Objectives The objective of this study was to evaluate the effects of different lesion sets of ablation in patients undergoing mitral surgery plus maze. Background The role of lesion sets on outcome ...after maze is poorly defined. Methods A total of 141 patients were prospectively followed up. Two different lesion sets were prepared: 32 patients underwent a radiofrequency left atrial lesion set of maze (“limited”), and 109 had combined left and right atrial lesion sets of maze ± ganglionic plexi isolation (“extensive”). A longitudinal observational study assessed the role of “extensive” versus “limited” ablation on atrial fibrillation (AF), New York Heart Association (NYHA) functional class II/III, treatment with antiarrhythmic drugs, follow-up recovery of the ratio of E- to A-wave (E/A), and survival and time to hospitalization (overall and for heart failure). Results The prevalence of AF over time was lower in the “extensive” arm (adjusted relative risk RR: 0.10; 95% confidence interval CI: 0.03 to 0.31; p < 0.001), with significantly lower prevalence at discharge, 3 months, and 18 months. The prevalence of patients in NYHA functional class II/III over time was lower in the “extensive” arm (adjusted RR: 0.11; 95% CI: 0.03 to 0.34; p < 0.001), with significant differences at any assessment (except the third month). The differences in E/A recovery and use of antiarrhythmic drugs were less marked, with an RR of 1.55 (95% CI: 0.99 to 2.42; p = 0.05) and RR of 0.76 (95% CI: 0.54 to 1.06; p = 0.11), respectively, with a significantly lower prevalence of antiarrhythmic drugs in the “extensive” ablation arm at 12, 18, and 24 months. Rates of hospitalization for heart failure, overall hospitalization, and the combined event death/hospitalization were lower in the “extensive” arm (p = 0.11, p = 0.003, and p = 0.002, respectively). Conclusions The addition of right-sided ablation improves clinical and electrophysiologic results after maze procedure.
Conduction disorders and permanent pacemaker implantation are common complications in patients who undergo transcatheter aortic valve implantation (TAVI). The aim of this study was to assess the ...incidence and clinical significance of new bundle branch block in patients who underwent TAVI with the Medtronic CoreValve Revalving System (MCRS) or the Edwards SAPIEN valve (ESV). Data from 238 patients with no previous pacemaker implantation, left bundle branch block (LBBB) or right bundle branch block at baseline electrocardiography who underwent TAVI with either MCRS (n = 87) or ESV (n = 151) bioprostheses from 2007 to 2011 were analyzed. New-onset LBBB occurred in 26.5% patients (n = 63): 13.5% with the ESV (n = 20) and 50.0% with the MCRS (n = 43) (p = 0.001). Permanent pacemaker implantation was required in 12.7% of patients (n = 8) because of complete atrioventricular block (ESV n = 2, MCRS n = 4), LBBB and first degree atrioventricular block (MCRS n = 1) and new-onset LBBB associated with sinus bradycardia (MCRS n = 1). At discharge, LBBB persisted in 8.6% of ESV patients (n = 13) and 32.2% of MCRS patients (n = 28) (p = 0.001). On multivariate analysis, the only predictor of LBBB was MCRS use (odds ratio 7.2, 95% confidence interval 2.9 to 17.4, p <0.001). Persistent new-onset LBBB at discharge was not associated with overall (log-rank p = 0.42) or cardiovascular (log-rank p = 0.46) mortality. New-onset right bundle branch block was documented in 4.6% of patients (n = 11), with no statistically significant differences between the ESV and MCRS. In conclusion, new-onset LBBB is a frequent intraventricular conduction disturbance after TAVI with a higher incidence with the MCRS compared with the ESV. LBBB persists in most patients, but in this cohort, it was not a predictor of overall or cardiovascular mortality or permanent pacemaker implantation.
Acute kidney injury (AKI) occurs in as many as 40% of patients after cardiac surgery and requires dialysis in 1% of cases. Acute kidney injury is associated with an increased risk of mortality and ...morbidity, predisposes patients to a longer hospitalization, requires additional treatments, and increases the hospital costs. Acute kidney injury is characterized by a progressive worsening course, being the consequence of an interplay of different pathophysiologic mechanisms, with patient-related factors and cardiopulmonary bypass as major causes. Recently, several novel biomarkers have emerged, showing reasonable sensitivity and specificity for AKI prediction and protection. The development and implementation of potentially protective therapies for AKI remains essential, especially for the relevant impact of AKI on early and late survival.
Few data on atrial fibrillation (AF) progression from the first paroxysmal episode are available.
The purpose of this study was to assess the progression of AF not due to potentially reversible ...causes in patients treated according to current guidelines recommendations that also include catheter ablation.
Among 402 screened patients with first AF, 106 patients (mean age 57.5 years) were selected and followed for 5 years. Of these patients, 54 had lone AF and 52 had comorbidities.
Fifty patients (61.1% with lone AF) had no further recurrence after 5 years. The remaining 56 patients within 19 months after the first episode developed recurrent paroxysmal AF requiring long-term antiarrhythmic drug therapy, which was continued in 45 patients and was stopped because of intolerance/failure in 11 patients who underwent catheter ablation. AF became persistent in 24 of the 45 patients on antiarrhythmic drug therapy and then permanent in 16, of whom 6 had refused catheter ablation at the time of persistence. No AF recurrences or AF progression occurred after ablation. Kaplan-Meier curves demonstrated that patients with comorbidities were more likely to progress than were those with lone AF (P <.001) and that patients who underwent catheter ablation were at lower risk for progression to permanent AF than were those on antiarrhythmic drug therapy (P = .029). Age, diabetes, and heart failure (P <.001) predict final progression to permanent AF.
Patients with first AF and comorbidities are at higher risk for rapid progression to permanent AF, and age, diabetes, and heart failure are independent predictors. Catheter ablation rather than antiarrhythmic drug therapy is beneficial in eliminating recurrences delaying arrhythmia progression.
Background Recent evidence supports the important role of inflammation in atrial fibrillation (AF) after coronary artery bypass grafting (CABG) and there is growing evidence that statin has cardiac ...antiarrhythmic effects. The aim of this study was to assess the efficacy of preoperative statins in preventing AF after CABG in a longitudinal observational study. Methods Over a two-year period, 405 consecutive patients underwent isolated CABG procedures. Univariate analysis was performed exploring the relationship regarding statin use and AF development. A propensity score for treatment with statins was obtained from core patient characteristics. The role of statin therapy on postoperative AF was assessed by means of a conditional logistic model, while stratifying on the quintiles of the propensity score. All analysis was performed retrospectively. Results Postoperative AF occurred in 29.5% of the patients with preoperative statin therapy compared with 40.9% of those patients without it ( p = 0.021). No statistical differences among development of AF and type, dose, or duration of preoperative statin therapy were observed. Preoperative statins were associated with a 42% reduction in risk of AF development after CABG surgery (odds ratio OR 0.58, 95% confidence interval CI 0.37 to 0.91, p = 0.017, while stratifying on the propensity score). No different effect of statins on AF was observed with respect to age groups (≤ 70 and >70 years) (interaction p = 0.711). Conclusions Preoperative statins may reduce postoperative AF after CABG. Patients undergoing elective revascularization may benefit from a preventive statin approach.
To evaluate the feasibility, efficacy, and safety of catheter-based radiofrequency renal sympathetic denervation for treatment of resistant hypertension.
Twenty-four patients with essential ...hypertension unresponsive to at least three antihypertensive agents underwent renal denervation (RDN). Three patients had variant renal anatomy. Comorbidities included diabetes (n = 11), renal failure (n = 4), and obstructive sleep apnea (n = 2). The effect on 24-hour ambulatory blood pressure (BP) was assessed at 6 months. Patients with a decrease in systolic BP of at least 10mm Hg were considered responders.
RDN was bilateral in 19 patients and single-sided in five. The 19 patients with bilateral RDN showed mean reductions in 24-hour ambulatory BP of 20.7/8.7mm Hg±18.1/9.9 (systolic/diastolic; P = .0001/P = .0012). Sixteen bilaterally treated patients (84.2%) showed a systolic BP reduction of at least 10mm Hg and were considered responders, whereas only one of the five patients with single-sided RDN showed a response. Two responders with sleep apnea showed improvement in polysomnography indices, and one with left concentric ventricular hypertrophy showed complete cardiac remodeling 11 months after the RDN procedure. Renal function remained unchanged in all patients, including those with renal failure. Optical coherence tomography of the renal arteries in one patient showed sporadic endothelial scarring. Renal angiograms at 9 months (one patient) and 12 months (two patients) had normal findings.
Catheter-based RDN was carried out safely, even in patients with comorbidities, abnormal renal arteries, or anatomic variants. The response rate for bilateral RDN (84.2%) was comparable to previous reports.
Background Chronic obstructive pulmonary disease is a risk factor for postoperative lung injury. Contradictory results have been published about leukocyte filtration (LF) because of the heterogeneity ...of patients and interventions, type of LF, and comorbidities. Methods Sixty patients with mild moderate chronic obstructive pulmonary disease (forced expiratory volume in 1 second 40% to 80%) undergoing aortic valve surgery were randomly assigned to receive systemic arterial and cardioplegic LF during cardiopulmonary bypass (group L, 30 patients) or standard cardiopulmonary bypass (group S). Perioperative interleukin-6, interleukin-8, and tumor necrosis factor-alpha were sampled at different time points. The PaO2 /inspired oxygen fraction (FiO2 ) and alveoloarterial oxygen gradient (AaDO2 ) were measured preoperatively, at intensive care unit arrival, and at 24, 48, and 72 hours postoperatively; lung compliance was measured after intubation, at intensive care unit arrival, and at 4 and 8 hours postoperatively; and radiographic lung injury score was determined preoperatively and at 24, 48 and 72 hours. Length of intubation, intensive care unit stay, hospital stay, need for noninvasive positive-pressure ventilation, acute lung injury, and pneumonia were recorded. Repeated-measures analysis of variance assessed group, time, and group by-time interactions. Results Preoperative and intraoperative data were comparable. Proinflammatory cytokine leakage was reduced by LF. Group L showed shorter intubation time (median 9.5 hours versus group S, 15.0 hours; p = 0.0001), and intensive care unit length of stay (median 19.0 hours versus group S, 24.5; p = 0.0001), lower need for noninvasive positive-pressure ventilation (5 of 30, 16.7%, versus 12 of 30, 40%; p = 0.042). The AaDO2 , PaO2 /FiO2 , lung compliance, and radiographic lung injury score worsened early postoperatively, followed by progressive improvements (time p ≤ 0.001 for all). Such decline of AaDO2 , PaO2 /FiO2 , lung compliance, and radiographic lung injury score was significantly attenuated by LF (group by-time p = 0.0001 for AaDO2 , PaO2 /FiO2 , and lung compliance; p = 0.004 for radiographic lung injury score). Conclusions Arterial plus cardioplegic LF significantly reduced proinflammatory cytokine release after cardiopulmonary bypass, thus ameliorating postoperative indexes of lung function and overall respiratory outcome.
Background Leukocyte filtration has been reported to reduce inflammatory damage during cardiopulmonary bypass. We evaluated the role of leukocyte filtration on hospital outcome and postoperative ...morbidity. Methods Eighty-two consecutive patients who underwent isolated coronary artery bypass grafting were randomly assigned (1:1) to receive leukocyte filters on both arterial and cardioplegia lines or standard arterial filters during cardiopulmonary bypass. Hospital outcome, postoperative markers of morbidity, and biochemical assays were compared. Data were collected preoperatively, intraoperatively, and postoperatively. Costs for patients receiving intraoperative leukofiltration were compared with control patients getting standard arterial filters. Results Hospital mortality and intensive care unit and hospital length of stay were similar. Although duration of ventilation and incidence of pneumonia were comparable, leukocyte-depleted patients showed a higher ratio of arterial partial pressure of oxygen to fraction of inspired oxygen ( p = 0.008) and lower need for postoperative noninvasive ventilation ( p = 0.041). Control patients showed higher need for continuous furosemide infusion ( p = 0.013) and for renal replacement therapy ( p = 0.014), in association with higher serum creatinine ( p = 0.038) and blood urea ( p = 0.18) and lower glomerular filtration rate ( p = 0.038). Leukocyte-depleted patients required lower doses of inotropic agents ( p = 0.56), whereas troponin I leakage and incidence of postoperative atrial fibrillation were comparable. No differences were found in terms of postoperative cerebral dysfunction or neutrophil and platelet counts, as well as postoperative bleeding and need for transfusions. Finally, leukodepletion proved significantly cost-beneficial, with a 37% cost reduction. Conclusions Although hospital outcomes were similar in terms of mortality and length of stay, the improvements in pulmonary, renal, and myocardial function, in association with the cost benefit, justify the use of leukocyte-depletion filters in the clinical practice.
Background Cerebrovascular accidents are devastating and worrisome complications after thoracic endovascular aortic repair. The aim of this study was to determine cerebrovascular accident predictors ...after thoracic endovascular aortic repair. Methods Between January 2001 and June 2008, 76 patients treated with thoracic endovascular aortic repair were prospectively enrolled. The study cohort included 61 men; mean age was 65.4 ± 16.8 years. All patients underwent a specific neurologic assessment on an hourly basis postoperatively to detect neurologic deficits. Cerebrovascular accidents were diagnosed on the basis of physical examination, tomography scan or magnetic resonance imaging, or autopsy. Results Cerebrovascular accidents occurred in 8 (10.5%) patients, including 4 transient ischemic attack and 4 major strokes. Four cases were observed within the first 24-hours. Multivariable analysis revealed that anatomic incompleteness of the Willis circle (odds ratio OR 17.19, 95% confidence interval CI 2.10 to 140.66), as well as the presence of coronary artery disease (OR 6.86, 95 CI% 1.18 to 40.05), were independently associated with postoperative cerebrovascular accident development. Overall hospital mortality was 9.2%, with no significant difference for patients hit by cerebrovascular accidents (25.0% vs 7.3%, p = 0.102). Conclusions Preexisting coronary artery disease, reflecting a severe diseased aorta and anomalies of Willis circle are independent cerebrovascular accident predictors after thoracic endovascular aortic repair procedures. A careful evaluation of the arch vessels and cerebral vascularization should be mandatory for patients suitable for thoracic endovascular aortic repair.
Endovascular intervention has emerged as a less traumatic alternative treatment for several diseases of the thoracic aorta.1,2 However, depending on the different aortic pathologies, procedure ...related complications have become increasingly evident: severe complications include type I endoleaks, migration, and endograft (EG) collapse, as well as those observed during conventional surgery (eg, stroke and paraplegia).3,4 One of the emerging and most alarming complication of thoracic endografting is iatrogenic retrograde type A acute dissection (RTAAD).5 Retrograde type A acute dissection is defined as acute aortic dissection that originates distally to the ascending aorta with a retrograde flap progression into the ascending aorta.6 This complication has been previously described during conventional cardiac surgery with high mortality rate; previous case reports suggested that the fragility of the aortic wall and Marfan disease were predisposing factors to such a life-threatening complication.7-9 This report presents a case of iatrogenic RTAAD after EG repair of a descending thoracic penetrating aortic ulcer, requiring emergent surgical replacement of the ascending aorta and the aortic arch. The available English literature on RTAAD was also reviewed, in order to recognize potential predisposing factors and specific strategies to prevent it.
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