Coronary artery disease is the most common type of cardiovascular disease, leading to high mortality rates worldwide. Although the vast majority can be treated effectively and safely by medical ...therapy, revascularization strategies remain essential for numerous patients. Outcomes of both percutaneous coronary intervention and coronary artery bypass grafting improve in a rapid pace, resulting from technical innovation and ongoing research. Progress has been achieved by technical improvements in coronary stents, optimal coronary target and graft selection, and the availability of minimally invasive surgical strategies. Besides technical progress, evidence‐based patient‐tailored decision‐making by the Heart Team is the basic precondition for optimal outcome. The combination of fast innovation and long‐term clinical evaluations creates a dynamic field. Research outcomes should be carefully interpreted according to the techniques used and the trial's design. Therefore, more and more trial outcomes suggest that revascularization strategies should be tailored towards the specific patient. Although the European Society of Cardiology/European Association for Cardio‐Thoracic Surgery guidelines on myocardial revascularization date from 2018 and a large variety of trial outcomes on revascularization strategies in chronic coronary syndrome have been published since, we aim to provide an updated overview within this review.
The aim of this article is to describe a unilateral approach for totally thoracoscopic ablation and left atrial appendage closure for the treatment of atrial fibrillation to simplify the procedure, ...avoid a technically more demanding thoracoscopy on the left side and potentially reduce postoperative pain without compromising the lesion set.
Abstract
Aims
Our objectives were to compare effectiveness and long-term prognosis after epicardial thoracoscopic atrial fibrillation (AF) ablation vs. endocardial catheter ablation, in patients with ...prior failed catheter ablation or high risk of failure.
Methods and results
Patients were randomized to thoracoscopic or catheter ablation, consisting of pulmonary vein isolation with optional additional lines (2007–2010). Patients were reassessed in 2016/2017, and those without documented AF recurrence underwent 7-day ambulatory electrocardiography. The primary rhythm outcome was recurrence of any atrial arrhythmia lasting >30 s. The primary clinical endpoint was a composite of death, myocardial infarction, or cerebrovascular event, analysed with adjusted Cox proportional hazard ratios (HRs). One hundred and 24 patients were randomized with 34% persistent AF and mean age 56 years. Arrhythmia recurrence was common at mean follow-up of 7.0 years, but substantially lower with thoracoscopic ablation: 34/61 (56%) compared with 55/63 (87%) with catheter ablation adjusted HR 0.40, 95% confidence interval (CI) 0.25–0.64; P < 0.001. Additional ablation procedures were performed in 8 patients (13%) compared with 31 (49%), respectively (P < 0.001). Eleven patients (19%) were on anti-arrhythmic drugs at end of follow-up with thoracoscopy vs. 24 (39%) with catheter ablation (P = 0.012). There was no difference in the composite clinical outcome: 9 patients (15%) in the thoracoscopy arm vs. 10 patients (16%) with catheter ablation (HR 1.11, 95% CI 0.40–3.10; P = 0.84). Pacemaker implantation was required in 6 patients (10%) undergoing thoracoscopy and 3 (5%) in the catheter group (P = 0.27).
Conclusion
Thoracoscopic AF ablation demonstrated more consistent maintenance of sinus rhythm than catheter ablation, with similar long-term clinical event rates.
Thoracoscopic surgical ablation has evolved into a successful strategy for symptomatic atrial fibrillation (AF) refractory to other therapy. More widespread referral is limited by the lack of ...information on potential complications. Our aim was to systematically evaluate 30-day complications of totally thoracoscopic surgical ablation.
We retrospectively studied consecutive patients undergoing totally thoracoscopic surgical ablation at a referral centre in the Netherlands (2007-2016). Patients received pulmonary vein isolation, with additional lesion lines as needed, and left atrial appendage exclusion. The primary outcomes were freedom from any complications and freedom from irreversible complications at 30-days. Secondary outcomes included intra- and post-operative complications according to severity. Included were 558 patients with median age 62 years (interquartile range 56-68 years), 70% male and 53% with a previous failed catheter ablation. The cohort consisted of 43% paroxysmal AF, 47% persistent AF, and 10% long-standing persistent AF. Freedom from any 30-day complication was 88.2%, and from complications with life-long affecting consequences 97.5%. The intra-operative complication rate was 2.3% with no strokes or death observed. The median hospital length of stay was 4 days. The percentage of patients with major and minor complications at 30-days was 3.2% and 8.1%, respectively, with one patient dying of an ischaemic stroke. The only patient groups with excess complications were women aged ≥70 years and patients with a history of congestive heart failure.
Totally thoracoscopic ablation is associated with a low complication rate in a referral centre and may be a useful alternative to other rhythm control strategies.
Background Our objective was to analyze the causes, timing, and results of reoperation after primary repair for acute type A dissection. Methods One hundred and four consecutive patients underwent a ...reoperation after previous type A aortic dissection repair (1972 to 2008). Supracoronary ascending aorta replacement (SCAR) was commonly performed during primary repair and it was associated with aortic root replacement in 13 cases and with hemiarch replacement in 26 patients. Progression of aortic dilatation was seen in 91 patients (87%), aortic regurgitation in 21 (20%), and false aneurysm in 15 patients (14%). A redo Bentall procedure was performed in 34 cases, arch replacement in 42 patients, and thoracoabdominal aorta replacement in 20 patients. The median follow-up was 6.5 years (range 0.3 to 23.8 years). Results The in-hospital mortality after redo surgery was 7.7%. The global survival rate at 1, 5, and 10 years was 92%, 82%, and 58%, respectively. Proximal reoperations were more frequent in patients who had SCAR and flap extension into the aortic root. Patients with an unresected intimal tear and distal extension of dissection flap experienced a higher rate of aortic arch and thoracoabdominal aorta redo procedures. Conclusions More extensive acute dissection repair results in a lower rate of reoperation. Mortality for redo surgery after type A acute dissection repair is acceptable. This finding should be taken into account in proposing a widespread of more complex and extensive surgery for type A acute dissection.
Abstract
Interventricular septum defects are a known complication after an aortic valve replacement, but not after mitral surgery. We present a case of a 65-year-old female who underwent unsuccessful ...mitral valvuloplasty through port-access surgery, followed by uneventful mechanical bioprosthesis replacement. Postoperatively, the patient experienced multiple arrhythmias and recovered poorly. A systolic murmur led to echocardiography, showing an interventricular septum rupture. This was closed with 2 polypropylene pledgeted mattress sutures, via the right atrium and tricuspid valve through midsternal access. The authors believe that the most likely cause is tearing of 2 deeply placed adjacent sutures in the septum, creating localized weakening of the septum susceptible to further rupture. We therefore underline the importance of adequate exposure, especially at the notorious anterior annulus.
Known complications after mitral valvuloplasty or valve replacement are death, resternotomy for bleeding/tamponade, myocardial infarction, stroke, infection, atrial fibrillation, prosthetic endocarditis, thromboembolism, paravalvular leak (PVL) and prosthesis failure 1.
Abstract
In this article, we describe the modified technique of a unilateral closed-chest thoracoscopic ablation and left atrial appendage closure including a box lesion that is made by ...radiofrequency clamps only for the treatment of atrial fibrillation. By abandoning the unidirectional pen devices and replacing these by radiofrequency clamps, we aim to further improve the procedural efficacy and shorten operation time while minimizing surgical exposure for the patient.
Since its introduction, thoracoscopic ablation has evolved towards a safe and efficacious rhythm control strategy for symptomatic atrial fibrillation (AF) and is currently indicated with a class IIA recommendation for (long-standing) persistent and post-ablation AF 1.
The purpose of this study was to update the current evidence regarding the efficacy and safety of the totally thoracoscopic maze (TT-maze) procedure for the treatment of atrial fibrillation (AF). ...Fourteen studies published between 2011 and 2016 and comprising 1171 patients were included as follows: 545 (46%) patients had paroxysmal AF (pAF), 268 (23%) persistent AF (persAF) and 358 (31%) longstanding persistent AF (LSPAF). Fixed- and random-effect models were used to calculate the pooled overall freedom from atrial arrhythmias. The 1- and 2-year pooled overall antiarrhythmic drug (AAD) free (off-AAD) success rates were 78% (95% confidence interval (CI): 72-83%, n = 13) and 77% (95% CI: 64-86%, n = 6), respectively. The 1- and 2-year pooled on-AAD success rates were 84% (95% CI: 78-89%, n = 5) and 85% (95% CI: 78-90%, n = 3), respectively. Subanalysis regarding the different types of AF revealed a 1-year pooled off-AAD success rate of 81% (95% CI: 73-86%, n = 7) for pAF, 63% (95% CI: 57-69%, n = 5) for persAF and 67% (95% CI: 52-79%, n = 3) for LSPAF. The overall in-hospital complication rate was <3% (n = 36). We conclude that the TT-maze is an effective strategy for the treatment of AF with maintained efficacy at the 2-year follow-up. Furthermore, the TT-maze has demonstrated similar efficacy to the Cox Maze IV procedure at the midterm follow-up with a lower complication rate. Extended follow-up research is needed to determine whether the high success rates after TT-maze will be stable over time.
Introduction
Totally thoracoscopic ablation for symptomatic atrial fibrillation (AF) refractory to drug or catheter based therapy is indicated as a Class 2A recommendation according to latest ...guidelines. Evidence for long‐term rhythm control and stroke reduction is limited. The aim of this study was to report on long‐term outcome after totally thoracoscopic ablation.
Methods and Results
In total 82 consecutive patients were included that underwent totally thoracoscopic ablation including left appendage closure (2012‐2013). The primary outcome was freedom from atrial arrhythmia recurrence. Secondary outcomes were survival, freedom from cerebrovascular events, freedom from reablation and definite pacemaker implantation. The mean age was 59.9 ± 8.6 years and 71% were male. The mean CHA2DS2‐VASc score was 1.2 ± 1.0. The overall freedom from atrial arrhythmia was 60% after a mean follow up of 4.0 ± 0.6 years. Freedom from cerebrovascular events was 98.8% after mean follow‐up of 4.4 ± 0.3 years and overall survival was 98.8%, with one noncardiac related death. The observed rate of ischemic stroke, hemorrhagic stroke or transient ischemic attack was 0.3 per 100 patient‐years.
Conclusions
Totally thoracoscopic ablation is an effective sustainable rhythm control therapy for AF with a reasonable recurrence rate and low stroke rate when performed in dedicated AF centers.
Background Aortic false aneurysm is a rare complication after cardiac surgery. Aortic dissection, infection, arterial wall degeneration, and poor surgical technique are recognized as risk factors for ...the occurrence of postsurgical false aneurysm. Despite some recent reports about percutaneous false aneurysm exclusion, a complex surgical reoperation is needed in most of the cases. Methods We retrospectively reviewed our experience in 43 patients who received a reoperation for postsurgical aortic false aneurysm in the last 14 years. Thirty-three patients were male. The mean age was 60 ± 12 years. Most of the patients received prior aortic surgery on the aortic root, the ascending aorta, the aortic arch, and the descending thoracic aorta (38 patients). False aneurysm was diagnosed during follow-up evaluation in the absence of any symptoms in 23 cases. Univariate and multivariate analyses on 18 perioperative variables were performed. Results In-hospital mortality was 6.9% (3 patients). The postoperative course was complicated in 17 cases (39%). At multivariate analysis, a preoperative history of coronary artery disease and postoperative sepsis were independent risk factors for hospital mortality. Survival rates at 1, 5, and 10 years were 94%, 79%, and 68%, respectively. Freedom from reoperation was 86% at 1 year and 72% at 5 and 10 years. Conclusions Despite a high postoperative complication rate, a reoperation for postsurgical aortic false aneurysm can be performed with acceptable mortality and good mid-term and long-term outcomes.
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