Patient survival in severe low-flow, low-gradient aortic stenosis after aortic valve replacement or conservative management

Background and aim

Classical and paradoxical low‐flow, low‐gradient (LFLG) aortic stenosis (AS) are the most challenging subtypes of AS. The current therapeutic options are aortic valve replacement (AVR) and conservative management: AVR promotes long‐term survival but is invasive, while conservative management yields a poor prognosis but is noninvasive since it uses no aortic valve replacement (noAVR). The present meta‐analysis investigated the rate of survival of patients with LFLG AS undergoing either AVR or noAVR interventions.

Methods

The meta‐analysis compared the outcomes of AVR with those of noAVR in terms of patient survival. In both groups, a meta‐regression was conducted to investigate the impact on patient survival of the left ventricular ejection fraction (LVEF), either preserved (paradoxical LFLG AS) or reduced (classical LFLG AS).

Results

The relative risk of survival between the AVR and noAVR groups was 1.99 [1.40, 2.82] (p = .0001), suggesting that survival tends to be better in AVR patients than in noAVR patients. The meta‐regression revealed that a reduced LVEF may be related to a higher survival in AVR patients when compared to a preserved LVEF (p = .04). Finally, the analysis indicated that LVEF seems not to be prognostic of survival in noAVR patients (p = .18).

Conclusions

Patients with LFLG AS have better survival if they undergo AVR. In AVR patients, reduced LVEF rather than preserved LVEF is related to better survival, whereas there seems to be no difference in prognostic value between reduced and preserved LVEF in noAVR patients.

Impact of renal function impairment assessed by CKDEPI estimated glomerular filtration rate on early and late outcomes after coronary artery bypass grafting

BACKGROUND

We explore the association between short- and long- term adverse outcomes following coronary artery bypass grafting (CABG) and the degree of preoperative renal dysfunction classified on glomerular fraction estimated with Chronic Kidney Disease-Epidemiology Collaboration equation (eGFR_CKD-EPI). We also try to identify cut-off values of eGFR_CKD-EPI able to predict post-CABG unfavorable events and assess whether a reclassification with new thresholds is necessary.

METHODS

One-thousand-one-hundred-eighty-six consecutive patients undergoing CABG between 2005 and 2014 were categorized in 4 groups according to the eGFR_CKD-EPI: Group 1 (≥60ml/min/1.73m²; n=1199), Group 2 (45-59ml/min/1.73m²; n=358), Group 3 (30-44ml/min/1.73m²; n=171) and Group 4 (≤29ml/min/1.73m²; n=126). Median follow-up was 66months [IQR 46-84].

RESULTS

eGFR_CKD-EPI ≤30ml/min/1.73m², ≤41ml/min/1.73m², ≤27ml/min/1.73m² and ≤29ml/min/1.73m² were strong predictors of early mortality (OR 5.88 [95% CI 2.59-11.25]), stroke (2.59 [1.43-3.71]), prolonged length of stay (3.49 [1.24-5.92]) and postoperative dialysis (3.68 [1.34-4.91]), respectively. In addition, eGFR_CKD-EPI ≤26ml/min/1.73m², ≤25ml/min/1.73m², ≤35ml/min/1.73m² and ≤29ml/min/1.73m² predicted all-cause death (hazard ratio 2.74 [95% CI 2.10-3.92] cardiovascular death (sub-hazard ratio 2.11 [95% CI 1.42-3.90]), myocardial infarction (2.01 [1.32-3.70]) and heart failure (2.24 [1.41-3.93]), respectively. Analyses corrected by age and left ventricular ejection fraction confirmed these findings.

CONCLUSIONS

In our experience, the use of the eGFR_CKD-EPI equation led to categorization with a significantly lower number of patients at risk for post-CABG complications. This might have important clinical repercussions on allocation of healthcare resources and more targeted prevention and management of CABG complications.

Does sinus rhythm conversion after cardiac surgery affect postoperative health- related quality of life?

Background

We investigated the impact and the predictive value of sinus rhythm at 12 months (SR₁₂) on subscales of three different HrQoL questionnaires: SF-36., EuroQoL and MFI 20.

Methods

Data of 125 cardiac surgery patients with pre-operative AF from our previous randomized trial were used. Based on their rhythm outcome patients were divided in two groups: SR₁₂ or AF at 12 months follow up (non-SR₁₂). All questionnaires were self-administered pre-operatively and at 3 months, 6 months and 12 months after surgery.

Results

Synus rhytm at 12 months was predictive of improvement of SF36- mental score (MS, p = 0.021), Euro-QoL-MS (p = 0.009), VAS (p = 0.006), and MFI 20-MS (p = 0.009). We failed to find any significant interactions between SR₁₂ and any of the other significant risk factors: age <65 years, paroxysmal type of AF and preoperative AF duration <12 months. In contrast, SR₁₂ was not significant in predicting physical score (PS) subscales of any of the questionnaires (all, p > 0.05) which were predicted by age <65 years (SF36-PS, p = 0.029) by paroxysmal type of AF and age <65 years (Euro-QoL-PS, p = 0.017 and p = 0.04, respectively) and by AF duration <12 months, paroxysmal type of AF and age < 65 years (MFI 20-PS, p = 0.019, p = 0.020 and p = 0.015, respectively).

Conclusions

Specific mental-related HrQoL scales are much more sensitive to sinus rhythm conversion. Sinus rithm mantainance shows significant effects on mental scores independently of other cofactors. Successful conversion to sinus rhythm after surgical ablation during cardiac surgery does not significantly affect phisical health related quality of life during 1 year follow up.

Contact forces during hybrid atrial fibrillation ablation: an in vitro evaluation

PURPOSE

Data on epicardial contact force efficacy in dual epicardial-endocardial atrial fibrillation ablation procedures are lacking. We present an in vitro study on the importance of epicardial and endocardial contact forces during this procedure.

METHODS

The in vitro setup consists of two separate chambers, mimicking the endocardial and epicardial sides of the heart. A circuit, including a pump and a heat exchanger, circulates porcine blood through the endocardial chamber. A septum, with a cut out, allows the placement of a magnetically fixed tissue holder, securing porcine atrial tissue, in the middle of both chambers. Two trocars provide access to the epicardium and endocardium. Force transducers mounted on both catheter holders allow real-time contact force monitoring, while a railing system allows controlled contact force adjustment. We histologically assessed different combinations of epi-endocardial radiofrequency ablation contact forces using porcine atria, evaluating the ablation's diameters, area, and volume.

RESULTS

An epicardial ablation with forces of 100 or 300 g, followed by an endocardial ablation with a force of 20 g did not achieve transmurality. Increasing endocardial forces to 30 and 40 g combined with an epicardial force ranging from 100 to 300 and 500 g led to transmurality with significant increases in lesion's diameters, area, and volumes.

CONCLUSIONS

Increased endocardial contact forces led to larger ablation lesions regardless of standard epicardial pressure forces. In order to gain transmurality in a model of a combined epicardial-endocardial procedure, a minimal endocardial force of 30 g combined with an epicardial force of 100 g is necessary.

Comparing short versus standard-length balloon for intra-aortic counterpulsation: results from a porcine model of myocardial ischaemia-reperfusion

OBJECTIVES

We compare a short and a standard-size balloon with same filling volumes to verify the differences in terms of visceral flow, coronary circulation and haemodynamic performance during aortic counterpulsation in an animal model of myocardial ischaemia-reperfusion injury.

METHODS

Eighteen healthy pigs underwent 120-min ligation of the left anterior descending coronary artery followed by 6 h of reperfusion, and they were randomly assigned to have intra-aortic balloon counterpulsation (IABP) with a 40-ml short-balloon (n = 6) or a 40-ml standard-length balloon (n = 6), or to undergo no IABP implantation (controls, n = 6). Haemodynamics and visceral and coronary flows were measured at baseline (t0), at 2 h of ischaemia (t1) and every hour thereafter until 6 h of reperfusion (from tR1 to tR6), respectively.

RESULTS

Mesenteric flows increased significantly at tR1 only in the short-balloon group (P < 0.001) and it was constantly higher than in the standard-balloon group regardless of mean arterial pressure, systemic vascular resistance and cardiac output (CO; all, P < 0.001). Renal blood flows were significantly increased during IABP treatment with values constantly and significantly higher in short balloons at any following experimental step (all, P < 0.05). IABP improved CO and coronary blood flow, and reduced afterload, myocardial resistances and myocardial oxygen consumption without differences between the short and the standard-length balloon (all, P > 0.05).

CONCLUSIONS

The short balloon prevents visceral ischaemia and, compared with the standard-size balloon, it does not lose IABP beneficial cardiac and coronary-related effects. Further studies are warranted to confirm our findings.

3D-echo in preoperative assessment of aortic cusps effective height

Effective height, which represents the height difference between the central free margins and the aortic insertion lines can be easily determined by 2-D echocardiography and allows for identification of prolapse in the native cusps and assessment of prolapse correction after valve repair. Nonetheless, it allows to see only two of three aortic valve (AV) coaptation planes and this may lead to misunderstanding of the underlying pathophysiological mechanism for aortic regurgitation and hence in unsuccessful repair. In contrast, 3D transoesophageal echocardiography and multiple plane reconstruction lets visualize all the three coaptation planes between the AV cusps and it represents an invaluable tool in the assessment of aortic valve geometry. It is highly recommendable before AV repair to accurately study the complex three dimensional cusps anatomy and their geometric interrelation with aortic root.

Unreliability of aortic size index to predict risk of aortic dissection in a patient with Turner syndrome

Aortic size index (ASI) has been proposed as a reliable criterion to predict risk for aortic dissection in Turner syndrome with significant thresholds of 20-25 mm/m². We report a case of aortic arch dissection in a patient with Turner syndrome who, from the ASI thresholds proposed, was deemed to be at low risk of aortic dissection or rupture and was not eligible for prophylactic surgery. This case report strongly supports careful monitoring and surgical evaluation even when the ASI is < 20 mm/m² if other significant risk factors are present.

Cytokine removal on extracorporeal life support for treatment of acute endotoxemia: a randomized controlled animal study

BACKGROUND

We prospectively evaluated the effectiveness of resin adsorption incorporated in an extracorporeal life support (ELS) circuit in an animal model of sepsis for removal of cytokines and prevention of hemodynamic deterioration during the treatment of septic shock.

METHODS

Twelve female landrace pigs were randomly assigned to two groups, a study group(n=6), treated with high-flow resin adsorption (300 mL/min) and ELS, and a control group (n=6), treated only with ELS. Septic shock was induced by intravenous 0.02 μg/kg/min infusion was of Escherichia coli lipopolysaccharide (LPS). Measurements were carried out in the study group at baseline, at the end of LPS injection(t0) at 30(t1), 60(t2), 90(t3) and 120 min (t4) and 60 min after stopping resin-adsorption (t5). In the control group measurements were performed at baseline (t0), t1 and only t2, as no control animal survived beyond this latter experimental timepoint.

RESULTS

The final population consisted of 9 animals, five in the study group and 4 in the control group. Plasma values of both tumor necrosis factor α (TNF-α) and interleukin-6 (IL-6) were reduced during resin-adsorption (t1-t4) while these mediators increased in controls undergoing ELS only. With a clearance of TNF-α of 15,233 pg/min and IL-6 of 10,233 pg/min, 79.2% of TNF-α and 95.3% of IL-6 produced were adsorbed. Systemic vascular resistance decreased significantly in both groups at t0. While it further was reduced during the control experiments at t1 and t2, it returned to normal in the study animals. Cardiac output increased at t0, t1 and t2 in the control experiments. In contrast, in study animals after a peak at t0, it returned to the baseline value and did not vary thereafter.

CONCLUSIONS

Combined resin-adsorption and ELS improved hemodynamics resulting from effective removal of inflammatory mediators in a pig model of septic shock.

Minimally invasive mitral valve surgery: a systematic review

In the recent years minimally invasive mitral valve surgery (MIMVS) has become a well-established and increasingly used option for managing patients with a mitral valve pathology. Nonetheless, whether the purported benefits of MIMVS translate into clinically important outcomes remains controversial. Therefore, in this paper we provide an overview of MIMVS and discuss results, morbidity, mortality, and quality of life following mitral minimally invasive procedures. MIMVS has been proven to be a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality. Reported benefits of MIMVS include also decreased postoperative pain, improved postoperative respiratory function, reduced surgical trauma, and greater patient satisfaction. Finally, compared to standard surgery, MIMVS demonstrated comparable efficacy across a range of long-term efficacy measures such as freedom from reoperation and long-term survival.

Left ventricular strain in chronic ischemic mitral regurgitation in relation to mitral tethering pattern

BACKGROUND

The aim of this retrospective study was to explore whether different tethering patterns in chronic ischemic mitral regurgitation have different distributions of left ventricular (LV) systolic longitudinal, circumferential, and radial strain before and after mitral valve repair.

METHODS

Sixty-one patients with chronic ischemic mitral regurgitation who underwent mitral repair were divided on the basis of the preoperative anterior/posterior tethering angle ratio (cutoff value, 0.76). There were 29 patients with symmetric (group 1) and 32 with asymmetric (group 2) preoperative tethering patterns. Assessment of longitudinal peak systolic strain was performed offline by applying speckle-tracking imaging to the apical two-chamber, three-chamber, and four-chamber views of the left ventricle. Peak systolic radial and circumferential strain was obtained from short-axis views at the basal, middle, and apical levels. Twenty healthy subjects served as controls.

RESULTS

In group 1, baseline LV strain was impaired in all LV segments, with the worst values in the anterolateral, anterior, and inferolateral segments at the midventricular and basal levels. In contrast, asymmetric patients showed higher values in the inferior and inferoseptal walls and values closer to normal in the other segments. After surgery, all strain measurements showed significant improvements in all LV segments in group 2, whereas in Group 1, strain worsened in the inferoseptal, inferior, and anteroseptal walls and did not change in the other segments.

CONCLUSIONS

Patients with baseline symmetric tethering patterns showed more extensive abnormal strain, which was observed in all LV segments and was not reverted by surgery. These findings require confirmation in additional larger studies.

Early hemodynamic and biochemical changes in overloaded swine ventricle

The present study was undertaken to investigate, in an animal model, the relationship between sarcoplasmic reticulum Ca2+-ATPase (SERCA2a) activity, phospholamban phosphorylation, acylphosphatase activity, and hemodynamic changes that occur in the early phase of pressure overload. In 54 study-group pigs, weighing 40±5 kg each, an aortic stenosis was created with a band of umbilical tape tied around the aorta; 18 sham-operated pigs formed our control group. Eight animals (6 study and 2 control) were randomly assigned to each experimental time (0.5, 3, 6, 12, 24, 48, 72, 96, and 168 hr). All indices of left ventricular function declined significantly, with a peak at 6 hr and a return to baseline at 168 hr. At each observational time, SERCA2a activity, Ca2+ uptake, and acylphosphatase activity rose significantly, with a maximum increase at 6 hr. These changes indicated a higher expression of these proteins; conversely, phospholamban did not show significant changes in its concentration or in its phosphorylation status. Nuclear proto-oncogene c-fos expression rose at 6 hr. A strong inverse correlation was found when Ca2+-ATPase activity, Ca2+-ATPase expression, Ca2+ uptake, and acylphosphatase were compared with indices of systolic function. In our model of induced pressure overload, an initial phase of depressed myocardial contractility was accompanied by an increased sarcoplasmic reticulum function and by higher Ca2+-ATPase and Ca2+ uptake activities mediated by acylphosphatase. This new finding of Ca2+ homeostasis might indicate a compensatory mechanism for mechanical stress. Further studies are needed to confirm our findings.

Longitudinal strain predicts left ventricular mass regression after aortic valve replacement for severe aortic stenosis and preserved left ventricular function

We explored the influence of global longitudinal strain (GLS) measured with two-dimensional speckle-tracking echocardiography on left ventricular mass regression (LVMR) in patients with pure aortic stenosis (AS) and normal left ventricular function undergoing aortic valve replacement (AVR). The study population included 83 patients with severe AS (aortic valve area <1 cm(2)) treated with AVR. Bioprostheses were implanted in 58 patients (69.8 %), and the 25 remaining patients (30.2 %) received mechanical prostheses. Peak systolic longitudinal strain was measured in four-chamber (PLS4ch), two-chamber (PLS2ch), and three-chamber (PLS3ch) views, and global longitudinal strain was obtained by averaging the peak systolic values of the 18 segments. Median follow-up was 66.6 months (interquartile range 49.7-86.3 months). At follow-up, values of PLS4ch, PLS2ch, PLS3ch, and GLS were significantly lower (less negative) in patients who did not show left ventricular (LV) mass regression (all P < 0.001). Baseline global strain was the strongest predictor of lack of LVMR (odds ratio 3.5 (95 % confidence interval 3.0-4.9), P < 0.001), and GLS value ≥-9.9 % predicted lack of LVMR with 95 % sensitivity and 87 % specificity (P < 0.001). Other multivariable predictors were the preoperative LV mass value (cutoff value ≥147 g/m(2), P < 0.001), baseline effective orifice area index (cutoff ≤0.35 cm(2)/m(2), P = 0.01), and baseline mean gradient (cutoff ≥58 mmHg, P = 0.01). Finally, we failed to find interactions between GLS and other significant parameters (all P < 0.05). Global longitudinal strain accurately predicts LV mass regression in patients with pure AS undergoing AVR. Our findings must be confirmed by further larger studies.

Mitral valve repair or replacement for ischemic mitral regurgitation? The Italian Study on the Treatment of Ischemic Mitral Regurgitation (ISTIMIR)

OBJECTIVE

It is uncertain whether mitral valve replacement is really inferior to mitral valve repair for the treatment of chronic ischemic mitral regurgitation. This multicenter study aimed at providing a contribution to this issue.

METHODS

Of 1006 patients with chronic ischemic mitral regurgitation and impaired left ventricular function (ejection fraction < 40%) operated on at 13 Italian institutions between 1996 and 2011, 298 (29.6%) underwent mitral valve replacement whereas 708 (70.4%) received mitral valve repair. Propensity scores were calculated by a nonparsimonious multivariable logistic regression, and 244 pairs of patients were matched successfully using calipers of width 0.2 standard deviation of the logit of the propensity scores. The postmatching median standardized difference was 0.024 (range, 0-0.037) and in none of the covariates did it exceed 10%.

RESULTS

Early deaths were 3.3% (n = 8) in mitral valve repair versus 5.3% (n = 13) in mitral valve replacement (P = .32). Eight-year survival was 81.6% ± 2.8% and 79.6% ± 4.8% (P = .42), respectively. Actual freedom from all-cause reoperation and valve-related reoperation were 64.3% ± 4.3% versus 80% ± 4.1%, and 71.3% ± 3.5% versus 85.5% ± 3.9 in mitral valve repair and mitral valve replacement, respectively (P < .001). Actual freedom from all valve-related complications was 68.3% ± 3.1% versus 69.9% ± 3.3% in mitral valve repair and mitral valve replacement, respectively (P = .78). Left ventricular function did not improved significantly, and it was comparable in the 2 groups postoperatively (36.9% vs 38.5%, P = .66). At competing regression analysis, mitral valve repair was a strong predictor of reoperation (hazard ratio, 2.84; P < .001).

CONCLUSIONS

Mitral valve replacement is a suitable option for patients with chronic ischemic mitral regurgitation and impaired left ventricular function. It provides better results in terms of freedom from reoperation with comparable valve-related complication rates.

Left atrial strain and strain rate before and following restrictive annuloplasty for ischaemic mitral regurgitation evaluated by two-dimensional speckle tracking echocardiography

AIMS

We retrospectively evaluated left atrial (LA) strain and strain rate (SR) before and after undersized mitral ring annuloplasty (UMRA) for chronic ischaemic mitral regurgitation (CIMR) with two-dimensional speckle-tracking echocardiography.

METHODS AND RESULTS

Left atrial volumes, LA reservoir, LA conduit, LA contractile phases, and LA ejection fraction (LAEF) were measured in 95 CIMR patients who underwent coronary bypass grafting and UMRA. Left atrial peak global strain (ε), LA reservoir (SRp), LA conduit (SRE), and LA contractile phase (SRA) strain rates were obtained at the baseline and at the follow-up (median 41.5 months, interquartile range 23-61). Based on the recurrence of mitral regurgitation (MR) at the follow-up, the patients were divided into two groups: patients with (group MR+, n = 30) or without (group MR-, n = 65) recurrent MR. Twenty age-and gender-matched healthy adults were controls. In the MR- group, baseline ε (P < 0.001), SRP (P < 0.001), SRE (P < 0.001), and SRA (P < 0.001) were enhanced, while in MR+ group, ε (P < 0.001), SRP (P = 0.03), SRE (P = 0.03), and SRA (P = 0.003) were worse than controls. At the follow-up, none of these indices changed in the MR+ group while all returned to normal values in patients belonging to the MR- group. Left atrial deformation correlated with corresponding volumetric parameters. Furthermore, we found a direct correlation between SRE and early peak diastolic velocity (E) (ρ = 0.52, P = 0.02) and E-wave deceleration time (ρ = 0.50, P = 0.02). Finally, there was a strong correlation between ε, SRP, and SRA (ρ = 0.72, P < 0.001 and ρ = 0.79, P < 0.001, respectively) and SRE (ρ = 0.69, P < 0.001 and ρ = 0.71, P < 0.001, respectively). Finally, ε, SRP, and SRE (all, P < 0.001) were co-factors associated to recurrent MR.

CONCLUSION

Left atrial peak global strain, peak systolic SR, and peak early diastolic SR were cofactors associated to recurrent MR. The assessment of LA strain and SR, in addition to other echocardiographic parameters, can be helpful in detecting patients undergoing UMRA who are unlikely to benefit from annuloplasty.

Left ventricular dyssynchrony is associated with recurrence of ischemic mitral regurgitation after restrictive annuloplasty

BACKGROUND

In our study, we investigated the impact of papillary muscle systolic dyssynchrony (DYS-PAP) obtained by 2D speckle-tracking echocardiography (2D-STE) in the prediction of recurrent ischemic mitral regurgitation (MR) after restrictive annuloplasty.

METHODS

The study population consisted of 524 consecutive patients who survived coronary artery bypass grafting (CABG) and restrictive annuloplasty, performed between 2001 and 2010 at 3 different Institutions and who met inclusion criteria. The assessment of DYS-PAP was performed preoperatively and at follow-up (median 45.3 months [IQR 26-67]) by 2D-STE in the apical four-chamber view for the anterolateral papillary muscle (ALPM) and apical long-axis view for the posteromedial papillary muscle (PMPM).

RESULTS

Recurrence of MR (≥ 2+ in patients with no/trivial MR at discharge) was found in 112 patients (21.3%) at follow-up. Compared to patients without recurrence of MR, these patients had higher DYS-PAP values at baseline (60.6 ± 4.4 ms vs. 47.2 ± 2.9 ms, p<0.001) which significantly worsened at follow-up (74.4 ± 5.2 ms, p=0.002 vs. baseline). In contrast, in patients with no MR recurrence, DYS-PAP was significantly reduced (25.3 ± 4.4 ms, p=0.002 vs. baseline). At logistic regression analysis DYS-PAP (odds ratio [OR]: 4.8, 95% Confidence Interval [CI]: 3.4-8.2, p<0.001), was the strongest predictor of recurrent MR with a cutoff ≥ 58 ms (95%CI 51-66 ms). The model showed an area under the Receiver Operating Characteristic (ROC) curve of 0.97 (CI 0.94-0.99 [optimism-corrected 0.94; CI 0.89-0.95]) with 98% sensitivity (CI 96-100% [optimism-corrected 95%; CI 91-96%]) and 90% specificity (CI 85-94% [optimism-corrected 87%; CI 82-90%]).

CONCLUSIONS

DYS-PAP represents a reliable tool to identify patients with ischemic MR who can benefit from restrictive annuloplasty.

The hybrid approach for the surgical treatment of lone atrial fibrillation: one-year results employing a monopolar radiofrequency source

BACKGROUND

The hybrid technique combines a mono or bilateral epicardial approach with a percutaneous endocardial ablation in a single-step procedure. We present our early results with this technique employing a monopolar radiofrequency source through a right thoracoscopy in patients with lone atrial fibrillation (LAF).

METHODS

Between June 2009 and December 2010 nineteen consecutive patients (mean 60.8 ± 8.6 years, 84.2% male) underwent right unilateral minimally invasive hybrid procedure for LAF at our Institution. Ten patients (52.6.6%) had long-standing persistent AF while four (21.1%) had persistent and five (26.3%) paroxysmal AF. All patients were followed-up according the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECA) and Society of Thoracic Surgeon (STS) guidelines.

RESULTS

There were neither early nor late deaths. It was possible to complete all the procedures as planned without any conversion to cardiopulmonary bypass. No patient died during the follow up. At one year, 7/19 (36.8%) patients were in sinus rhythm with no episode of AF and off antiarrhythmic drugs (AAD). Time-related prevalence of postoperative AF peaked at 44.4% (41.3-47.4) at two weeks, was 30.4% (27.3-34.9) at three months, fell to 14.2% (11.6-18.1) by 6 months and was 13.3% (11.0-17.4) at 12 months Among patients with long-standing persistent (LSP) AF, 20% (2/10) were in Sinus rythm and off AAD. One-year success rates were 50% (2/4) in persistent and 60% (3/5) in paroxysmal AF. At 12 months estimated prevalence of antyarrhythmic drugs and Warfarin use were 26% (22.4-33.1) and 48% (37.2-53.2), respectively.

CONCLUSIONS

One year results combining the percutaneous endocardial with the right thoracoscopic epicardial technique were, in our experience, not satisfactory, particularly in patients with LSP and persistent AF. Our findings need to be confirmed by larger studies.