WOLF-OHTSUKA PROCEDURE

Patient-oriented Information about Wolf-Ohtsuka ProcedureToshiya Ohtsuka MD, PhD[Introduction of Dr. Ohtsuka]

Dr. Toshiya Ohtsuka is currently a consultant atrial-fibrillation (afib) surgeon, chief ofWolf-Ohtsuka Minimally Invasive Afib Surgery Center, New-heart Watanabe
International Institute, Tokyo, Japan. He has developed Wolf-Ohtsuka Procedure (WOP)from Wolf Mini-maze Procedure and, starting Oct. 2008, experienced over 2,000 cases ofWOP. He is everyday treating afib patients coming from not only nationwide but othercountries, and training the selected surgeons in Japan who are qualified to learn the WOP.
He graduated from Tohoku University Medical School in
1986, and received clinical residency for general surgery andadvanced training for cardio-thoracic surgery at Tokyo
University Hospital and its affiliated institutes to acquire theJapanese board of general surgery and cardio-thoracic
surgery. He also had a research opportunity to be awarded
PhD by Tokyo University and contributed to educational
service there as associate professor.
In 1996-8, he gained a clinical fellowship to stay inCincinnati, OH, USA, and study minimally invasive cardiothoracic surgery under instructions by Drs. Randall K. Wolf
and John B. Flege. A close relationship with Dr. Wolf has
never ceased and they communicate with each other and exchange constructive opinions
about the afib procedures privately and openly to improve their therapeutic efficacies.
In academic accomplishment, he has presented his works countless times in not only
domestic but also international symposia, and authored and published papers profusely inmajor cardiology, cardio-thoracic surgery journals, most of which were dedicated to clinicalinvestigations in the field of minimally invasive endoscopic surgery.
He is councilor of many medical societies, ranging from cardiothoracic, endo-surgical,cardiological, to arrhythmiological, in Japan, and responsible for major minimally invasive
cardiac-surgery groups. He is a founder of the Japan Left Atrial Appendage Club, which is aquite unique society organized to study left atrial appendage management in afib patients.
He is married with a daughter. His hobby is magic, golf and reading English whodunits. Heis a professional of English-Japanese translation of English novels and a holder of nationallicense of English-speaking tour guide.
[What is WOP done for?]W

OP has two major objectives. One is rhythm-control: conversion of your atrial
fibrillation (afib) into stable, sustainable sinus rhythm (SR). Surgical epicardial
ablations contribute to this purpose. The other is prevention of cardiogenic stroke andelimination of blood thinners, attained by resection of the left atrial appendage (LAA).
1WOLF-OHTSUKA PROCEDURE[How is WOP done?]is a totally endoscopic surgery; 1 cm port, four each at both axillae, is used forW OPentry into the thoracic cavity and the procedure is completed through the ports by thesurgeon watching endoscopic images.

If your afib is paroxysmal:
Afib is treated with bilateral en-bloc pulmonary isolations, and superior vena cava isolation if
necessary. Operative time is about 1h on average.
If your afib is persistent:
Prior to surgery, just after general anesthesia has been established, you undergo directcurrent cardioversion, called DC challenge. If your SR is awaken and steadily appears onEKG, you will receive surgical ablations including bilateral pulmonary vein isolations and thebox-shaped isolation at the back wall of the left atrium. If the DC challenge fails, only
producing negative or extremely poor outcomes, you may undergo LAA resection alone.
Operative time is 1h plus on average. LAA-resection-alone version takes about 20min.
With either type of afib, you always receive resection of the LAA.
Technologies used for WOP: Atricure Clamp (and Pen) for the epicardial ablations andEthicon cut-and-staple instrument for the LAA resection.

2

WOLF-OHTSUKA PROCEDURE[What benefits can YOU gain from WOP?]
1. SR:
The cure rate mainly depends on your afib type, remodeling of your heart (dilation of the left
atrium, leakage of mitral/tricuspid valves, etc) and a history of the treatment you havereceived in the past. Nevertheless, after WOP, 2-year cure rate was as high as 93% inparoxysmal, 86% in persistent, 70% in long-standing (<5 y) persistent, and 52% in verylong-standing (>5y) persistent afib cases.

2. Prevention of cardiogenic stroke and elimination of blood thinners:
WOP cases with high risks of stroke and of anticoagulation were retrospectively studied
and the clinical outcomes were analyzed and published in the major cardiology journal*. In
the 4 year follow-up period, only 0.26 stroke-events/100 patient-years occurred despite thefact that the patients quit blood thinners immediately after WOP. This outcome is the bestrecord ever in the world when compared with other methods including simple
anticoagulation and transcutaneous implant of the LAA plug such as Watchman device.
Immediately (or 4 weeks for some) after surgery you can get out of blood thinners unless
you have suffered extremely poor heart function, hematological disorders or other extra
reasons. Antiplatelet drugs, routinely used after Watchman implant, are not required.
*Ohtsuka T, et al. Thoracoscopic stapler-and-loop technique for left atrial appendage closure in nonvalvular atrial fibrillation: Mid-term outcomes in 201 patients. Heart Rhythm 2018:15;1314-20.

[Risks of WOP and its possible variation/alterations]in 2008, as of Nov. 2022, Dr. Ohtsuka has experienced more than 2,000 cases
S tartingof WOP, the largest case-volume of this kind in the world. His unmatched experiencehas made the procedural risk, mortality/morbidity extremely rare, but not zero. The possible
major complications associated with the WOP would be:
3

WOLF-OHTSUKA PROCEDURE

1. Massive bleeding
2. Stroke
3. Phrenic nerve palsy
4. Serious infection
5. Others
The port-access endoscopic procedure might be converted to open-thoracotomy approachfor trouble shooting, or handling of unexpected problems such as tight and diffuse scars in
the pleural or pericardial cavities which would be generated for various reasons. If suchproblem is too serious to overcome, the epicardial ablations might be omitted or abandonedin half way, although the LAA resection can be accomplished in all cases. Cardiopulmonary
bypass machine stays near the operating table, which is used only in emergency
circumstances. To solve each problem, any problem, surgical team will share theinformation with you and your family and take any possible counter-measures: medications,
surgical methods, and whatever. Homogenous blood products, biological glue, are routine
stand-by items to cope with serious anemia, bleeding events or other critical situations,although the mean blood loss is usually negligible and therefore they have seldom been
extremely rarely used before.
[Postoperative course and follow-up protocol]After WOP, you fully wake up on the operating table and have the respiratory tube takenout before carried to the ICU to stay there for a day or two. Although the intensity
varies in patients, you will feel pain due to not wounds but the chest tube placed
intraoperatively on the diaphragm. It is an important monitor to check for postoperativebleeding and drain out extra pleural fluids which will otherwise accumulate in the chest andcause shortness of breath or other uncomfortable symptom. The tubes are usually takenout on Day 1 or 2. Until then, you can request intravenous or oral pain killers. Once the tube
is out, you will be liberated from most pains and very likely can walk around the floor. You
will be discharged on Day 5 to 7. Before discharge, stiches or skin-staplers are all removed
and you are allowed to take shower once or twice in the hospital. After discharge, Dr.
Ohtsuka recommend you stay in Tokyo for another 2 weeks or longer to see you in the outpatient clinic so that he can examine the heart-rhythm on EKG and the residual pleural
effusions on chest X-ray, and accordingly adjust medications. A low dose of prednisone may
be used for a week or so to reduce the effusions. Your heart-rhythm may fluctuate between
SR and afib for a while after surgery. This period, 1-3 months in general, is called “BlankingTime” and considered a healing process from heat-ablations: your heart has actually
suffered burns. In this specific time, anti-arrhythmic drugs may be temporarily added and,most importantly, you should be gentle to your heart: restrain yourself from stressful work,
hard exercise, much alcohol or caffeine not to accelerate your heart beats. If your afib had
been persistent, following Dr. Ohtsuka’s instructions, you would have started to takeamiodarone 1 month prior to surgery. You will continue to take it for a while following aweaning protocol. There are some patients who will undergo DC to treat difficult afib or
atrial flutter. You may still feel soreness from time to time on the chest, usually your front orback. That sensation is most likely associated with the intercostal nerves and the resulting
muscle spasm. It will be gone in time, so just relax and use a pain-killer of your choice if you
like to take. After you go home, Dr. Ohtsuka will continue to communicate with you on email, virtual consultation and so on.
4

WOLF-OHTSUKA PROCEDURE[How to Contact Dr. Ohtsuka or New-heart Watanabe International Institute?]

Contact Dr. Ohtsuka first with e-mail, ootsukadr@sd6.so-net.ne.jp . Please
describe the minimum information below. He will reply as soon as possible.
1. Age and gender
2. Body height and weight
3. Afib type (paroxysmal? Persistent? How long?) and the history of treatment(medications, catheter ablation, etc)
4. Past history of other illness and its treatment
5. Clinical data, if possible (Chest X-ray, echo-cardiography, etc)
New-heart Watanabe International Institute:
Mail: renkei@newheart.jp
Address: 3-19-11 Hamada-yama, Suginami-ku, Tokyo 168-0065 Japan
Tel: 81-3-3311-1119; Fax: 81-3-3311-3119

We’ll fight afib to get the patients’ life back!

5