Postsurgical late reinterventions for atrial fibrillation (AF) include cardioversions (CV) or catheter ablations (CA). Commonly used methods for reporting and modeling the frequency and timing of CA ...or CV have well-known shortcomings.
The purpose of this study was to present intuitive and robust methods to visualize, summarize, and model late reinterventions type/timing and vital status simultaneously.
We present (1) the SMART plot (Summary of Mortality And Outcomes Reported Over Time); (2) the reintervention mean cumulative function (MCF); and (3) the proportional means model and the proportional rates model. We illustrate these methods in 3 groups: patients age ≤60 years, 60-75 years (reference), and >75 years who underwent surgical AF ablation.
Patients age >75 years had a significantly lower MCF of CVs (hazard ratio HR 0.50, P <.001). MCF for CAs was not significantly lower for patients age >75 years (HR 0.57, P = .13). For combined reinterventions (CV or CA), the age group >75 years had a significantly lower MCF (HR 0.51, P <.001). There were no significant differences in late CV or CA reintervention patterns for patients age ≤60 years.
The methods presented provide a comprehensive framework for displaying, summarizing, and modeling repeated late reinterventions after surgical AF ablation. Other areas of application are described, further emphasizing the potential for immediate use.
Bicuspid aortic valve (BAV) is a common congenital heart diagnosis and is associated with aortopathy. Current guidelines for aortic resection have been validated but are based on aortic diameter, ...which is insufficient to predict acute aortic events. Clinical and translational collaboration is necessary to identify biomarkers that can individualize the timing of prophylactic surgery for BAV aortopathy. We describe our multidisciplinary BAV program, including research protocols aimed at biomarker discovery and results from our longitudinal clinical registry. From 2012-2018, 887 patients enrolled in our clinical BAV registry with the option to undergo four dimensional flow cardiovascular magnetic resonance imaging (4D flow CMR) and donate serum plasma or tissue samples. Of 887 patients, 388 (44%) had an elective BAV-related procedure after initial presentation, while 499 (56%) continued with medical management. Of medical patients, 44 (9%) had elective surgery after 2.3 ± 1.4 years. Surgery patients' biobank donations include 198 (46%) aorta, 374 (86%) aortic valve, and 314 (73%) plasma samples. The 4D flow CMR was completed for 215 (50%) surgery patients and 243 (49%) medical patients. Patients with BAV aortopathy can be safely followed by a multidisciplinary team to detect indications for surgery. Paired tissue and hemodynamic analysis holds opportunity for biomarker development in BAV aortopathy.
Introduction
Surgical management of atrial fibrillation (AF) is a well‐established method of preventing complications and late mortality in patients presenting with AF before mitral valve (MV) ...surgery. However, despite a substantial body of evidence and a Class I recommendation to apply surgical ablation (SA) concomitant to MV surgery, the utilization of SA remains low.
Methods
In this study, we sought to summarize the current trends in the SA of AF during MV surgery and update the medical community on its advantages, including perioperative mortality and morbidity, freedom from AF, as well as long‐term survival and stroke rates.
Results
The data indicate that SA can be added with no increased risk (and perhaps a reduction in perioperative risk) and improved late survival compared to patients with AF left untreated during MV surgery.
Discussion
Inconsistent application of SA may be related to inaccurate perceptions regarding the complexity of the procedure itself, extended cross‐clamp and bypass times with attendant increased risks, views that it is ineffective, and increased need for an early pacemaker.
Conclusion
Education in the proper performance of SA, including careful placement of the lesions and attainment of the full transmural effect, contributes to procedure success. Propagating the safety and positive outcomes may also address the concerns.
Surgical ablation of atrial fibrillation (AF) in conjunction with other cardiac surgery is now a class I guideline recommendation. Multiple studies have demonstrated that the concomitant surgical ...ablation of AF can be performed safely and effectively during valve and coronary artery bypass grafting (CABG) resulting in a return to sinus rhythm postoperatively and improved long‐term results. However, the surgical ablation of AF at the time of other cardiac surgery is performed less often than it should be, especially in patients undergoing CABG and aortic valve surgery. Randomized‐controlled trials designed to determine the effect of treating AF concomitantly with other cardiac surgical procedures have lacked long‐term follow up, but multiple, large observational studies have demonstrated an improved quality of life, a decrease in long‐term strokes, and improved late survival in patients who undergo AF ablation. However, the potential survival benefit of concomitant AF ablation was not addressed by either the Society of Thoracic Surgery or American Association for Thoracic Surgery guideline committees. Left atrial appendage closure is an important part of the surgical ablation of AF as it significantly reduces the long‐term risk of stroke following cardiac surgery and improves the success of AF treatment. In this study, we update the electrophysiology and surgical community on the recommended surgical techniques for AF ablation and its effect on perioperative morbidity, perioperative mortality, as well as its long‐term effects on stroke, quality of life, and survival.
Gender differences in the corrected QT interval have been noted since Bazett's initial description during the 1920s. The mechanism of this gender difference is unknown, and this study was undertaken ...to evaluate potential autonomic and menstrual cycle effects on the QT interval. The study population consisted of a healthy volunteer sample of 23 women and 20 men. Twelve-lead electrocardiographic determinations were made at rest and following double autonomic blockade (with atropine and propranolol) during the menstrual, follicular, and luteal phases of the menstrual cycle. Men were studied during 3 separate visits as controls. The corrected QT interval at baseline tended to be longer in women than men (421 ± 16 ms vs 414 ± 15 ms: p <0.07). Following double autonomic blockade, the corrected QT interval increased to 439 ± 11 ms: p <0.001). However, the gender difference in corrected QT interval was unchanged (443 ± 15 ms vs 437 ± 12 ms). At baseline, there was no significant difference in the corrected QT interval among the 3 phases of the menstrual cycle (421 ± 10, 423 ± 18, and 420 ± 18 in the menstrual, follicular, and luteal phases, respectively) and the corrected QT interval was longer in women than men at each visit. Following double autonomic blockade, the corrected QT interval in women was shorter in the luteal phase (438 ± 16 ms) versus the menstrual (446 ± 15 ms) or the follicular phase (444 ± 13 ms; p <0.05). However, this difference, which was not present at baseline, does not appear to be responsible for the gender difference in the QT interval at rest. In conclusion, our results confirm that the corrected QT interval tends to be longer in women than men. Differences in autonomic tone and menstrual cycle variability in the corrected QT in women at rest do not appear to be responsible for the gender differences in the QT interval. The mechanism responsible for the longer QT interval in women remains to be defined.
Concomitant atrial fibrillation often goes untreated because of surgeon concerns regarding lesion set complexity and pump times. We describe a new cryoablation procedure to address this.
From June ...2013 to March 2021, a modified CryoMaze III procedure was used using 3 left atrial ± 3 right atrial cryo-applications creating the key lesions of the Cox Maze III procedure. Since 2018, 3-minute cryo-lesions were used for the left atrial box lesion for total cryoablation times of 8 minutes for the left atrium ± 6 minutes for the right atrium. By using propensity matching, patients undergoing mitral valve surgery with no atrial fibrillation history were compared with CryoMaze III–treated patients.
A total of 100% of the 277 patients with atrial fibrillation requiring mitral valve surgery ± other procedures received the modified CryoMaze III procedure. After propensity score matching (n = 161 each group), the modified CryoMaze III group had mean crossclamp and bypass times 10.5 and 13.4 minutes longer than the control group, respectively. There were no significant differences in 30-day mortality, morbidity, pacemaker use, renal dysfunction, or late survival between groups, but there were less postoperative strokes in the CryoMaze III group. Freedom from atrial fibrillation off antiarrhythmics was 77% (mean follow-up of 3.0 ± 2.1 years). At 12 months, freedom from atrial fibrillation off antiarrhythmics was 90% for the 3-minute ablation group. Late survival was similar to age- and sex-matched Centers for Disease Control and Prevention controls.
The modified CryoMaze III technique is efficient, safe, and effective. Education of the surgical community regarding the late benefits of ablation and the simplicity of this new technique should improve adoption of the Class I Guidelines to treat concomitant atrial fibrillation.
Degenerative mitral regurgitation repair using a measured algorithm could increase the precision and reproducibility of repair outcomes.
Direct and echocardiographic measurements guide the repair to ...achieve a coaptation length of 5 to 10 mm and minimize the risk of systolic anterior motion. Leaflet reconstruction restored the normal 2 to 1 ratio of anterior to posterior leaflet length without residual prolapse or restriction. The choice of ring size was based on anterior leaflet length, the distance from the leaflet coaptation point to the septum, and the anterior-posterior ring dimension. Freedom from reoperation and mitral regurgitation recurrence were based on multistate models.
One thousand fifty-one patients had mitral surgery and 1026 (97.6%) were repaired. A2 length was 27.2 ± 4.5 mm; and the reconstructed posterior leaflet was 13.9 ± 2.3 mm. Median ring size was 34 mm and strongly correlated to A2 length (R = 0.76; P < .001). The coaptation length at P2 after repair was 6.4 ± 1.7 mm and 87% of measurements were between 5 and 10 mm. Results at predischarge and 10 years, respectively, included mild regurgitation (7.5% and 26.1%), moderate (0.7% and 15.6%), moderate to severe (0% and 1.4%), and severe (0% and 0%), with mean mitral gradient values 3.5 ± 1.5 and 2.9 ± 1.2 mm Hg, respectively. Systolic anterior motion at discharge and last follow-up were 0.2% and 1.1%, respectively. Ten-year freedom from mitral valve reoperation was 99.7%.
A simple, reproducible, measured algorithm for degenerative mitral valve repair provides excellent early and late results and is a useful adjunct to established surgical techniques.
A quantitative algorithm for mitral repair using measurements to reconstruct the leaflets. Display omitted
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