Left Atrium Volume Reduction Procedure Concomitant With Cox-Maze Ablation in Patients Undergoing Mitral Valve Surgery: A Meta-Analysis of Clinical and Rhythm Outcomes

Background The management of an enlarged left atrium (LA) in mitral valve (MV) disease with atrial fibrillation (AF) is still being debated. It has been postulated that a reduction in LA size may improve patient outcomes. This meta-analysis aimed to assess rhythm and clinical outcomes of combined surgical AF treatment with or without LA volume reduction (LAVR) in patients undergoing MV surgery.Methods A systematic review was performed and all available literature to May 2022 was included. The primary endpoint was analysis of early and late mortality and rhythm outcomes. Secondary outcomes included early and late cerebrovascular accident (CVA) and permanent pacemaker implantation.Results The search strategy yielded 2,808 potentially relevant articles, and 19 papers were eventually included. The pooled estimated rate of 30-day mortality was 3.76% (95% CI 2.52-5.56). The incidence rate of late mortality and late cardiac-related mortality was 1.75%/year (95% CI 0.63-4.84) and 1.04%/year (95% CI 0.31-3.53), respectively. At subgroup analysis when comparing the surgical procedure with and without AF ablation, the ablation subgroup showed a significantly lower rate of postoperative CVA (p,0.0001) and higher restoration to sinus rhythm at discharge (p=0.0124), with only a trend of lower AF recurrence at 1 year (p=0.0608). At univariable meta-regression, reintervention was significantly associated with higher late mortality (p=0.0033). Conclusion In enlarged LA undergoing MV surgery, LAVR combined with AF ablation showed a trend of improved rhythm outcomes when compared with AF ablation without LAVR. Each LAVR technique has its advantages and disadvantages, which must be managed accordingly

Improved graft patency rates and mid-term outcome of diabetic patients undergoing total arterial myocardial revascularization

Objectives: Diabetes negatively affects the outcome of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) or coronary surgery. However, data are lacking with respect to the impact of arterial revascularization in the diabetic population. Methods: Between 1999 and 2003, 100 of 491 diabetics underwent coronary artery bypass graft surgery (CABG) with total arterial grafting (Group 1, G1); these patients were compared with 100 diabetics undergoing conventional CABG with saphenous veins (Group 2, G2), who were matched for Euroscore and other risk factors such as age, obesity, hypertension, left ventricular ejection fraction (LVEF), previous myocardial infarction and chronic obstructive pulmonary disease (COPD). Results: Both groups had a similar number of diseased coronary vessels (G1=2.6 vs G2= 2.7) and received a similar degree of myocardial revascularization (grafted vessels: G1=2.2 vs G2=2.4). Early outcome was comparable between the groups in terms of ventilatory support (G1=10.8±6 vs G2=10.4±5 hours), intensive care unit (ICU) stay (G1=24±12 vs G2=25±14 hours) and major post-operative complications such as atrial fibrillation (G1=26% vs G2=28%), peri-operative myocardial infarction (G1=1% vs G2=2%)and prolonged ventilatory support (G1=6% vs G2=5%). Hospital mortality was 2% in G1 and 3% in G2. Angiography was performed at a mean follow-up of 34 months in 65.9% and 71.1% of hospital survivors of G1 and G2 respectively: patients of G1 showed a significantly higher patency rate (G1=96% vs G2=83.6%, p=0.02). Additionally, patients of G1 showed a significantly lower incidence of recurrent myocardial ischemia (G1=7 pts. vs G2=18 pts., p=0.03), late myocardial infarction (G1=2 pts. vs G2=10 pts., p=0.03) and need for coronary reintervention (G1=1 pt. vs G2=12 pts, p=0.004). Conclusions: Total arterial grafting in diabetic patients significantly improved the benefits of coronary surgery providing at mid term a higher graft patency rate with a lower incidence of cardiac related events. (Heart International 2006; 3-4: 136-40

Treatment of non-restrictive cor triatriatum sinister during concomitant cardiac surgery

Abstract Background Cor triatriatum is a rare congenital heart disease representing the 0.4% of all congenital cardiac anomalies. To date, no specific genetic alteration has been associated to cor triatriatum. The left-sided presentation (cor triatriatum sinister (CTS)) generally consists in a fibromuscular membrane that divides the left atrium into two chambers, therefore generating a varying grade of flow obstruction depending on the shape, location, and membrane fenestration size. Cor triatriatum sinister can be isolated or associated to other congenital heart defects such as ostium secundum atrial septal defect, patent foramen ovale or abnormal pulmonary veins drainage. Case presentation Our case is a 63-year-old woman who was diagnosed with a non-restrictive membrane during a hospitalization for acute heart failure. In the following 6 months, she started to become symptomatic. However, the onset of symptoms was more likely related to mitral valve regurgitation worsening and previously unknown coronary artery disease, rather than to CTS. She underwent bi-atrial surgical ablation (Cox Maze IV procedure) for atrial fibrillation (AF), surgical resection of interatrial membrane with mitral annuloplasty, and myocardial revascularization. Conclusion The onset and severity of symptoms in patients with CTS mostly depend on membrane fenestration size, grade of stenosis generated and pulmonary veins drainage site. However, some cases may remain asymptomatic until adulthood; the degree of pulmonary hypertension and congestive heart failure is determined by the presence of additional cardiac anomalies and the fibromuscular membrane fenestration. In some cases, CTS may remain asymptomatic, thus the diagnosis can be incidental

Hybrid strategies for stand-alone surgical ablation of atrial fibrillation

Atrial fibrillation (AF) has been reported as a major cause of cardiac morbidity and mortality, and significantly reduces the quality of life in symptomatic patients. Current guidelines recommend antiarrhythmic drugs and catheter ablation (CA) as first-line therapy. Despite CA showed to be associated with lower incidence of periprocedural complications, rhythm outcomes are far from optimal. Indeed, patients undergoing CA frequently require multiple AF ablation procedures, especially in those with persistent and long-standing persistent AF. While surgical ablation can provide transmural lesions, surgical invasiveness has limited the widespread use of this approach due to the increased perioperative complications. The development of minimally invasive thoracoscopic approaches has renewed the interest towards surgical ablation, thus favoring more simplified ablation sets. Therefore, the concept of "hybrid" ablation has emerged in order to theoretically enhance advantages of both minimally invasive and CA procedures while seeking to improve rhythm outcomes and reduce invasiveness and incidence of perioperative complications. On one hand, it provides the effectiveness of a surgical ablation, on the other, electrical mapping during CA can identify and treat any ablation gap or provide additional ablation lines, thus improving the chance of a stable sinus rhythm restoration at longterm follow-up. Three main thoracoscopic strategies are currently available. All of them can be performed in conjunction with the "catheter ablation procedure": the "Fusion" technique, the bipolar clamp technique, and the most recent "convergent" technique. CA can be performed either simultaneously or with a staged approach after a blanking period in order to allow the ablation lesion to stabilize. Excellent results of the hybrid procedures have been reported in terms of rhythm outcomes and incidence of perioperative complications. This narrative review aims to discuss the rationale behind the concept of hybrid ablation for the treatment of AF regarding different available strategies, results and expert opinions

Safety and usefulness of composite grafts for total arterial myocardial revascularization: A prospective randomized evaluation

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Rhythm outcomes of minimally-invasive off-pump surgical versus catheter ablation in atrial fibrillation: A meta-analysis of reconstructed time-to-event data

Background: Mid- and long-term rhythm outcomes of catheter ablation (CA) for atrial fibrillation (AF) are reported to be suboptimal. Minimally invasive surgical off-pump ablation (MISOA), including both thoracoscopic and trans-diaphragmatic approaches, has been developed to reduce surgical invasiveness and overcome on-pump surgery drawbacks. We sought to compare the efficacy and safety of MISOA and CA for AF treatment. Methods: A systematic review and meta-analysis of the literature was performed including studies comparing MISOA and CA. The primary endpoint was survival freedom from AF at follow-up after a 3-month blanking period. Subgroup analysis of the primary endpoint was performed according to the type of surgical incision and hybrid approach. Results: Freedom from AF at 4 years was 52.1% ± 3.2% vs 29.1% ± 3.5%, between MISOA and CA respectively (log-rank p < 0.001; Hazard Ratio: 0.60 [95%Confidence Interval (CI):0.50-0.72], p < 0.001). At landmark analysis, a significant improvement in rhythm outcomes was observed in the MISOA group after the 5th month of follow-up (2 months from the blanking period). The Odds Ratio between MISOA and CA of postoperative cerebrovascular accident incidence and postoperative permanent pacemaker implant (PPM) were 2.00 (95%CI:0.91-4.40, p = 0.084) and 1.55 (95%CI:0.61-3.95, p = 0.358), respectively. The incidence rate ratio of late CVA between MISOA and CA was 0.86 (95%CI:0.28-2.65, p = 0.787), while for late PPM implant was 0.45 (95%CI:0.11-1.78, p = 0.256). Conclusions: The current meta-analysis suggests that MISOA provides superior rhythm outcomes when compared to CA in terms of sinus rhythm restoration. Despite the rhythm outcome superiority of MISOA, it is associated to higher postoperative complications compared to CA

Thoracoscopic epicardial pulmonary vein ablation for lone paroxysmal atrial fibrillation

Abstract Surgical treatment of atrial fibrillation recently gained new popularity since the introduction of different energy sources for ablative therapy as an alternative to the original &apos;&apos;cut-and-sew&apos;&apos; techniques. However, most of the cases have been performed together with other cardiac surgical procedures and mainly through a standard median sternotomy approach. We report here the first European case of closed-chest thoracoscopic pulmonary vein isolation in a patient with lone paroxysmal atrial fibrillation

Left internal thoracic artery−radial artery composite grafts as the technique of choice for myocardial revascularization in elderly patients: a prospective randomized evaluation

AbstractObjectivesThe technique of choice for myocardial revascularization in elderly patients remains a debated issue. We evaluated the potential advantages of the use of left internal thoracic artery-radial artery composite grafts compared with conventional coronary artery bypass grafts in elderly patients.MethodsWe prospectively enrolled 160 patients aged more than 70 years scheduled to undergo isolated myocardial revascularization. Patients were assigned at random to group 1, 80 patients undergoing total arterial revascularization (left internal thoracic artery on left anterior descending coronary artery plus radial artery), or group 2, 80 patients undergoing standard coronary artery bypass graft surgery (left internal thoracic artery on left anterior descending coronary artery plus saphenous veins). The radial artery was used in all cases as a composite Y-graft.ResultsPreoperative characteristics and risk factors (EuroSCORE: group 1 = 7.9 vs group 2 = 8.1), number of grafted coronary vessels (group 1 = 2.4 vs group 2 = 2.5), aortic crossclamping time (group 1 = 37 ± 7 minutes vs group 2 = 38 ± 7 minutes), ventilation time (group 1 = 22 ± 12 hours vs group 2 = 23 ± 11 hours), intensive care unit stay (group 1 = 39 ± 10 hours vs group 2 = 40 ± 9 hours), and hospital mortality (group 1 = 3.8% vs group 2 = 5%) were comparable between the groups. Comparison between the 2 groups in terms of early postoperative complications showed a higher incidence of cerebrovascular accidents in group 2 (group 1 = 0 patients vs group 2 = 4 patients, 5%). At a mean follow-up of 16 ± 3 months, patients in group 1 showed superior clinical results with a lower incidence of graft occlusion (group 1 = 2 vs group 2 = 11; P = .06) and angina recurrence (group 1 = 2 patients vs group 2 = 12 patients; P = .03). Multivariate analysis identified saphenous vein grafts as independent predictors for graft occlusion and angina recurrence.ConclusionsLeft internal thoracic artery-radial artery composite grafts proved to be a safe procedure in elderly patients. It improved the clinical outcome, providing a significantly higher graft patency rate and a lower incidence of late cardiac events

EACTS/ESCVS best practice guidelines for reporting treatment results in the thoracic aorta

Endovascular treatment of the thoracic aorta (TEVAR) is rapidly expanding, with new devices and techniques, combined with classical surgical approaches in hybrid procedures. The present guidelines provide a standard format for reporting results of treatment in the thoracic aorta, and to facilitate analysis of clinical results in various therapeutic approaches. These guidelines specify the essential information and definitions, which should be provided in each article about TEVAR: Definitions of disease conditions Extent of the disease Comorbidities Exact demographics of the patient material Description of the procedure performed Devices which were utilized Methods for reporting early and late mortality, and morbidity Reinterventions and additional procedures Statistical evaluation It is hoped that strict adherence to these criteria will make the future publications about TEVAR more comparable, and will enable the readership to draw their own, scientifically validated conclusions about the report

Perceval valve intermediate outcomes: a systematic review and meta-analysis at 5-year follow-up

ObjectivesNew technologies for the treatment of Aortic Stenosis are evolving to minimize risk and treat an increasingly comorbid population. The Sutureless Perceval Valve is one such alternative. Whilst short-term data is promising, limited mid-term outcomes exist, until now. This is the first systematic review and meta-analysis to evaluate mid-term outcomes in the Perceval Valve in isolation.MethodsA systematic literature review of 5 databases was performed. Articles included evaluated echocardiographic and mortality outcomes beyond 5 years in patients who had undergone Perceval Valve AVR. Two reviewers extracted and reviewed the articles. Weighted estimates were performed for all post-operative and mid-term data. Aggregated Kaplan Meier curves were reconstructed from digitised images to evaluate long-term survival.ResultsSeven observational studies were identified, with a total number of 3196 patients analysed. 30-day mortality was 2.5%. Aggregated survival at 1, 2, 3, 4 and 5 years was 93.4%, 89.4%, 84.9%, 82% and 79.5% respectively. Permanent pacemaker implantation (7.9%), severe paravalvular leak (1.6%), structural valve deterioration (1.5%), stroke (4.4%), endocarditis (1.6%) and valve explant (2.3%) were acceptable at up to mid-term follow up. Haemodynamics were also acceptable at up mid-term with mean-valve gradient (range 9-13.6 mmHg), peak-valve gradient (17.8-22.3 mmHg) and effective orifice area (1.5-1.8 cm(2)) across all valve sizes. Cardiopulmonary bypass (78 min) and Aortic cross clamp times (52 min) were also favourable.ConclusionTo our knowledge, this represents the first meta-analysis to date evaluating mid-term outcomes in the Perceval Valve in isolation and demonstrates good 5-year mortality, haemodynamic and morbidity outcomes.Key questionWhat are the mid-term outcomes at up to 5 years follow up in Perceval Valve Aortic Valve Replacement?Key findingsPerceval Valve AVR achieves 80% freedom from mortality at 5 years with low valve gradients and minimal morbidity.Key outcomesPerceval Valve Aortic Valve Replacement has acceptable mid-term mortality, durability and haemodynamic outcomes