actually been working closely with some of our industry partners to bring some of our experience out and to help proctor and train new programs that are starting, so that they can follow a similar pathway and be successful.

We're very proud of our success, but we view that as the first step. We want to make this an experience that other centers can build on and really be a leader in making this a universal sort of approach for cardiac surgery so that patients all over can have a less invasive option for their heart surgery.

Melanie Cole, MS: Well, you certainly are a leader in the industry, and this is a pretty exciting time in your field. Dr. Hodges, as we wrap up, where do you see the Robotic Cardiac Surgery Program at Bluhm Cardiovascular Institute growing over the next few years with the integration of AFib treatments? What do you envision and what would you like to see happen?

Kevin E. Hodges, MD: Great question. I think the future for robotic cardiac surgery is very, very exciting. I think you can anticipate Northwestern to continue their trajectory in the mitral valve space. I think we are really a leader in that area. We will continue to have great outcomes and think very carefully about expanding access to robotic mitral valve surgery to more patients, especially those with concomitant atrial fibrillation and tricuspid valve disease where the operations can be a little more complex. But when we can do it safely and effectively, we know that there's benefit for patients.

We're very excited about some of the technologic advancements that are coming down the road, both with the currently available platforms and some of the new platforms that are coming online. I'm excited to see how some of the advancements in instrumentation will help us to do a better job in the coronary space in particular. Right now, we are a little bit limited in what we can do in robotic coronary surgery just because of the availability of certain instruments, like a robotic coronary artery stabilizer device.

But we know that those are in the pipeline and development for a number of our industry partners. And we're looking forward to those things coming online so that we can do more complex cases safely in the coronary space.

Melanie Cole, MS (Host): Well, I hope you'll join us again and tell us more about those as they continue. And thank you again so much for joining us today and telling us all about that. And to refer your patient or for more information, please visit our websiteatbreakthroughs for physicians.nm.org/cardiovascular to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.