Abstract
Postoperative atrial fibrillation (POAF) is a common, expensive and potentially morbid complication following cardiac surgery. POAF occurs in around 35% of cardiac surgery cases and has a ...peak incidence on postoperative day 2. Patients who develop POAF incur on average $10 000–$20 000 in additional hospital treatment costs, 12–24 h of prolonged ICU time, and an additional 2 to 5 days in the hospital. POAF has been identified as an independent predictor of numerous adverse outcomes, including a 2- to 4-fold increased risk of stroke, reoperation for bleeding, infection, renal or respiratory failure, cardiac arrest, cerebral complications, need for permanent pacemaker placement, and a 2-fold increase in all-cause 30-day and 6-month mortality. The pathogenesis of POAF is incompletely understood but likely involves interplay between pre-existing physiological components and local and systemic inflammation. POAF is associated with numerous risk factors including advanced age, pre-existing conditions that cause cardiac remodelling and certain non-cardiovascular conditions. Clinical management of POAF includes both prophylactic and therapeutic measures, although the efficacy of many interventions remains in question. This review provides a comprehensive and up-to-date summary of the pathogenesis of POAF, outlines current clinical guidelines for POAF prophylaxis and management, and discusses new avenues for further investigation.
Late outcomes after the Cox maze IV procedure for atrial fibrillation Henn, Matthew C., MD; Lancaster, Timothy S., MD; Miller, Jacob R., MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
11/2015, Letnik:
150, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Abstract Objective The Cox maze IV procedure (CMPIV) has been established as the gold standard for surgical ablation; however, late outcomes using current consensus definitions of treatment failure ...have not been well described. To compare to reported outcomes of catheter-based ablation, we report our institutional outcomes of patients who underwent a left-sided or biatrial CMPIV at 5 years of follow-up. Methods Between January 2002 and September 2014, data were collected prospectively on 576 patients with AF who underwent a CMPIV (n = 532) or left-sided CMPIV (n = 44). Perioperative variables and long-term freedom from AF, with and without AADs, were compared in multiple subgroups. Results Follow-up at any time point was 89%. At 5 years, overall freedom from AF was 93 of 119 (78%), and freedom from AF off AADs was 77 of 177 (66%). No differences were found in freedom from AF, with or without AADs, at 1, 2, 3, 4, and 5 years for patients with paroxysmal AF (n = 204) versus with persistent/longstanding persistent AF (n = 305), or for those who underwent standalone versus a concomitant CMP. Duration of preoperative AF and hospital length of stay were the best predictors of failure at 5 years. Conclusions The outcomes of the CMPIV remain good at late follow-up. The type of preoperative AF or the addition of a concomitant procedure did not affect late success. The results of the CMPIV remain superior to those reported for catheter ablation and other forms of surgical AF ablation, especially for patients with persistent or longstanding AF.
Surgical ablation of atrial fibrillation (AF) is indicated both in patients with AF undergoing concomitant cardiac surgery and in those who have not responded to medical and/or catheter-based ...ablation therapy. This study examined our long-term outcomes following the Cox-Maze IV procedure (CMP-IV).
Between May 2003 and March 2018, 853 patients underwent either biatrial CMP-IV (n = 765) or a left-sided CMP-IV (n = 88) lesion set with complete isolation of the posterior left atrium. Freedom from atrial tachyarrhythmia (ATA) was assessed for up to 10 years. Rhythm outcomes were compared in multiple subgroups. Predictors of recurrence were determined using Fine–Gray regression, allowing for death as the competing risk.
The majority of patients (513/853, 60%) had nonparoxysmal AF. Twenty-four percent of patients (201/853) had not responded to at least 1 catheter-based ablation. Prolonged monitoring was used in 76% (647/853) of patients during their follow-up. Freedom from ATA was 92% (552/598), 84% (213/253), and 77% (67/87) at 1, 5, and 10 years, respectively. By competing risk analysis, incidence of first ATA recurrence was 11%, 23%, and 35% at 1, 5, and 10 years, respectively. On Fine–Gray regression, age, peripheral vascular disease, nonparoxysmal AF, left atrial size, early postoperative ATAs, and absence of sinus rhythm at discharge were the predictors of first ATA recurrence over 10 years of follow-up.
The CMP-IV had an excellent long-term efficacy at maintaining sinus rhythm. At late follow-up, the results of the CMP-IV remained superior to those reported for catheter ablation and other forms of surgical ablation for AF. Age, left atrial size, and nonparoxysmal AF were the most relevant predictors of late recurrence.
Overview of study design including total number of study patients undergoing elective Cox-Maze IV procedure with full box Lesion set for symptomatic atrial fibrillation (n = 853). Primary outcome was incidence of first ATA recurrence. By competing risk analysis, the estimated incidence of first ATA recurrence was 11%, 18%, 23%, 30%, and 35% at 1, 3, 5, 8, and 10 years, respectively. At 10 years, the survival in those who remained in sinus rhythm was 84% vs 77% in those who experienced at least 1 ATA recurrence (log-rank test, P = .03). Overall, the CMP-IV had excellent efficacy at maintaining sinus rhythm during the 10 years of follow-up. Display omitted
Objective The presence of pulmonary hypertension historically has been considered a significant risk factor affecting early and late outcomes after valve replacement. Given the number of recent ...advances in the management of pulmonary hypertension after cardiac surgery, a better understanding of its impact on outcomes may assist in the clinical management of these patients. The purpose of this study was to determine whether pulmonary hypertension remains a risk factor in the modern era for adverse outcomes after aortic valve replacement for aortic valve stenosis. Methods From January 1996 to June 2009, a total of 1080 patients underwent aortic valve replacement for primary aortic valve stenosis, of whom 574 (53%) had normal systolic pulmonary artery pressures (sPAP) and 506 (47%) had pulmonary hypertension. Pulmonary hypertension was defined as mild (sPAP 35–44 mm Hg), moderate (45–59 mm Hg), or severe (≥ 60 mm Hg). In the group of patients with pulmonary hypertension, 204 had postoperative echocardiograms. Results Operative mortality was significantly higher in patients with pulmonary hypertension (47/506, 9%, vs 31/574, 5%, P = .02). The incidence of postoperative stroke was similar ( P = .14), but patients with pulmonary hypertension had an increased median hospital length of stay (8 vs 7 days, P = .001) and an increased incidence of prolonged ventilation (26% vs 17%, P < .001). Preoperative pulmonary hypertension was an independent risk factor for decreased long-term survival (relative risk 1.7, P = .02). Those with persistent pulmonary hypertension postoperatively had decreased survival. Five-year survival (Kaplan–Meier) was 78% ± 6% with normal sPAP and 77% ± 7% with mild pulmonary hypertension postoperatively, compared with 64% ± 8% with moderate and 45% ± 12% with severe pulmonary hypertension ( P < .001). Conclusions In patients undergoing aortic valve replacement, preoperative pulmonary hypertension increased operative mortality and decreased long-term survival. Patients with persistent moderate or severe pulmonary hypertension after aortic valve replacement had decreased long-term survival. These data suggest that pulmonary hypertension had a significant impact on outcomes in patients undergoing aortic valve replacement and should be considered in preoperative risk assessment.
Roll up your sleeves, roll up your retractor, and repair the mitral valve Melby, Spencer J.
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
August 2018, 2018-08-00, 20180801, Letnik:
156, Številka:
2
Journal Article
Objectives Multiple mechanisms may be involved in postoperative atrial fibrillation. Therefore, our objective was to determine the risk factors for postoperative atrial fibrillation as a function of ...time after coronary artery bypass grafting or valve surgeries to determine which risk factors might predominate at different times. Methods Parametric hazard functions were determined for 1583 patients and then in subgroups (coronary artery bypass grafting alone, mitral valve procedure, and aortic valve replacement +/− coronary artery bypass grafting). Multivariable risk factor analyses were performed, and the risk for postoperative atrial fibrillation was estimated. Results The risk for postoperative atrial fibrillation for all patients was highest immediately postoperatively and at 48 hours. The initial peak risk declined to approximately zero within 18 hours postoperatively. A second peak occurred at 48 hours, followed by a slow decline over the following 4 to 7 days. The time intervals encompassing these peaks were termed phase I and phase II. Predominant risk factors in phase I were older age (relative risk RR, 1.6; P = .006), longer crossclamp time (RR, 1.3; P = .001), and mitral valve procedure (RR, 2.5; P = .0001). In phase II, these were older age (RR, 3.0; P < .0001), greater weight (RR, 1.6; P < .0001), and Caucasian race (RR, 2.5; P = .006). For patients receiving a mitral valve procedure, the risk for postoperative atrial fibrillation in phase II was higher and remained elevated for as long as 9 days postoperatively in comparison with isolated coronary artery bypass grafting, for which the risk returned to near baseline by postoperative day 6. Conclusions Phase I and phase II periods are associated with distinct risk factors; therefore, it is likely that the mechanisms of postoperative atrial fibrillation change over time.
Having the patience to allow a resident to operate on your grandmother Melby, Spencer J.
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
20/May , Letnik:
155, Številka:
5
Journal Article
Atrial fibrillation (AF) is the most common cardiac arrhythmia and the treatment options include medical treatment and catheter-based or surgical interventions. AF is a major cause of stroke, and its ...prevalence is increasing. The surgical treatment of AF has been revolutionized over the past 2 decades through surgical innovation and improvements in endoscopic imaging, ablation technology and surgical instrumentation. The Cox-maze (CM) procedure, which was developed by James Cox and introduced clinically in 1987, is a procedure in which multiple incisions are created in both the left and the right atria to eliminate AF while allowing the sinus impulse to reach the atrioventricular node. This procedure became the gold standard for the surgical treatment of AF. Its latest iteration is termed the CM IV and was introduced in 2002. The CM IV replaced the previous cut-and-sew method (CM III) by replacing most of the incisions with a combination of bipolar radiofrequency and cryoablation. The use of ablation technologies, made the CM IV technically easier, faster and more amenable to minimally invasive approaches. The aims of this article are to review the indications and preoperative planning for the CM IV, to describe the operative technique and to review the literature including comparisons of the CM IV with the previous cut-and-sew method. Finally, this review explores future directions for the surgical treatment of patients with AF.
Valve selection in dialysis-dependent patients can be difficult because long-term survival is diminished and bleeding risks during anticoagulation treatment are greater in patients with renal ...failure. In this study we analyzed long-term outcomes of dialysis-dependent patients who underwent valve replacement to help guide optimal prosthetic valve type selection.
Dialysis-dependent patients who underwent aortic and/or mitral valve replacement at 3 institutions over 20 years were examined. The primary outcome was long-term survival. A Cox regression model was used to estimate survival according to 5 ages, presence of diabetes, and/or heart failure symptoms.
Four hundred twenty-three available patients were analyzed; 341 patients had biological and 82 had mechanical valves. Overall complication and 30-day mortality rates were similar between the groups. Thirty-day readmission rates for biological and mechanical groups were 15% (50/341) and 28% (23/82; P = .005). Five-year survival was 23% and 33% for the biological and mechanical groups, respectively. After adjusting for age, New York Heart Association (NYHA) class, and diabetes using a multivariable Cox regression model, survival was similar between groups (hazard ratio, 0.93; 95% confidence interval, 0.66-1.29; P = .8). A Cox regression model on the basis of age, diabetes, and heart failure, estimated that patients only 30 or 40 years old, with NYHA class I-II failure without diabetes had a >50% estimated 5-year survival (P < .001).
Dialysis-dependent patients who underwent valve replacement surgery had poor long-term survival. Young patients without diabetes or NYHA III or IV symptoms might survive long enough to justify placement of a mechanical valve; however, a biological valve is suitable for most patients.
Impact of age on atrial fibrillation recurrence following surgical ablation MacGregor, Robert M.; Khiabani, Ali J.; Bakir, Nadia H. ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
11/2021, Letnik:
162, Številka:
5
Journal Article
Recenzirano
Odprti dostop
The incidence of atrial fibrillation (AF) in patients older than 75 years of age is expected to increase, and its treatment remains challenging. This study evaluated the impact of age on the outcomes ...of surgical ablation of AF.
A retrospective review was performed of patients who underwent the Cox-maze IV procedure at a single institution between 2005 and 2017. The patients were divided into a younger (age <75 years, n = 548) and an elderly cohort (age ≥75 years, n = 148). Rhythm outcomes were assessed at 1 year and annually thereafter. Predictors of first atrial tachyarrhythmia (ATA) recurrence were determined using Fine–Gray regression, allowing for death as the competing risk.
The mean age of the elderly group was 78.5 ± 2.8 years. The majority of patients (423/696, 61%) had nonparoxysmal AF. The elderly patients had a lower body mass index (P < .001) and greater rates of hypertension (P = .011), previous myocardial infarction (P = .017), heart failure (P < .001), and preoperative pacemaker (P = .008). Postoperatively, the elderly group had a greater rate of overall major complications (23% vs 14%, P = .017) and 30-day mortality (6% vs 2%, P = .026). The percent freedom from ATAs and antiarrhythmic drugs was lower in the elderly patients at 3 (69% vs 82%, P = .030) and 4 years (65% vs 79%, P = .043). By competing risk analysis, the incidence of first ATA recurrence was greater in elderly patients (33% vs 20% at 5 years; Gray test, P = .005). On Fine–Gray regression adjusted for clinically relevant covariates, increasing age was identified as a predictor of ATAs recurrence (subdistribution hazard ratio, 1.03; 95% confidence interval, 1.02-1.05, P < .001).
The efficacy of the Cox-maze IV procedure was worse in elderly patients; however, the majority of patients remained free of ATAs at 5 years. The lower success rate in these greater-risk patients should be considered when deciding to perform surgical ablation.
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