Background Severe symptomatic aortic stenosis (AS) is associated with high mortality without intervention. The impact of waiting time for aortic valve replacement (AVR), either surgically or ...transcatheter, has not been reported. Methods From January 2008 to December 2012, we identified 1,005 patients with severe symptomatic AS. AVR was recommended for 823 patients (82%). Of these 823 patients, 721 (87.6%) underwent AVR. We modeled overall survival (OS) since AVR recommendation or intervention date using Cox and multistate models. Results Overall, the median (first, third quartiles) waiting time until operation was 2.9 (1.3, 5.1) weeks. Mortality at these times was lower ( p < 0.001) in the AVR group (1.2%, 0.3%, 1.7%, respectively) than in the group that did not receive AVR (6.9%, 2.9%, 9.8%, respectively). Thirty-day mortality after AVR was 3.9% (3.2% surgical AVR SAVR and 7.0% transcatheter AVR TAVR). In patients receiving AVR, waiting time was not associated with increased mortality. Mortality while waiting for AVR was 3.7% and 11.6% at 1 and 6 months, respectively. Mortality while waiting for TAVR was higher than that for SAVR (1-, 6-, and 12-month mortality of 3.7%, 8.0%, and 9.6%, respectively, in SAVR group and 3.8%, 23.3%, and 27.5%, respectively, in TAVR group; p < 0.001). Conclusions Some patients do not receive AVR in a timely fashion, and prolonged waiting time for AVR is associated with mortality greater than the AVR operative mortality. Although waiting time was not associated with poor operative outcomes after AVR, many patients may die while waiting for AVR. Patients should receive AVR on a semiurgent, not elective, basis.
Objective Patients undergoing cardiac surgery with a history of untreated atrial fibrillation have reduced survival compared with similar patients without atrial fibrillation. We sought to compare ...the midterm survival of patients who received concomitant surgical ablation treatment for atrial fibrillation (atrial fibrillation ablated) with that of matched patients without a history of atrial fibrillation (no atrial fibrillation). Methods We evaluated 3262 consecutive patients (813 25% with atrial fibrillation and 2449 75% without preoperative atrial fibrillation) undergoing cardiac surgery at a single institution from April 2004 to April 2009. Of patients with atrial fibrillation, 565 (70%) were treated with a concomitant surgical ablation procedure. Propensity scores were calculated on the basis of 37 known preoperative risk factors and yielded 744 patients. Midterm survival was compared between patients with atrial fibrillation ablation (n = 372) and patients without atrial fibrillation (n = 372). Survival was also compared between patients with successful vs unsuccessful ablation, and a matched analysis was performed at 1 year between the 2 groups. Results Mean follow-up was 2.7 ± 1.6 years. Patients without atrial fibrillation and patients with treated atrial fibrillation had similar early 30-day mortality (1.2% vs 0.3%, P = .37) and overall mortality rates (11.6% vs 9.4%, P = .344), respectively. Survival analysis showed no differences at 1, 3, and 5 years between the 2 groups (log-rank P = .22). At last follow-up, 78% of treated patients were free of atrial fibrillation. At 1 year, 68% of patients were free of atrial fibrillation and antiarrhythmic medication. Freedom from atrial fibrillation and antiarrhythmic medication at 1 year predicted improved midterm survival ( P = .03) compared with patients in atrial fibrillation or taking antiarrhythmic medication. Propensity-matched analysis after 1 year demonstrated improved survival for patients who were successfully treated ( P = .016). Conclusions Patients undergoing surgical treatment of atrial fibrillation had survival similar to that of patients without a history of atrial fibrillation. Those with successful sinus restoration had improved survival compared with those who were treated but remained in atrial fibrillation.
Background Controversy exists when performing surgical atrial fibrillation ablation whether there is an increase in postoperative complications using biatrial (BA) lesions compared with only left ...atrial (LA) lesions, and some studies indicate similar efficacy. This study compares the clinical outcomes of BA and LA ablation lesions in mitral valve surgery patients. Methods From 2004 through 2014, 2,137 patients had mitral valve surgery with or without other surgeries in a single center. Of those, 836 (39%) had preoperative atrial fibrillation, and of those, 724 (86%) underwent atrial fibrillation ablation surgery; 257 patients had BA lesion sets and 359 had LA lesion sets. Propensity score matching of BA and LA patients was performed. Results Baseline differences included more postoperative complications in the BA group, specifically, permanent pacemaker placement (13% versus 7%; p = 0.006). Freedom from atrial fibrillation off antiarrhythmic drugs (72% BA versus 75% LA; p = 0.50), postoperative ablation (7% BA versus 5% LA; p = 0.20), stroke (0.11 versus 0.11 per 10 person-years; p = 0.91), and survival were similar between the groups. After matching, patients in the LA group had a higher freedom from postoperative ablation ( p = 0.015), but no difference in freedom from atrial fibrillation off antiarrhythmic drugs (79% BA versus 69% LA; p = 0.09), and no difference in permanent pacemaker placement (10% versus 12%; p = 0.57). Conclusions Patients undergoing mitral surgery with LA or BA ablation had similar outcomes, survival, and complications. Limiting lesions to the LA is an effective alternative to BA ablation for patients undergoing ablation with concomitant mitral valve surgery.
Background Current guidelines recommend at least 24-hour Holter monitoring at 6-month intervals to evaluate the recurrence of atrial fibrillation (AF) after surgical ablation. In this prospective ...multicenter study, conventional intermittent methods of AF monitoring were compared with continuous monitoring using an implantable loop recorder (ILR). Methods From August 2011 to January 2014, 47 patients receiving surgical treatment for AF at 2 institutions had an ILR placed at the time of operation. Each atrial tachyarrhythmia (ATA) of 2 minutes or more was saved. Patients transmitted ILR recordings bimonthly or after any symptomatic event. Up to 27 minutes of data was stored before files were overwritten. Patients also underwent electrocardiography (ECG) and 24-hour Holter monitoring at 3, 6, and 12 months. ILR compliance was defined as any transmission between 0 and 3 months, 3 and 6 months, or 6 and 12 months. Freedom from ATAs was calculated and compared. Results ILR compliance at 12 months was 93% compared with ECG and Holter monitoring compliance of 85% and 76%, respectively. ILR devices reported a total of 20,878 ATAs. Of these, 11% of episodes were available for review and 46% were confirmed as AF. Freedom from ATAs was no different between continuous and intermittent monitoring at 1 year. Symptomatic events accounted for 187 episodes; however, only 10% were confirmed as AF. Conclusions ILR was equivalent at detecting ATAs when compared with Holter monitoring or ECG. However, the high rate of false-positive readings and the limited number of events available for review present barriers to broad implementation of this form of monitoring. Very few symptomatic events were AF on review.
Abstract Objectives A hemiarch reconstruction, using deep hypothermic circulatory arrest, is the conventional approach for proximal aortic arch reconstruction, but it carries risks of neurologic ...events and coagulopathy. The addition of a hemiarch reconstruction to an aortic root replacement may prevent future aortic arch pathology. Outcomes of this approach at a tertiary care institution were examined to determine whether the addition of a hemiarch reconstruction to an aortic root replacement conferred any additional risk. Methods A total of 384 patients underwent an aortic root replacement between April 2004 and June 2012. Of them, 177 (46%) had hemiarch replacement. Propensity score matching yielded 133 pairs of patients receiving hemiarch and non-hemiarch. Results Sinus segment diameter was similar between groups; ascending aortic diameter was greater in the hemiarch group (median 50 vs 44 mm; P < .001). The hemiarch group had longer perfusion (median 186 vs 120.5 minutes; P < .001) and crossclamp times (median 140 vs 104 minutes; P < .001); median circulatory arrest was 13 minutes. There was no difference, hemiarch versus no hemiarch, in 30-day mortality (3.0% vs 1.5%; P = .41), stroke (2.3% vs 4.5%; P = .31), reoperation for bleeding (11% vs 10%; P = .84), or overall survival (5-year 88.0% 95% confidence interval, 81.9-94.0 vs 91.4% 95% confidence interval, 85.8-96.9, P = .24). Conclusions In this series, aortic root replacement ± hemiarch reconstruction had low mortality. Addition of hemiarch replacement extended perfusion times but not at the expense of safety. Hemiarch reconstruction should be performed when the aortic root aneurysm extends into the distal ascending aorta.
Objectives Randomized controlled trials of permanent atrial fibrillation ablation surgery have shown improved outcomes compared with control patients undergoing concomitant cardiac surgery. Little ...has been reported regarding patients with paroxysmal atrial fibrillation. We hypothesized that treating paroxysmal atrial fibrillation during cardiac surgery would not adversely affect the perioperative risk and would improve the midterm outcomes. Methods From April 2004 to June 30 2012, 4947 patients (excluding those with transcatheter aortic valve implants, left ventricular assist devices, trauma, transplantation, and isolated atrial fibrillation surgery) underwent cardiac surgery, and 1150 (23%) had preoperative atrial fibrillation. Of these, 552 (48%) had paroxysmal atrial fibrillation. Three groups were compared using propensity score matching: treated (n = 423, 77%), untreated (n = 129, 23%), and no atrial fibrillation (n = 3797). Results The treated patients had 30-day mortality similar to that of the untreated patients and those without atrial fibrillation. They had fewer perioperative complications (26% vs 46%, P = .001), greater freedom from atrial fibrillation at the last follow-up visit (81% vs 60%, P = .007), and lower mortality (hazard ratio 0.47, P = .007) compared with the untreated patients. Compared with those without atrial fibrillation, the treated patients had fewer perioperative complications (25% vs 48%, P < .001), lower freedom from atrial fibrillation at the last follow-up visit (84% vs 93%, P = .001), and similar mortality. Conclusions Concomitant surgical ablation of paroxysmal atrial fibrillation was not associated with increased perioperative risk. The treated patients had greater late freedom from atrial fibrillation and midterm survival compared with the untreated patients, and similar midterm survival compared with the patients without atrial fibrillation. These results suggest that paroxysmal atrial fibrillation warrants treatment consideration in select patients undergoing cardiac surgery.
Objective Surgical ablation of atrial fibrillation is generally safe and effective, but atrial fibrillation redevelops in approximately 20% of patients. We sought to determine anatomic factors, ...technology factors, or both that contribute to these failures. Methods Four hundred eight patients underwent 5 types of atrial fibrillation ablation depending on their atrial fibrillation history and need for concomitant surgical intervention: the classic maze procedure, high-intensity focused ultrasound, the left atrial maze procedure, the biatrial maze procedure, and pulmonary vein isolation. Ninety-five percent of patients with preoperative atrial fibrillation underwent surgical ablation. Results Patients undergoing high-intensity focused ultrasound had a high rate of late postoperative percutaneous ablation (37.5%) after surgical intervention ( P < .001 vs the other groups). At last follow-up, freedom from atrial fibrillation and need for ablation was as follows: classic maze procedure, 90%; high-intensity focused ultrasound, 43%; left atrial maze procedure, 79%; biatrial maze procedure, 79%; and pulmonary vein isolation, 69% ( P < .001 between groups). For those with atrial fibrillation, mapping and ablation were performed in 23.6% (n = 27), and all patients with high-intensity focused ultrasound had failure of the box lesion around the pulmonary veins. Of those with just the left atrial maze procedure or pulmonary vein isolation, the right atrium was the source for failure in 75% (6/8). Conclusions Patients undergoing high-intensity focused ultrasound had a high need for postoperative ablation and low freedom from atrial fibrillation. The classic maze procedure had the best results. Left atrial ablation might allow failure from right atrial foci. Matching the technology and lesion set to the patient yields good results and can be applied in 95% of patients. We suggest others obtain late catheter ablation to correct remaining atrial fibrillation, and add to the paucity of late data regarding failure mode.
Abstract Objective Paravalvular regurgitation is a known complication after transcatheter and sutureless aortic valve replacement. Paravalvular regurgitation also may develop in patients undergoing ...percutaneous mitral valve replacement. There are few studies on contemporary surgical valve replacement for comparison. We sought to determine the contemporary occurrence of paravalvular regurgitation after conventional surgical valve replacement. Methods We performed a single-center retrospective database review involving 1774 patients who underwent valve replacement surgery from April 2004 to December 2012: aortic in 1244, mitral in 386, and combined aortic and mitral in 144. Follow-up echocardiography was performed in 73% of patients. Patients with endocarditis were analyzed separately from noninfectious paravalvular leaks. Statistical comparisons were performed to determine differences in paravalvular regurgitation incidence and survival. Results During follow-up, 1+ or greater (mild or more) paravalvular regurgitation occurred in 2.2% of aortic cases and 2.9% of mitral cases. There was 2+ or greater (moderate or more) paravalvular regurgitation in 0.9% of aortic and 2.2% of mitral cases ( P = .10). After excluding endocarditis, late noninfectious regurgitation 2+ or greater was detected in 0.5% of aortic and 0.4% of mitral cases ( P = .93); there were no reoperations or percutaneous closures for noninfectious paravalvular regurgitation. Conclusions In an academic medical center, the overall rate of paravalvular regurgitation is low, and late clinically significant noninfectious paravalvular regurgitation is rare. The benchmark for paravalvular regurgitation after conventional valve replacement is high and should be considered when evaluating patients for transcatheter or sutureless valve replacement.
Abstract Objective Pulmonary hypertension (PHT) has been considered a risk factor for mortality in cardiac surgery. Among mitral valve surgery (MVS) patients, we sought to determine if severe PHT ...increases mortality risk and if patients who undergo concomitant tricuspid valve surgery (TVS) incur additional risk. Methods Preoperative PHT was assessed in 1571 patients undergoing MVS, from 2004 to 2013. Patients were stratified into PHT groups as follows (mm Hg): none (<35); moderate (35-49); severe (50-79); and extreme (≥80). Propensity-score matching resulted in a total of 430 patients, by PHT groups, and 384 patients, by TVS groups. Results Patients with severe PHT had higher mortality, both 30-day (4% PHT vs 1% no PHT, P < .02) and late (defined as survival at 5 years): 75.5% severe versus 91.9% no PHT ( P < .001). In propensity-score–matched groups, severe PHT was not a risk factor for 30-day (3% each, P = 1.0) or late mortality (86.2% severe vs 87.1% no PHT; P = .87). TVS did not increase 30-day (4.7% TVS vs 4.2% no TVS, P = .8) or late mortality (78.7% TVS vs 75.3% no TVS, P = .90). Late survival was lower in extreme PHT (75.4% vs no PHT 91.5%, P = .007), and a trend was found in 30-day mortality (11% extreme vs 3% no PHT, P = .16). Conclusions Mortality in MVS is unaffected by severe PHT or the addition of TVS, yet extreme PHT remains a risk factor. Severe PHT (50-79 mm Hg) should not preclude surgery; concomitant TVS does not increase mortality.
Ventricular septal myectomy in patients with obstructive hypertrophic cardiomyopathy (HC) has been shown to reduce left ventricular (LV) outflow tract (LVOT) gradient and improve symptoms, although ...little data exist regarding changes in left atrial (LA) volume and LV diastolic function after myectomy. We investigated changes in LA size and LV diastolic function in patients with HC after septal myectomy from 2004 to 2011. We studied 25 patients (age 49.2 ± 13.1 years, 48% women) followed for a mean of 527 days after surgery who had serial echocardiography at baseline and at most recent follow-up, at least 6 months after myectomy. In addition to myectomy, 3 patients (12%) underwent Maze surgery and 13 (52%) underwent mitral valve surgery, of whom 5 had a mitral valve replacement or mitral annuloplasty. Patients with mitral valve replacement or mitral annuloplasty were excluded from LV diastolic function analysis. LA volume index decreased (from 47.2 ± 17.6 to 35.9 ± 17.0 ml/m2 , p = 0.001) and LV diastolic function improved with an increase in lateral e′ velocity (from 7.3 ± 2.9 to 9.8 ± 3.1 cm/sec, p = 0.01) and a decrease in E/e′ (from 14.8 ± 6.3 to 11.7 ± 5.5, p = 0.051). Ventricular septal thickness and LVOT gradient decreased, and symptoms of dyspnea and heart failure improved, with reduction in the New York Heart Association functional class III/IV symptoms from 21 (84%) to 1 (4%). In conclusion, relief of LVOT obstruction in HC by septal myectomy results in improved LV diastolic function and reduction in LA volume with improved symptoms.
PDF
