This study sought to determine outcomes in patients with severe, asymptomatic aortic stenosis (AS), stratified by treatment recommendation.
Between January 2005 and December 2013, 4,998 patients had ...severe AS by echocardiography, of whom 308 were identified as asymptomatic by medical record review. Five patients were deemed inoperable, and 38 were lost to follow-up. Of the remaining 265 patients, aortic valve replacement (AVR) was recommended in 104, and watchful waiting (WW) was recommended in 161. Probabilities of undergoing surgery and of death from recommendation date were estimated using a multistate model. Cox regression analysis was used to determine independent risk factors for death.
Probability of death at 1 year after recommendation was 5.2% in the WW group and 4.7% in the AVR group. At 2 years after recommendation, survival in the AVR-recommended group was 92.5% versus 83.9% in the WW group (p = 0.044). In the WW group, the probability of dying or undergoing surgery was 43.9% by 2 years. Undergoing surgery was independently associated with higher survival in the AVR-recommended group (hazard ratio HR, 0.17; p = 0.038) and in the WW group (HR, 0.39; p = 0.044). A higher ejection fraction (HR, 0.58; p < 0.001) was associated with better survival, whereas renal failure (HR, 2.81; p = 0.009) was associated with worse survival.
The strategy of early AVR is associated with improved survival in asymptomatic patients.
Surgical ablation for atrial fibrillation concomitant with cardiac surgery is now a Class I recommendation for selected patients. Understanding how the revised recommendations will affect appropriate ...use of surgical ablation is challenging because the reported prevalence of preoperative atrial fibrillation depends on the definition used. The objective was to determine the prevalence of atrial fibrillation in the 3 years before cardiac surgery and the rate of concomitant surgical ablation.
Patients with and without a diagnosis of atrial fibrillation in the 3 years before surgical coronary artery bypass, aortic valve replacement, or mitral valve replacement/repair were identified in the 2014 Medicare Standard Analytical File.
Patients had prior atrial fibrillation in 28.4% of 79,134 cardiac surgeries. Prior atrial fibrillation was associated with risk factors for increased cardiac surgical morbidity/mortality, including recent heart failure, renal failure, and lung disease. Black patients were less likely to have prior atrial fibrillation but more likely to have had infrequent care for it. Isolated coronary artery bypass had the lowest prevalence but highest absolute number of prior atrial fibrillation cases. Concomitant surgical ablation was performed in 22.1% of patients with prior atrial fibrillation. Patients with mitral valve surgery were 3-fold more likely to receive surgical ablation. Women were less likely to have prior atrial fibrillation but less likely to have surgical ablation when they did.
Medicare beneficiaries had a substantially higher prevalence of atrial fibrillation diagnoses in the 3 years before cardiac surgery than previously published rates of preoperative atrial fibrillation. Concomitant surgical ablation was performed in less than one-quarter of patients with atrial fibrillation undergoing cardiac surgery for other indications.
The prevalence of AF in the 3 years preceding cardiac surgery was 28% in the Medicare population. Patients undergoing MV surgery were more likely to have concomitant SA for AF. This study presents the first detailed data on the rate of SA in Medicare beneficiaries. The prevalence of AF is higher than in prior reports. The treatment rate is lower and varies considerably by the type of cardiac surgery performed. Display omitted
Anterior and bileaflet degenerative mitral regurgitation (DMR) repairs are challenging. We examined our early and late outcomes for repair using four techniques, without neochord repair.
Between ...02/01/2006– 06/30/2021, a total of 2,368 patients had mitral valve +/- other surgery by one surgeon, including 1,160 with DMR. Clinical follow-up was conducted annually (mean 6.8±4.4 years).
Repair was performed in 1137 (98%) of patients (mean age 60.5±11.9 years). Repair rate varied between groups: 99% for isolated posterior leaflet (794/799); 91% isolated anterior leaflet (83/91); and 96% bileaflet prolapse (260/270; p<0.001). Thirty-day mortality was 0.2%. On a scale of 0-4+ MR, mean MR grade decreased from 3.8±0.6 pre-operative to 0.07±0.3 at discharge, including moderate (2+) in 0.6% (7/1137) overall, and 0.9% (3/343) with anterior prolapse. None were more than 2+ at discharge. Between the 3 groups of leaflet prolapse there was no significant difference in long-term survival (p=0.26), freedom from MV reintervention (p=0.12; 99.4% overall) and freedom from >moderate (2+) MR (p=0.16; 98.3% overall). The 4 most common anterior leaflet repair techniques chord transfer 17%; commissuroplasty 10%; Alfieri (edge-to-edge) 6%), ring with posterior resection (4.3%) had similar freedom from 10-year reintervention (99.4%, 94%, 100%, 100% respectively; p=0.29).
Complex anterior leaflet prolapse repairs are successful using a variety of techniques without neochord implantation. Although neochords are popular, there are other ways to repair complex valves that don't require as much judgment and experience.
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We sought to compare outcomes after two surgical approaches for the treatment of atrial fibrillation (AF): a minimally invasive, staged hybrid approach combining surgery with catheter ablation, ...Hybrid Maze (HM) and the classic cut and sew Maze (CM).
From April 2004 to March 2010, 63 stand-alone AF procedures were performed by two surgeons at a single center and followed up for ≥6 months. CM was offered to all patients. After July 2007, patients were also prospectively offered a two-stage HM: stage 1 = a beating heart bipolar radiofrequency pulmonary vein isolation and left atrial appendage ligation; stage 2 = transvenous catheter ablation connecting the pulmonary veins to each other and the mitral annulus when AF was present after stage 1. Outcomes were compared between 25 HM and 38 CM using χ or Fisher exact test analysis.
Postoperatively, there was no difference in 30-day mortality (0%), complications (4% HM vs. 18% CM), or median length of stay (5 days). At last follow-up, 88% of HM and 95% of CM were free from AF; 80% of HM and 90% of CM were free from AF and antiarrhythmic medication (P ≥ 0.3). Twenty-nine percent of HM required a subsequent catheter ablation (stage 2) when compared with 8% of the CM patients (P = 0.04). Freedom from AF and antiarrhythmic medication at 1 year was 52% for the HM and 87.5% for the CM (P = 0.004).
In AF patients reluctant to undergo a CM but willing to undergo subsequent catheter ablation, a minimally invasive approach is a reasonable strategy. Because pulmonary vein isolation alone may be sufficient in two-thirds of patients and delayed reconnection is common, an interval two-stage hybrid approach may prove preferable over a one-stage combined hybrid approach; however, successful sinus restoration may take longer with this approach.
Introduction
Atrial fibrillation (AF) is a growing health problem and is associated with increased risk of stroke. The Cox‐Maze surgical procedure has offered the highest success rate, but ...utilization of this technique is low due to procedure invasiveness and complexity. Advances in catheter ablation and minimally invasive surgical techniques offer new options for AF treatment.
Methods
In this review, we describe current trends and outcomes of minimally invasive treatment of persistent and long‐standing persistent AF.
Results
Treatment of persistent and long‐standing persistent AF can be successfully treated using a team approach combining cardiac surgery and electrophysiology procedures. With this approach, the 1‐year freedom from AF off antiarrhythmic drugs was 85%.
Discussion
There are a variety of techniques and approaches used around the world as technology evolves to help develop new treatment strategies for AF. Our report will focus on a hybrid treatment approach using surgical and electrophysiology approaches providing enhanced treatment options by replicating Cox‐Maze IV lesions using skills from each specialty. Closure of the left atrial appendage as part of these procedures enhances protection from late stroke. A team approach provides a cohesive evaluation, treatment, and monitoring plan for patients. Development of successful, less invasive treatment options will help address the growing population of patients with AF.
The Maze Procedure and Postoperative Pacemakers Cox, James L.; Ad, Niv; Churyla, Andrei ...
The Annals of thoracic surgery,
November 2018, 2018-11-00, 20181101, Letnik:
106, Številka:
5
Journal Article
Recenzirano
Odprti dostop
There is concern that the right atrial lesions of the maze procedure lead to more permanent pacemakers postoperatively and that they provide little therapeutic advantage over left atrial lesions ...alone.
A discussion of the pertinent anatomy related to atrial fibrillation and the performance of the maze procedure, the potential ways that the specialized conduction system could theoretically be damaged by the procedure, non–procedure-related causes for increased postoperative pacemaker requirements, and the basis for the efficacy of the right atrial lesions of the maze procedure are presented. Several factors that can lead to a dysfunctional sinoatrial node preoperatively in patients with atrial fibrillation are also discussed.
The reasons new permanent pacemakers are required after a maze procedure include the high success rates of the surgery with subsequent unmasking of preoperative sick sinus syndrome, excessive extracardiac dissection that damages the autonomic nerve input to the heart, premature pacemaker implantation for a temporary junctional rhythm immediately postoperatively, surgical error, and patient selection.
There are numerous reasons why patients need new pacemakers after a maze procedure, but the right atrial lesions of the procedure rarely, if ever, are the cause.
Mitral repair for asymptomatic (New York Heart Association NYHA class I) degenerative mitral regurgitation (MR) is supported by the guidelines, but is not performed often. We sought to determine ...outcomes for asymptomatic patients when compared with those with symptoms.
Between 2004 and 2018, 1027 patients underwent mitral replacement (22) or repair with or without other cardiac surgery (1005), the latter being grouped by NYHA class: I (n = 470; 47%), II (n = 408; 40%), or III/IV (n = 127; 13%). Statistical analyses included propensity score matching and weighting, and multistate models.
The proportion of patients designated as NYHA class I undergoing surgery increased steadily during this period (P < .001). Overall, 30-day mortality was 0.4%, and zero for patients designated NYHA class I. Unadjusted 10-year survival was significantly greater in patients designated NYHA class I compared with II and III/IV (P < .001). Freedom from reoperation at 10 years was 99.8% overall, and 100% for patients designated NYHA class I. In patients designated as NYHA class I, predischarge and 10-year moderate MR were 0.7% and 20.1%, whereas more than moderate was zero and 0.6%. Preoperative ejection fraction less than 60% was associated with late mortality (P = .025). After covariate-adjustments, freedom from MR and tricuspid regurgitation were not statistically significantly different by NYHA class. However, overall survival was significantly worse in patients with NYHA class III/IV, compared with class II.
Mitral repair in asymptomatic patients is safe and durable. Careful monitoring until class II symptoms is appropriate. However, repair before ejection fraction decreases below 60% is important for late overall survival.
In asymptomatic DMR repair patients, 10-year reoperation was 0%, and late 3-4+ MR was low. Display omitted
Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG). Currently, there is no reliable way to determine preoperatively which patients will ...develop POAF following CABG. The aim of this study was to determine whether preoperative left atrial (LA) strain analysis might identify patients destined to develop POAF following CABG.
From 2016 to 2018, 211 patients who had a preoperative left ventricular ejection fraction >50% and adequate preoperative, predischarge, and follow-up echo images for interpretation underwent isolated CABG surgery. Postoperatively, patients had continuous rhythm monitoring until hospital discharge. Retrospective speckle-tracking analysis of preoperative echocardiograms was performed to calculate preoperative left ventricular global longitudinal strain and LA compliance and contraction strains in 92 matched patients. Multivariate logistic regression and Cox proportional hazards models were used to determine the predictors of POAF after CABG.
POAF occurred in 50 patients (24%). They were older, had longer intensive care unit and hospital stays, and a slightly greater 30-day mortality (P = .07). Preoperative LA volume index was larger in the patients with POAF but still “normal” as defined by current guidelines. However, preoperative LA compliance and contraction strains were significantly lower in patients who developed POAF after CABG.
Decreased preoperative LA strain measurements, especially LA-fractional area change, LA-emptying fraction, and LA-reservoir strain, taken jointly, are more specific and sensitive than other preoperative parameters in identifying patients who will develop POAF following CABG. The ability to identify patients preoperatively who are destined to develop POAF following CABG provides a basis for limiting POAF prophylactic therapy to only those patients undergoing CABG who are most likely to benefit from it rather than to all patients undergoing CABG.
A total of 211 patients undergoing isolated coronary artery bypass grafting (CABG) who had a retrospective analysis of their preoperative standard echo parameters and strain analysis of their LA, left ventricle, and right ventricle using 2-dimensional (2D) speckle-tracking echocardiogram analysis. The patients were divided into 2 groups for comparison based on whether or not they developed postoperative atrial fibrillation (POAF). The 50 patients who had abnormal preoperative LA strain measurements developed POAF. The 161 patients who had normal preoperative LA strain measurements did not develop POAF. Display omitted
This study compares outcomes of patients with preoperative atrial fibrillation undergoing coronary artery bypass grafting (CABG) with or without concomitant atrial fibrillation ablation in a ...nationally representative Medicare cohort.
This study examined early and late outcomes in CABG patients with a preoperative history of atrial fibrillation to determine the correlation between surgical atrial fibrillation ablation to mortality and stroke or systemic embolization.
In the Medicare-linked Society of Thoracic Surgeons database, 361,138 patients underwent isolated CABG from 2006 to 2013; 34,600 (9.6%) had preoperative atrial fibrillation; 10,541 (30.5%) were treated with surgical ablation (ablation group), and 23,059 were not (no ablation group). Propensity score matching was performed using a hierarchical mixed model. Long-term survival was summarized using Kaplan-Meier curves and Cox regression models with robust variance estimation. The stroke or systemic embolization incidence was modeled using the Fine-Gray model. Median follow-up was 4 years.
Long-term mortality in propensity score-matched CABG patients (mean age 74 years; Society of Thoracic Surgeons risk score, 2.25) receiving ablation versus no ablation was similar (log-rank P = .30). Stroke or systemic embolization occurred in 2.2% versus 2.1% at 30 days and 9.9% versus 12.0% at 5 years (Gray P = .0091). Landmark analysis from 2 to 5 years showed lower mortality (hazard ratio, 0.89; 95% confidence interval 0.82-0.97; P = .0358) and lower risk of stroke or systemic embolization (hazard ratio, 0.73; 95% confidence interval, 0.61-0.87; P = .0006) in the ablation group.
Concomitant ablation in CABG patients with preoperative atrial fibrillation is associated with lower stroke or systemic embolization and mortality in patients who survive more than 2 years.
The Medicare-linked Society of Thoracic Surgeons database was queried for patients undergoing isolated CABG from 2006 to 2013 and 34,600 out of 361,138 patients (9%) had preoperative AF. The Cox maze IV maze lesion set is shown. However, detailed lesion set information was not available in our study. A comparison was made of 10,541 patients who had AF treated at the time of CABG, to the 23,059 who did not. Propensity score matching was used to balance the groups. End points of stroke or systemic embolization and mortality were analyzed. Landmark analysis from 2 to 5 years showed lower mortality (hazard ratio, 0.89; 95% confidence interval, 0.82-0.97; P = .0358) and lower risk of stroke or systemic embolization (hazard ratio 0.73; 95% confidence interval, 0.61-0.87; P = .0006) in the surgical ablation group. Display omitted
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