Atrial fibrillation (AF) is the most common of all cardiac arrhythmias, affecting roughly 1% of the general population in the Western world. The incidence of AF is predicted to double by 2050. Most ...patients with AF are treated with oral medications and only approximately 4% of AF patients are treated with interventional techniques, including catheter ablation and surgical ablation. The increasing prevalence and the morbidity/mortality associated with AF warrants a more aggressive approach to its treatment. It is the purpose of this invited editorial to describe the past, present, and anticipated future directions of the interventional therapy of AF, and to crystallize the problems that remain.
Gender disparities in short- and long-term outcomes have been documented in cardiac and valvular heart surgery. However, there is a paucity of data regarding these differences in the bicuspid aortic ...valve (BAV) population. The aim of this study was to examine gender-specific differences in short- and long-term outcomes after surgical aortic valve (AV) replacement in patients with BAV. A retrospective analysis was performed in 628 consecutive patients with BAV who underwent AV surgery from April 2004 to December 2013. To reduce bias when comparing outcomes by gender, propensity score matching obtained on the basis of potential confounders was used. Women with BAV who underwent AV surgery presented with more advanced age (mean 60.7 ± 13.8 vs 56.3 ± 13.6 years, p <0.001) and less aortic regurgitation (29% vs 44%, p <0.001) and had a higher risk for in-hospital mortality (mean Ambler score 3.4 ± 4.4 vs 2.5 ± 4.0, p = 0.015). After propensity score matching, women received more blood products postoperatively (48% vs 34%, p = 0.028) and had more prolonged postoperative lengths of stay (median 5 days interquartile range 5 to 7 vs 5 days interquartile range 4 to 6, p = 0.027). Operative, discharge, and 30-day mortality and overall survival were not significantly different. In conclusion, women with BAV who underwent AV surgery were older, presented with less aortic regurgitation, and had increased co-morbidities, lending higher operative risk. Although women received more blood products and had significantly longer lengths of stay, short- and long-term outcomes were similar.
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 Background Gender disparities have been established in patients who have atrial fibrillation (AF), and in their outcomes after medical treatment for AF. This study evaluated differences in ...outcome by gender in patients who underwent surgical treatment for AF. Methods From April 2004 to December 2012, a total of 936 patients had surgical treatment for AF. Outcomes were analyzed by gender using propensity score–matching methods. Results Of the 936 subjects, 571 (61%) were men; women were older (aged 68.6 ± 11.3 vs 66.9 ± 11.9 years; P = .033), had more heart failure (44% vs 37%; P = .024), more mitral valve surgery (72% vs 50%; P < .001) and more tricuspid valve surgery (41% vs 18%; P < .001). Men underwent more coronary artery bypass surgery (37% vs 19%; P < .001) and aortic valve surgery (38% vs 31%; P = .029). Women had higher late stroke rate per 10 person-years (0.15 vs 0.07; P = .035), fewer catheter ablations (6.0% vs 9.8%; P = .017), and a trend toward fewer cardioversions for recurrent AF (15.7% vs 19.2%; P = .20). After propensity-score matching, late stroke rates per 10 person-years trended higher in women (0.12 vs 0.04; P = .13). No significant gender differences were found in overall survival (5-year survival: 78.8% in men, and 81.0% in women; P = .40) or freedom from AF without antiarrhythmic drugs at last follow-up (71.8% in men vs 73.6% in women, P = .59). Conclusions Women sought surgery treatment at older ages and with more heart failure. No gender-based differences were found in stroke, overall survival, or procedure success, after propensity-score matching.
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.
Objectives Multiple techniques have been used to repair degenerative mitral valve prolapse with leaflet elongation, without creating systolic anterior motion. We describe a simple, reproducible, ...measured technique to guide repair. Methods From January 2010 to July 2012, 171 patients underwent mitral valve repair; 128 (75%) with Carpentier type II prolapse. For 48 patients (37.5%), the resected posterior leaflet free edge was partially folded to restore the normal 2:1 ratio of the A2 and P2. All patients underwent complete ring annuloplasty sized to the height of A2. Results The preoperative A2/P2 ratio was 1.5 ± 0.5. After repair, the A2/P2 ratio was 1.9 ± 0.3 and 2.0 ± 0.3 in the no fold and partial fold groups, respectively ( P = .57). The ring sizes were larger in the partial fold group ( P < .001) because the A2 height was larger ( P = .001). No obstructive systolic anterior motion was present. Of the 171 patients, 91.4% had grade 4+ preoperative mitral regurgitation, with no 3 or 4+ mitral regurgitation during follow-up. At the last follow-up visit, grade 2+ mitral regurgitation was observed in 5% of the patients. No 30-day mortalities or reoperations occurred. Conclusions Partial fold of the posterior leaflet free edge is a simple technique to restore the normal 2:1 ratio of A2/P2 with a ring size determined by the A2 height. Using just the A2 height, mitral surgeons can reproducibly repair the posterior leaflet prolapse, choose the appropriate ring size, and avoid more complex leaflet reconstruction or judgment of the neochord length.
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.
Background The classic cut and sew maze is thought to reduce stroke, in part because of left atrial appendage (LAA) elimination. Multiple LAA elimination techniques have evolved with the introduction ...of new surgical treatment options for atrial fibrillation (AF), but the impact on stroke remains unknown. We studied the rate of late neurologic event (LNE) in the era of contemporary AF surgery. Methods From April 21, 2004, to June 30, 2011, 773 patients underwent surgery for AF. In 131 patients, the LAA was excised. In 579, alternative elimination techniques were used (97 external ligation, 313 internal ligation, 126 stapled excision, 23 stapled excision plus internal ligation, 5 internal plus external ligations, and 15 that did not fit into any category); 63 LAAs were left intact and excluded from analyses. Complete follow-up was obtained by medical record review and phone call. Median survival follow-up was 3.3 years (first and third quartiles, 1.6 and 5.0). An LNE was defined as either a documented stroke or transient ischemic attack 30 or more days after surgery. Baseline characteristics and outcomes between LAA techniques were compared using χ2 , Fisher's exact tests, and Student's t tests. Results There were 25 LNEs (3.5%) overall; the median occurrence time was 3.6 years (first and third quartiles, 1.9 and 5.4) after surgery. There were 17 strokes and 8 transient ischemic attacks. Of 45 demographic and surgical variables, only age, aortic valve surgery, and perioperative neurologic event (<30 days after cardiac surgery) independently predicted LNE ( p = 0.003, 0.021, and 0.010, respectively). Late neurologic events occurred with an annual rate of 1.13% in patients with alternative elimination techniques, and 0.20% in patients with excised LAA ( p = 0.001). Patients in AF at any time were more likely to have LNE, but this was not an independent predictor. Conclusions After surgery for AF ablation, there is ongoing low risk of LNE even when the LAA is surgically excised. Further investigation should be pursued to clarify whether a difference exists with alternative elimination techniques and in patients in whom AF is successfully eliminated.
Background Multiple formats have been used to deliver information needed for informed consent before a medical procedure, but data comparing formats are conflicting. Methods Sixty-three patients (45 ...men, age 61 ± 16 years) undergoing an initial diagnostic cardiac electrophysiology study were randomly assigned to 1 of 3 groups: oral, written, or video informed consent using a standardized text for all 3 formats. Anxiety levels were assessed with the Spielberger State-Trait Anxiety Inventory (STAI), and questionnaires were used to assess patient comprehension and satisfaction with the informed consent process. Physician time needed to obtain informed consent was also measured. The effect of informed consent format on anxiety state was evaluated by comparing STAI before and after consent. Multivariable analysis was performed to assess the effects of baseline characteristics on the state anxiety scores. Results For the oral, written, and video formats, the mean anxiety trait scores were 39 ± 9, 34 ± 8, and 31 ± 7, respectively ( P = .005), and baseline anxiety state scores were 49 ± 12, 37 ± 12, and 36 ± 11, respectively ( P = .0006). None of the formats had a significant effect on patient anxiety state after consent was obtained. After the procedure, anxiety state declined ( P < .0001). There were no differences among the comprehension scores, and patient satisfaction was equivalent among formats. The oral format required the longest physician time ( P = .06). Conclusion For electrophysiologic testing, all 3 formats have similar effects on anxiety and produce equivalent patient comprehension. The oral format requires more physician time. Given the standardization achievable with a written or video format, physicians may consider these options to facilitate obtaining informed consent.
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