The effect of the Cox-maze procedure for atrial fibrillation concomitant to mitral and tricuspid valve surgery

ObjectivesAtrial fibrillation (AF) is associated with less favorable outcomes in patients undergoing mitral valve and tricuspid valve surgery. Despite growing evidence on the potential benefits of surgical ablation for AF there is significant variability among surgeons in treatment of AF. The purpose of our study was to assess the effect of the Cox-maze procedure on operative and follow-up outcomes.MethodsIn our prospective study, patients who underwent isolated mitral valve or mitral valve+tricuspid valve surgery without history of AF (n = 506), with untreated AF (n = 75), or with Cox-maze procedure (n = 236) were included (N = 817). Sinus rhythm was captured according to Heart Rhythm Society guidelines. Patients who underwent the Cox-maze procedure were propensity score matched to patients without history of AF resulting in 208 pairs of patients.ResultsOperative outcomes were comparable after propensity score matching (Cox-maze procedure vs no AF) stroke/transient ischemic attack (0.5% vs 0.5%; P = 1.00), renal failure (2.9% vs 1.4%; P = .34), and operative mortality (1.4% vs 1.4%; P = 1.00). High return to sinus rhythm was documented at 6, 12, and 24 months (92%, 91%, and 86%, respectively) as well as sinus rhythm off antiarrhythmic drugs (79%, 84%, and 82%, respectively). Incidence of embolic stroke in patients who underwent Cox-maze procedure was 1.7% (4 out of 232 patients) and 5.1 cases per 1000 person-years. No difference in 4-year cumulative survival between propensity score-matched groups (91.9% vs 86.9%; log rank, 1.67; P = .20), but higher for patients who underwent Cox-maze procedure versus patients with untreated AF (hazard ratio, 2.47; P = .048). Higher additive European System for Cardiac Operative Risk Evaluation (odds ratio, 1.40; P < .001) and limited surgeon experience with Cox-maze procedure (odds ratio, 3.60; P < .001) were significant predictors for failure to perform Cox-maze procedure.ConclusionsIn our center, 76% of patients undergoing mitral valve or mitral valve+tricuspid valve surgery experiencing AF underwent concomitant Cox-maze procedure, which is considerably higher than the national average. No increased morbidity was associated with the Cox-maze procedure with the benefit of very low thromboembolic rate. These results suggest the need for performance-based education for AF surgical ablation to achieve optimal outcomes

Institutional and National Trends in Isolated Mitral Valve Surgery Over the Past Decade.

PURPOSE OF REVIEW: To review trends in practice for mitral valve surgery in the US over the past decade. RECENT FINDINGS: Advances in the understanding of mitral valve pathophysiology and the technology involved with mitral valve surgery have led to significant changes of the current practice for mitral valve surgery, with mitral valve repair being the technique of choice. Mitral valve repair is currently applied to close to 60% of patients having surgery for mitral valve disease in the US. This trend in the change of practice also contributed to a sharp decrease in the use of mechanical mitral valve prosthesis even in the younger population. SUMMARY: Current practice for mitral valve surgery in the US reflects a steady increase in performed procedures over the last decade. The increased use of mitral valve repair techniques to address mitral valve disease can be related to increased surgical experience and greater understanding of the pathophysiology of mitral valve disease as well as the improved outcome related to mitral valve repair

Endovascular Stent-Graft Repair of Penetrating Descending Aortic Ulcer.

This article presents a case in which covered stent-graft cuffs were used to treat a penetrating ulcer of the descending thoracic aorta. An 80-year-old woman presented with penetrating ulcer in the descending thoracic aorta. Two endovascular stent graft cuffs were used for total exclusion of the penetrating ulcer, because the patient had a high operative risk. Her postoperative course was uneventful, and follow-up computed tomographic angiography showed complete coverage of the ulcer without evidence of leak. This case demonstrates that endoluminal stent-graft repair of penetrating descending thoracic aortic ulcers is a safe, less-invasive treatment, especially for elderly, high-risk patients

Long-term outcome following concomitant mitral valve surgery and Cox maze procedure for atrial fibrillation

Objective—Atrial fibrillation (AF) is associated with increased early and long-term morbidity/ mortality following valve surgery. This study examined long-term influence of concomitant full Cox maze (CM) and mitral valve procedures on freedom from atrial arrhythmia and stroke. Methods—This sample comprised patients who underwent CM with a mitral valve procedure (N = 473). Data on rhythm, medication status, and clinical events captured according to Heart Rhythm Society guidelines at 6, 9, 12, 18, and 24 months and yearly thereafter up to 7 years. Results—Mean age was 65 years, mean left atrium size was 5.3 cm, and 15% had paroxysmal AF. Perioperative stroke occurred in 2 patients (0.4%) and operative mortality was 2.7% (n = 13). Return to sinus rhythm regardless of antiarrhythmic drugs at 1, 5, and 7 years was 90%, 80%, and 66%. Sinus rhythm off antiarrhythmic drugs at 1, 5, and 7 years was 83%, 69%, and 55%. Freedom from embolic stroke at 7 years was 96.6% (0.4 strokes per 100 patient-years) with a majority of patients off anticoagulation medication. Greater odds of atrial arrhythmia recurrence during 7 years was associated with longer AF duration (odds ratio [OR], 1.07; P = .001), whereas lower odds were associated with cryothermal energy only (OR, 0.64; P = .045) and greater surgeon experience (OR, 0.98; P = .025). Conclusions—This study suggests that the addition of CM to mitral valve procedures, even with a high degree of complexity, did not increase operative risk. In long-term follow-up, the CM procedure demonstrated acceptable rhythm success, reduced AF burden, and remarkably low stroke rate. Individual surgeon experience and training may notably influence long-term surgical ablation for AF success

Endovascular Stent-Graft Repair of Penetrating Descending Thoracic Aortic Ulcer

This article presents a case in which covered stent-graft cuffs were used to treat a penetrating ulcer of the descending thoracic aorta. An 80-year-old woman presented with penetrating ulcer in the descending thoracic aorta. Two endovascular stent graft cuffs were used for total exclusion of the penetrating ulcer, because the patient had a high operative risk. Her postoperative course was uneventful, and follow-up computed tomographic angiography showed complete coverage of the ulcer without evidence of leak. This case demonstrates that endoluminal stent-graft repair of penetrating descending thoracic aortic ulcers is a safe, less-invasive treatment, especially for elderly, high-risk patients

The use of del Nido cardioplegia in adult cardiac surgery: A prospective randomized trial

Objectives—The del Nido cardioplegia solution has been used extensively in congenital heart surgery for more than 20 years and more recently for adults. This randomized controlled trial examined whether expanding this technique to adult cardiac surgery confers benefits in surgical workflow and clinical outcome compared with blood-based cardioplegia. Methods—Adult first-time coronary artery bypass grafting (CABG), valve, or CABG/valve surgery patients requiring cardiopulmonary bypass (CPB) were randomized to del Nido cardioplegia (n = 48) or whole blood cardioplegia (n = 41). Primary outcomes assessed myocardial preservation. Troponin I was measured at baseline, 2 hours after CPB termination, 12 and 24 hours after cardiovascular intensive care unit admission. Alpha was set at P \u3c .001. Results—Preoperative characteristics were similar between groups, including age, Society of Thoracic Surgeons risk score, CABG, and valve procedures. There was no significant difference on CPB time (97 vs 103 minutes; P = .288) or cross-clamp time (70 vs 83 minutes; P = .018). The del Nido group showed higher return to spontaneous rhythm (97.7% vs 81.6%; P = .023) and fewer patients required inotropic support (65.1% vs 84.2%; P = .050), but did not reach statistical significance. Incidence of Society of Thoracic Surgeons-defined morbidity was low, with no strokes, myocardial infarctions, renal failure, or operative deaths. For del Nido group patients, troponin levels did not increase as much as for control patients (P = .040), but statistical significance was not reached. Conclusions—Evidence from this study suggests del Nido cardioplegia use in routine adult cases may be safe, result in comparable clinical outcomes, and streamline surgical workflow. The trend for troponin should be investigated further because it may suggest superior myocardial protection with the del Nido solution

Screening for AAAs in Patients Who Have Undergone CABG

The article describes the experience at Inova Fairfax with a screening program to identify patients for abdominal aortic aneurysm (AAA) and carotid occlusive disease, following coronary artery bypass grafting (CABG)