Studies investigating the efficacy of concomitant surgical atrial fibrillation (AF) ablation in hypertrophic obstructive cardiomyopathy (HOCM) patients undergoing myectomy are scarce and limited in ...terms of sample size. We aim to summarize current outcomes of concomitant surgical AF ablation in HOCM patients undergoing surgical myectomy.
This systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included all studies reporting any of the following outcomes of concomitant surgical AF ablation in HOCM patients: freedom from recurrence of AF, overall survival and complications. Outcomes were evaluated using traditional meta-analysis at given time-points and using pooled Kaplan-Meier curves.
A total of 13 studies were included, resulting in a total of 616 individual patients available for analysis. AF was paroxysmal in 68.1% of the patients (95% CI 56.0–78.2%; I2 = 87.1%; 8 studies, 583 participants). The majority of patients (86.2%) underwent either conventional Cox Maze III or IV (95% CI 39.7–98.3%; I2 = 92.4%; 8 studies, 616 patients) procedure. The incidence of early post-operative pacemaker implantation was 6.1% (95% CI 3.1–11.8%). Overall survival at 3, 5 and 7 years was 95.6% (95% CI 93.4–97.9%), 93.6% (95% CI 90.8–96.5%) and 90.5% (95% CI 86.5–94.6%), respectively. Freedom from recurrent AF at 3, 5 and 7 years was 77.6% (95% CI 73.7–81.7%), 70.6% (95% CI 65.8–75.7) and 63.2% (95% CI 56.2–73.8%), respectively.
This meta-analysis supports concomitant surgical AF ablation at the time of surgical myectomy in HOCM patients, as it seems to be safe and effective in terminating AF.
•This is the first systematic review and meta-analysis aimed to evaluate efficacy, survival benefit and safety of concomitant surgical AF ablation in HOCM patients undergoing surgical septal myectomy.•Concomitant surgical AF ablation during septal myectomy seems to be safe and effective on short- and long-term•Survival and freedom from recurrent AF at 7 years were 90.5% and 63.2%, respectively
To evaluate the relationship between the timing of either ticagrelor or clopidogrel discontinuation and bleeding-related complications in patients undergoing isolated on-pump coronary artery bypass ...grafting (CABG).
Between January 2012 and December 2014, 705 consecutive patients underwent isolated on-pump CABG at our institution. Of these, 626 were eligible for this study. Surgery under acetylsalicylic acid (ASA) was performed in 404 patients (ASA group) and 222 patients underwent surgery under dual antiplatelet treatment (DAPT). Patients exposed to DAPT were stratified into the following groups: ticagrelor within 72 h prior to surgery (Group T ≤ 72, n = 63); ticagrelor within 72-120 h prior to surgery (Group T72-120, n = 21); clopidogrel within 120 h prior to surgery (Group C ≤ 120, n = 125); clopidogrel within 120-168 h prior to surgery (Group C120-168, n = 13).
Transfusion requirements in Group T ≤ 72 (72.1 vs 41.3%, P < 0.001) and Group C ≤ 120 (71.2 vs 41.3%, P < 0.001) were significantly higher compared with the ASA group. Multivariable analysis, comparing Group C ≤ 120, C120-168, T ≤ 72 and T72-120 with the ASA group, revealed Group C ≤ 120 and Group T ≤ 72 as predictors of bleeding-related complications. No increased incidence of bleeding-related complications was seen when ticagrelor was discontinued >72 h or clopidogrel >120 h prior to surgery.
Ticagrelor discontinuation >72 h and clopidogrel discontinuation >120 h prior to surgery were not associated with an increased risk of bleeding-related complications. Based on these findings, a period of ticagrelor discontinuation shorter than advised by current international guidelines might be justifiable.
•Mitral valve surgery for severe degenerative regurgitation in asymptomatic patients is safe.•Valve repair is feasible regardless of the complexity of lesions causing valve regurgitation.•Early ...surgery results in life expectancy and quality of life comparable to the general population.•Postoperative supraventricular rhythm disturbances are common and need further investigation.
In asymptomatic patients with severe degenerative mitral valve regurgitation (MR), early surgery is often performed in experienced centers. The patient- and valve-related results and the quality of life after surgery in these patients remain insufficiently explored.
Between 1/2000 and 12/2015, 83 asymptomatic patients (mean age 56.6±12.6 years, 21 female) without any complications related to long-lasting MR underwent early surgery. Follow-up clinical and echocardiographic data and health-related quality of life assessment (SF-36) were studied and matched to the general population.
Repair rate was 100% and early mortality was 0%. Residual MR (≥grade 2+) was seen in 1 (1%) patient who underwent a successful re-repair while 4 (5%) patients needed permanent pacemaker implantation. At a median follow-up of 7.6 (IQR 4.1–11.9) years, 6 late deaths occurred. The 10-year overall survival rate was 91.5% (95% CI 84.2–98.8%) and was comparable to the general population. The health-related quality of life (84% complete) did not differ from the general population. One patient underwent late reintervention. Median echocardiography follow-up was 5.2 years (IQR 2.4–10.4; 98% complete). The 10-year freedom from recurrent MR rate (≥grade 2+) was 86.7% (95% CI 76.1–97.3%). The 10-year freedom from any atrial tachycardia rate was 68.7% (95% CI 55.2–82.2%) while 7 (8%) patients underwent late pacemaker implantation.
Early surgical intervention in asymptomatic patients with severe MR can be performed safely and restores normal life expectancy and quality of life. However, the frequency of late arrhythmias and pacemaker implantation is high and needs further evaluation.
The optimal choice of graft material in patients ≥70 years of age undergoing coronary artery bypass grafting remains unknown. A systematic review of literature was conducted by searching PubMed, ...Embase, Web of Science, and Cochrane Library databases for original publications that compared bilateral internal thoracic artery (BITA) grafting with single internal thoracic artery grafting in patients ≥70 years of age. Data were extracted by 2 independent investigators and meta-analyzed with the use of random effects. A total of 10 studies, including 11,185 patients, met the inclusion criteria. No differences in early mortality and morbidity, with the exemption of sternal wound complications which were more frequently observed in the BITA group (odds ratio 1.72, 95% 1.00 to 2.96 confidence interval CI, p = 0.05; propensity score-matched population odds ratio 1.58, 95% CI 1.09 to 2.29, p = 0.02), were observed. Overall survival was superior in the overall patient population (hazard ratio HR 0.76, 95% CI 0.66 to 0.86, p <0.001), after applying a blanking period of 3 months to the overall patient population (HR 0.77, 95% CI 0.64 to 0.92, p = 0.005) as well as in the matched population (HR 0.72, 95% CI 0.58 to 0.89, p = 0.002); in all cases, a benefit was readily seen within a few years after surgery. The difference in freedom from major adverse cardiac and cerebrovascular events failed to reach statistical significance (overall patient population HR 0.55, 95% CI 0.27 to 1.13, p = 0.10; matched population HR 0.52, 95% CI 0.23 to 1.16, p = 0.11). In conclusion, BITA grafting can be safely performed in patients ≥70 years of age as late clinical benefits are expected to manifest themselves readily within a few years after surgery.
Real-world evidence supporting the reproducibility and superiority of valve repair over replacement in active mitral valve infective endocarditis is lacking.
Data from a prospective nationwide ...database, including all cardiac surgical procedures in The Netherlands, were used. Adult patients undergoing primary mitral valve intervention who had a diagnosis of active infective endocarditis and who underwent surgery between 2013 and 2020 were included. Survival analysis was performed for the whole follow-up period as well as after applying the landmark of 90 days.
Of 715 patients who met the inclusion criteria, 294 (41.1%) underwent valve repair. Mitral valve repair rates decreased slightly over the course of the study. The early mortality rate was 13.0%, and a trend of steadily declining early mortality rates over the course of the study, despite a steady increase in patient complexity, was observed. On risk-adjusted analysis, mitral valve replacement demonstrated inferior results when compared with valve repair (adjusted hazard ratio, 2.216; 95% CI, 1.425-3.448; P < .001), even after a landmark analysis was performed (adjusted hazard ratio 2.489; 95% CI, 1.124-5.516; P = .025). These results were confirmed by a propensity score-adjusted analysis (adjusted hazard ratio 2.251; 95% CI, 1.029-4.21; P = .042).
Contemporary trends in mitral valve surgery for active infective endocarditis suggest growing patient complexity but slightly declining early mortality rates. A trend of decreasing mitral valve repair rates was seen. The results of this study suggest improved late outcomes of valve repair compared with valve replacement.
Anterior cruciate ligament injuries of the knee represent an increasing problem among the active female population in comparison to their male counterparts. Besides temporary or prolonged joint ...dysfunction, such injuries may predispose an individual to early osteo-arthritis. Recognizing the sex differences is essential for the determination of preventive measures against these injuries. Besides anatomical and biomechanical differences, the role of hormonal oscillation during the menstrual cycle has been hypothesized. This manuscript presents a literature review based on cruciate ligament and menstrual cycle research published between 1992 and 2012. According to the experimental and epidemiologic studies, menstrual cycle was shown to be linked to anterior cruciate ligament injuries. The pre-ovulatory phase represents an increased risk, with the peak serum levels of estrogen emerging toward the end of that phase. However, the significance of menstrual cycle seems to be of lesser importance in preventive measures against female anterior cruciate injuries.
Poškodbe sprednje križne vezi kolenskega sklepa postajajo vse pogostejši problem aktivne ženske populacije v primerjavi v moškimi. Poleg začasno ali celo trajno okrnjene funkcije sklepa povečujejo tudi tveganje za nastanek zgodnje artroze. Prepoznava dejavnikov tveganja za nastanek tovrstnih poškodb v povezavi z razlikami med spoloma bi bila smiselna pri razvoju preventivnih ukrepov pred tovrstnimi poškodbami. Pregledane laboratorijske in epidemiološke raziskave v letih 1992-2012 so poleg anatomskih in biomehanskih razlik potrdile povezavo med nihanjem hormonov menstrualnega cikla in tveganjem za poškodbo sprednje križne vezi. Preovulatorna faza predstavlja obdobje največjega tveganja zaradi povečane koncentracija estrogena. Kljub navedenim ugotovitvam je videti pomen mesečnega nihanja hormonov premajhen, da bi na njem lahko učinkovito gradili preventivne programe pred poškodbami kolenskih vezi pri ženskah.
The risk factors for the development of mitral annular calcification (MAC) in degenerative mitral valve disease and the effect it may have on patient-and valve-related outcomes require further ...evaluation.
Between January 2002 and December 2015, 627 patients underwent mitral valve operations for degenerative disease. MAC was seen in 75 patients (12%); 73 (97%) underwent valve repair (6 without annuloplasty ring implantation) and 2 (3%) underwent valve replacement after an unsuccessful repair attempt.
MAC was linked to patient age, female sex, and degenerative disease subtype. Early mortality was comparable between patients with and without MAC (3 of 75 4% vs 10 of 552 2%, p = 0.20. In patients with MAC, one-third of the deaths were directly related to annular decalcification and reconstruction. Early repair failure was more common in patients with MAC (8 of 75 11% vs 17 of 552 3%, p = 0.006). During follow-up, no differences in overall survival or freedom from late reintervention were observed. However, at 8 years after the operation, freedom from recurrent mitral regurgitation was worse in patients with MAC. In these patients, repair failure was linked to nonuse of ring annuloplasty. For patients with MAC in whom annular decalcification and annuloplasty were performed, repair durability was comparable to patients without MAC.
Mitral valve surgery in degenerative disease accompanied by MAC is safe. Optimal surgical strategy includes annular decalcification (when this would prevent implantation of an annuloplasty ring) and ring annuloplasty and will lead to results similar to patients without MAC. However, repair performance is hampered when the annulus is not addressed. For these patients, alternative repair techniques should be explored in the future.
Severe cases of infective endocarditis (IE) of the aortic valve can cause aortic root destruction and affect the surrounding structures, including the aortic-mitral continuity, the anterior mitral ...valve leaflet and the roof of the left atrium. Reconstruction after resection of all infected tissue remains challenging. We describe our surgical approach and the mid-term results.
Between January 2004 and December 2015, 35 patients underwent surgery for extensive IE of the aortic valve with destruction of the aortic root, the aortic-mitral continuity and the mitral valve. Mean age was 60.4 ± 13.7; 26/35 (74%) patients had prosthetic valve endocarditis. Four patients were in critical preoperative state. Median EuroSCORE II was 18.0% interquartile range (IQR) 11.0-26.7.
Aortic root replacement was performed in 32 (91%) patients. The remaining patients underwent aortic valve replacement. Reconstruction of the aortic-mitral continuity and the roof of the left atrium were performed using a folded pericardial patch. In 28 patients (80%), mitral valve repair was performed. Postoperative mechanical circulatory support, acute kidney failure and surgical re-exploration were seen in 5 (16%), 10 (31%) and 4 (13%) patients, respectively. Early survival rate was 77% (27 patients). During a median follow-up of 29.8 months (IQR 6.4-62.9), 7 (26%) patients required reintervention (3-42 months after surgery); 4 were due to mitral incompetence, early in our experience.
Extensive IE of the aortic root with destruction of the surrounding tissues remains a complex disease with high morbidity and mortality rates. Our technique allows native mitral valve preservation but is technically challenging.
The added value of computed tomography (CT) follow-up after elective proximal aortic surgery is unclear. We evaluated the benefit of CT follow-up by assessing the incidence of aorta-related ...complications and reinterventions detected during routine CT follow-up.
Data on 314 patients undergoing first time elective proximal aortic surgery between 2000 and 2015 were collected. The primary study end points were aorta-related complications and reinterventions, detected during routine CT follow-up. Secondary study endpoints included all aorta-related complications and reinterventions, irrespective of the mode of detection and survival.
Median CT follow-up time was 6.8 (IQR 4.1-9.8) years, during which a total of 1303 routine follow-up CT-scans (median 4, IQR 3-5) were performed. During CT follow-up, aorta-related complications were detected in 18 (5.7%) patients, of which 6 (1.6%) underwent reintervention. In total, 28 aorta-related complications were observed in 23 (7.3%) patients, of which 9 led to reintervention. In order to detect 1 aorta-related complication leading to reintervention, 218 routine follow-up CT-scans were required. The unadjusted and EuroSCORE II adjusted hazard ratios of not undergoing CT follow-up on mortality were 1.260 (95% CI 0.705-2.251) and 0.830 (95% CI 0.430-1.605), respectively.
Following first time elective proximal aortic surgery, aorta-related complications are uncommon, are not always detected during CT follow-up and, if detected, often do not result in reintervention. Therefore, a more conservative CT follow-up protocol could be considered in selected patients to reduce lifetime radiation burden and health care costs.
The objective of this study was to assess the performance of a tissue engineering process–treated bovine pericardium patch (CardioCel, Admedus Regen Pty Ltd, Perth, Australia) in the setting of ...reconstructive mitral valve surgical procedures.
Between March 2014 and April 2016, 30 patients (57.2 ± 14.3 years of age; 27% female) underwent mitral valve leaflet repair with a CardioCel patch.
Perioperative mortality was 7% (2 patients, non–graft related). In the 28 remaining patients, predischarge echocardiography demonstrated good repaired valve function. At a mean follow-up of 1.7 ± 0.9 years, three additional deaths occurred (two resulting from infective endocarditis and one non–cardiac related). On follow-up echocardiography (follow-up time of 1.7 ± 0.8 years; available for 26 of 28 93% hospital survivors), recurrent regurgitation was seen in 2 patients (both with infective endocarditis), and 1 patient underwent reoperation (no infection at the level of patch repair was observed). In the remaining patients, the most recent echocardiogram demonstrated no regurgitation or mild regurgitation and stable gradients. The thickness and echodensity of the implanted patch on follow-up echocardiograms were comparable with postoperative echocardiograms.
Initial results with the CardioCel patch in mitral valve repair operations were satisfactory. The resistance to infection and late degeneration will need to be assessed in the future.
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