Left atrial wall tension directly affects the restoration of sinus rhythm after Maze procedure

Clinical Characteristics and Rhythm Outcomes in Patients With Atrial Myopathy After Successful Catheter Ablation of Atrial Fibrillation

BACKGROUND

Although successful atrial fibrillation (AF) ablation can maintain sinus rhythm and reduce the left atrial (LA) dimension, blunted LA reverse remodeling can be observed in patients with atrial myopathy. We explored the potential mechanisms and long-term outcomes in patients with blunted LA reverse remodeling after successful AF catheter ablation.

METHODS AND RESULTS

We included 1685 patients who underwent baseline and 1-year follow-up echocardiograms, had a baseline LA dimension ≥40 mm, and did not have a recurrence of AF within a year. The patients were divided into tertile groups according to the delta value of the change in LA dimension on the preprocedure and 1-year postprocedure echocardiography. After propensity score matching for age, sex, AF type, and LA dimension, 1272 patients were finally included in the analyses (424 in each group; the least/blunted, moderate, and the most reverse remodeling group). The patients in the T1 group (blunted LA reverse remodeling) were independently associated with higher left ventricular mass index (odds ratio [OR], 1.014 [95% CI, 1.005-1.022], P=0.001), change in ΔH2FPEF score (heavy, hypertensive, atrial fibrillation, pulmonary hypertension, elder, filling pressure) score (OR, 1.445 [95% CI, 1.121-1.861], P=0.004), ventricular epicardial adipose tissue volume (OR, 1.010 [95% CI, 1.003-1.017], P=0.003), thinner LA wall thickness (OR, 0.461 [95% CI, 0.271-0.785], P=0.004), lower LA voltage (OR, 0.670 [95% CI, 0.499-0.899], P=0.008), and showed higher long-term AF recurrence (log-rank P<0.001) than other groups.

CONCLUSIONS

Blunted LA reverse remodeling after AF catheter ablation, which is suggestive of atrial myopathy, was independently associated with a larger ventricular epicardial adipose tissue volume and worsening of H2FPEF score. Blunted LA reverse remodeling after AF catheter ablation was also an independent predictor for higher recurrences of AF post-1-year AF catheter ablation.

Left Atrium Volume Reduction Procedure Concomitant With Cox-Maze Ablation in Patients Undergoing Mitral Valve Surgery: A Meta-Analysis of Clinical and Rhythm Outcomes

BACKGROUND

The management of an enlarged left atrium (LA) in mitral valve (MV) disease with atrial fibrillation (AF) is still being debated. It has been postulated that a reduction in LA size may improve patient outcomes. This meta-analysis aimed to assess rhythm and clinical outcomes of combined surgical AF treatment with or without LA volume reduction (LAVR) in patients undergoing MV surgery.

METHODS

A systematic review was performed and all available literature to May 2022 was included. The primary endpoint was analysis of early and late mortality and rhythm outcomes. Secondary outcomes included early and late cerebrovascular accident (CVA) and permanent pacemaker implantation.

RESULTS

The search strategy yielded 2,808 potentially relevant articles, and 19 papers were eventually included. The pooled estimated rate of 30-day mortality was 3.76% (95% CI 2.52-5.56). The incidence rate of late mortality and late cardiac-related mortality was 1.75%/year (95% CI 0.63-4.84) and 1.04%/year (95% CI 0.31-3.53), respectively. At subgroup analysis when comparing the surgical procedure with and without AF ablation, the ablation subgroup showed a significantly lower rate of postoperative CVA (p<0.0001) and higher restoration to sinus rhythm at discharge (p=0.0124), with only a trend of lower AF recurrence at 1 year (p=0.0608). At univariable meta-regression, reintervention was significantly associated with higher late mortality (p=0.0033).

CONCLUSION

In enlarged LA undergoing MV surgery, LAVR combined with AF ablation showed a trend of improved rhythm outcomes when compared with AF ablation without LAVR. Each LAVR technique has its advantages and disadvantages, which must be managed accordingly.

A new procedure for elimination of atrial fibrillation associated with mitral valve disease: a proof-of-concept study

BACKGROUND

Left atrial enlargement and fibrosis have been linked to the pathogenesis of atrial fibrillation (AF). The authors aimed to introduce a novel concept and develop a new procedure for AF treatment based on these characteristics.

METHODS

The study included three stages. The first stage was a descriptive study to clarify the characteristics of the left atrial enlargement and fibrosis' distribution in patients with mitral valve disease and long-standing persistent AF. Based on these characteristics, the authors introduced a novel concept for AF treatment, and then translated it into a new procedure. The second stage was a proof-of-concept study with this new procedure. The third stage was a comparative effectiveness research to compare the clinical outcomes between patients with this new procedure and those who received Cox-Maze IV treatment.

RESULTS

Based on the nonuniform fashion of left atrial enlargement and fibrosis' distribution, the authors introduced a novel concept: reconstructing a left atrium with appropriate geometry and uniform fibrosis' distribution for proper cardiac conduction, and translated it into a new procedure: left atrial geometric volume reduction combined with left appendage base closure. As compared to the Cox-Maze IV procedure, the new procedure spent significantly shorter total surgery time, cardiopulmonary bypass time, and aortic cross-clamp time ( P <0.001). Besides, the new procedure was related to a shorter ICU stay period (odd ratio (OR)=0.45, 95% CI=0.26-0.78), lower costs (OR=0.15, 95% CI=0.08-0.29), and a higher rate of A wave of transmitral and transtricuspid flow reappearance (OR=1.76, 95% CI=1.02-3.04).

CONCLUSIONS

The new procedure is safe and effective for eliminating AF associated with mitral valve disease.

Implications of new-onset atrial fibrillation on in-hospital and long-term prognosis of patients with acute myocardial infarction: A report from the CBD bank study

BACKGROUND

An increase in the incidence of atrial fibrillation (AF) during the acute phase of myocardial infarction (AMI) has been observed. But it is still unclear whether the implications of new-onset AF on in-hospital and long-term prognosis are of similar magnitude.

METHODS

Using data from the CBD Bank study, 3,824 consecutive AMI patients, without prior AF, were analyzed. During the index hospitalization, all patients were monitored by continuous cardiac monitoring, twice daily performed 12- or 18-lead ECGs and timely ECG checks when cardiac symptoms occurred. Follow-up visits were routinely scheduled after discharge. Primary outcomes were all-cause death and cardiovascular death occurring during hospitalization and long-term follow-up. Secondary outcome was MACEs during hospitalization.

RESULTS

During the median hospital stay of 9.0 (7.0, 11.0) days, new-onset AF was documented in 133 (3.48%) patients; 95 (71.43%) patients had AF attacks within 3 days following AMI. Independent risk factors associated with new-onset AF were older age, larger left atrial diameter, higher level of NT-proBNP, and primary PCI. New-onset AF was found to be significantly associated with in-hospital all-cause death (OR 4.33, 95%CI: 2.37-7.89, P < 0.001), cardiovascular death (OR 4.10, 95%CI: 2.18-7.73, P < 0.001), and MACEs (OR 2.51, 95%CI: 1.46-4.33, P = 0.001). A total of 112 new-onset AF and 3,338 non-AF patients were followed up for 1,090 (365, 1,694) days after discharge. There was no significant association between new-onset AF and long-term all-cause death (HR 1.21, 95%CI: 0.77-1.92, P = 0.406) or cardiovascular death (HR 1.09, 95%CI: 0.61-1.97, P = 0.764).

CONCLUSION

New-onset AF following AMI is strongly associated with an increased risk of adverse in-hospital prognosis, but it does not affect prognosis in those who survive until hospital discharge.

Diabetes Mellitus Is an Independent Risk Factor for a Stiff Left Atrial Physiology After Catheter Ablation for Atrial Fibrillation

Background

Scar tissue formation after catheter ablation for atrial fibrillation (AF) may adversely affect the diastolic properties of the left atrium (LA), which can result in a stiff LA physiology in a small proportion of patients. In this study, we aimed to explore the relationship between diabetes mellitus and a stiff LA physiology after AF catheter ablation (AFCA).

Methods

A total of 1,326 patients who underwent de novo AFCA, and baseline and 1-year follow-up echocardiographies were enrolled. After 1:3 propensity score (PS) matching for age, sex, and AF type, we compared 211 patients with DM with 633 patients without DM. A stiff LA physiology was defined as estimated pulmonary arterial pressure increase of >10 mmHg and a right ventricular systolic pressure of >35 mmHg at 1-year follow-up echocardiography. Pulmonary vascular resistance (PVR) was estimated using echocardiographic parameters.

Results

Among the 844 PS-matched patients, a stiff LA physiology was observed in 32 patients (4.1%). The patients with DM showed a higher peak LA pressure (p < 0.001) and greater LA wall stress (p = 0.001) than did those without. A stiff LA physiology was independently associated with DM [Odds ratio (OR) = 2.39, 95% confidence interval (CI) 1.02-5.59, p = 0.045], empirical extra-pulmonary vein LA ablation (OR = 3.14, 95% CI 1.07–9.3, p = 0.038) and the ΔPVR (OR = 1.78, 95% CI 1.37–2.31, p < 0.001). The ΔPVR was independently associated with DM (β = 0.37, 95% CI 0.06-0.67, p = 0.020) and a stiff LA physiology (β = 1.40, 95% CI 0.70–2.10, p < 0.001). During the 38.8 ± 29.3months follow-up, the incidence of the clinical recurrence of AF was significantly higher in the patients with a stiff LA physiology than in those without (log rank p = 0.032).

Conclusion

A stiff LA physiology was independently associated with DM because of the relatively small decrease in the PVR after AFCA in this population. The patients with a stiff LA physiology had worse rhythm outcomes after AFCA than those without.

Risk Factors for Stiff Left Atrial Physiology 1 Year After Catheter Ablation of Atrial Fibrillation

Catheter ablation is the most effective rhythm control method for patients with atrial fibrillation (AF); however, it inevitably causes atrial tissue damage. We previously reported that AF catheter ablation (AFCA) increases left atrial (LA) pressure without changes in symptom scores. We hypothesized that extensive LA ablation increased the risk of stiff LA physiology. We included 1,720 patients (69.1% male, 60.0 [53.0-68.0] years old, 66.2% with paroxysmal AF) who underwent de novo AFCA and echocardiography before and 1-year after the procedure. Stiff LA physiology was defined, when the amount of the estimated pulmonary arterial pressure increase between the pre-procedural and the 1-year post-procedural follow-up echocardiography was >10 mmHg and when right ventricular systolic pressure (RVSP) was >35 mmHg at 1-year follow-up echocardiography. The failed rhythm control within 1 year was defined as recurrent AF despite using anti-arrhythmic drugs or cardioversion within a year of AFCA. We explored the incidence and risk factors for stiff LA physiology and the rhythm outcome of AFCA. Among the 1,720 patients, 64 (3.7%) had stiff LA physiology 1 year after AFCA. Stiff LA physiology was independently associated with diabetes (odds ratio [OR], 2.36 [95% CI, 1.14-4.87], p = 0.020), the ratio of the peak mitral flow velocity of the early rapid filling to the early diastolic velocity of the mitral annulus (E/Em; OR, 1.04 [95% CI, 1.00-1.10], p = 0.049), LA pulse pressure (Model 2: OR, 1.05 [95% CI, 1.00-1.11], p = 0.049), low LA voltage (OR, 0.36 [95% CI, 0.18-0.74], p = 0.005), empirical extra-pulmonary vein (PV) LA ablation (OR, 2.60 [95% CI, 1.17-5.74], p = 0.018), and radiofrequency (RF) ablation duration (Model 2: OR, 1.02 [95% CI, 1.01-1.03], p = 0.003). Although the incidence of post-AFCA stiff LA physiology was 3.7% and most of the cases were subclinical, the empirical extra-PV ablation was associated with this undesirable condition. In addition, patients who had low mean LA voltage before AFCA could be susceptible to stiff LA physiology.

Left Atrial Wall Stress and the Long-Term Outcome of Catheter Ablation of Atrial Fibrillation: An Artificial Intelligence-Based Prediction of Atrial Wall Stress

Atrial stretch may contribute to the mechanism of atrial fibrillation (AF) recurrence after atrial fibrillation catheter ablation (AFCA). We tested whether the left atrial (LA) wall stress (LAW-stress_[measured]) could be predicted by artificial intelligence (AI) using non-invasive parameters (LAW-stress_[AI]) and whether rhythm outcome after AFCA could be predicted by LAW-stress_[AI] in an independent cohort. Cohort 1 included 2223 patients, and cohort 2 included 658 patients who underwent AFCA. LAW-stress_[measured] was calculated using the Law of Laplace using LA diameter by echocardiography, peak LA pressure measured during procedure, and LA wall thickness measured by customized software (AMBER) using computed tomography. The highest quartile (Q4) LAW-stress_[measured] was predicted and validated by AI using non-invasive clinical parameters, including non-paroxysmal type of AF, age, presence of hypertension, diabetes, vascular disease, and heart failure, left ventricular ejection fraction, and the ratio of the peak mitral flow velocity of the early rapid filling to the early diastolic velocity of the mitral annulus (E/Em). We tested the AF/atrial tachycardia recurrence 3 months after the blanking period after AFCA using the LAW-stress_[measured] and LAW-stress_[AI] in cohort 1 and LAW-stress_[AI] in cohort 2. LAW-stress_[measured] was independently associated with non-paroxysmal AF (p < 0.001), diabetes (p = 0.012), vascular disease (p = 0.002), body mass index (p < 0.001), E/Em (p < 0.001), and mean LA voltage measured by electrogram voltage mapping (p < 0.001). The best-performing AI model had acceptable prediction power for predicting Q4-LAW-stress_[measured] (area under the receiver operating characteristic curve 0.734). During 26.0 (12.0–52.0) months of follow-up, AF recurrence was significantly higher in the Q4-LAW-stress_[measured] group [log-rank p = 0.001, hazard ratio 2.43 (1.21–4.90), p = 0.013] and Q4-LAW-stress_[AI] group (log-rank p = 0.039) in cohort 1. In cohort 2, the Q4-LAW-stress_[AI] group consistently showed worse rhythm outcomes (log-rank p < 0.001). A higher LAW-stress was associated with poorer rhythm outcomes after AFCA. AI was able to predict this complex but useful prognostic parameter using non-invasive parameters with moderate accuracy.

Surgical Atrial Fibrillation Ablation With and Without Left Atrium Reduction for Patients Scheduled for Mitral Valve Surgery: A Prospective Randomised Study

BACKGROUND

The influence of left atrium (LA) enlargement on atrial arrhythmia recurrence (AAR) after surgical ablation in patients with mitral valve (MV) disease remains unresolved.

OBJECTIVE

Left atrial size is critical to the success of concomitant atrial fibrillation (AF) ablation in patients scheduled for MV surgery. However, a large LA should not be a limiting factor when evaluating surgical candidates with AF if they receive appropriate treatment during concomitant ablation. This randomised study assessed whether adding LA reduction (LAR) to the maze procedure for MV surgery patients can improve freedom from AAR.

METHODS

From September 2014 to September 2017, 140 patients were randomly assigned into two groups. The maze group underwent MV surgery with concomitant surgical AF ablation (n=70). The maze + LA reduction group underwent MV surgery with concomitant AF ablation and LA reduction procedure (n=70). Rhythm outcomes were estimated by Holter monitoring, according to Heart Rhythm Society guidelines.

RESULTS

The concomitant LA reduction procedure did not increase early mortality and complications rates. Significant differences in freedom from AAR were observed at 24 months (maze, 78.4%; maze + LAR group, 92.3%; p=0.025). A significant difference in LA volume was detected at discharge (p<0.0001); however, it was not significantly different at 24 months (p=0.182).

CONCLUSIONS

Adding LA reduction to the maze procedure led to improvements in freedom from AAR for patients with AF and LA enlargement scheduled for MV surgery. A concomitant LA reduction procedure did not increase mortality and perioperative risk.

Mitral valve repair and surgical ablation for atrial functional mitral regurgitation

Background

This observational study aimed to share our experience in the surgical management of atrial functional mitral regurgitation (AFMR).

Methods

We retrospectively identified 82 AFMR patients (63.6±7.7 years) from June 2008 to November 2018 at our institution. Of these patients, 72.0% of them were classified as NYHA functional class III/IV, and all of them had persistent AF. All patients underwent mitral valve (MV) repair, and 52 (63.4%) received concomitant surgical ablation (SA). Patients were followed up for 26.1±27.6 months, and postoperative mitral regurgitation (MR) was assessed by echocardiography.

Results

There was no in-hospital mortality. The overall 1-year and 3-year survival rates were 97.5% and 92.9%, respectively, and 96.1% of patients recovered to NYHA functional class I/II at the latest follow-up. The left atrium (LA) diameter (P<0.001), left ventricular (LV) end-diastolic diameter (P<0.001), LV end-systolic diameter (LVESD) (P<0.001) and pulmonary artery pressure (P=0.006) significantly decreased postoperatively. The overall 1-year and 3-year freedom from recurrent MR rates were 94.3% and 65.3%, respectively, and a significant difference was found between the SA group and the non-SA group (93.8% and 93.8% vs. 95.5% and 44.2%, P=0.035). In a subgroup analysis, this significant difference was only found in the small LA group (≤60 mm).

Conclusions

Our results suggest that MV repair for AFMR is safe and effective. It improves heart failure symptoms and results in reverse-remodeling of both the LA and LV. Concomitant SA might benefit patients in terms of recurrent MR, especially in the small LA group (≤60 mm).

Midterm results of mitral valve repair for atrial functional mitral regurgitation: a retrospective study

Background

Annular dilation by left atrial remodeling is considered the main cause of atrial function mitral regurgitation. Although acceptable outcomes have been obtained using mitral ring annuloplasty alone for atrial functional mitral regurgitation, data assessing outcomes of this procedure are limited. Therefore, we aimed to assess midterm outcomes of mitral valve repair in patients with atrial functional mitral regurgitation.

Methods

We retrospectively studied 40 patients (mean age: 69 ± 9 years) who had atrial fibrillation that persisted for > 1 year, preserved left ventricular ejection fraction of > 40%, and mitral valve repair for atrial functional mitral regurgitation. The mean clinical follow-up duration was 42 ± 24 months.

Results

Mitral ring annuloplasty was performed for all patients. Additional repair including anterior mitral leaflet neochordoplasty was performed for 22 patients. Concomitant procedures included maze procedure in 20 patients and tricuspid ring annuloplasty in 31 patients. Follow-up echocardiography showed significant decreases in left atrial dimensions and left ventricular end-diastolic dimensions. Recurrent mitral regurgitation due to ring detachment or leaflet tethering was observed in five patients and was seen more frequently among those with preoperative left ventricular dilatation. Three patients without tricuspid ring annuloplasty or sinus rhythm recovery by maze procedure developed significant tricuspid regurgitation. Five patients who underwent the maze procedure showed sinus rhythm recovery. Rates of freedom from re-admission for heart failure at 1 and 5 years after surgery were 95 and 86%, respectively.

Conclusions

Mitral valve repair is not sufficient to prevent recurrent atrial functional mitral regurgitation in patients with preoperative left ventricular dilatation. Tricuspid ring annuloplasty may be required for long-term prevention of significant tricuspid regurgitation.

Defining Core competencies of the European Society for Sports Traumatology, knee surgery and arthroscopy

PURPOSE

The European Society for Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) identified the need to develop a competency-based core curriculum for ESSKA specialists, against which all their educational activities, resources and priorities for development could be mapped. The aim of this study was to take a research-based approach to developing a competency-based core curriculum for ESSKA specialists.

METHODS

A Core Curriculum Working Group, with experts representing the ESSKA Board, Sections and Committees, reviewed existing curricula and literature in their own specialist areas and developed a draft list of 285 core competencies for ESSKA specialists. All ESSKA members were asked to comment and rate the importance of these competencies, and the Working Group used these results to refine the curriculum.

RESULTS

Four hundred-forty responses to the online survey contained meaningful data. Almost all were ESSKA members, with broad representation of the countries, ages and backgrounds of the membership. All 285 core competencies were considered at least 'Important' for ESSKA specialists so are retained in the final curriculum, and no new competencies were added. 82 (29%) were considered 'Essential', constituting between 19% and 37% of the competencies within each specialist area. 96 (33.5%) were considered 'Very Important', and 107 (37.5%) 'Important'.

CONCLUSIONS

A competency-based core curriculum for ESSKA specialists was achieved through a systematic and scholarly approach, involving both expert opinion and engagement of the wider ESSKA membership. The core curriculum addresses the identified need in terms of educational development for ESSKA and should also be of interest to the wider orthopaedic and sports medicine communities.

The change in the mitral-septal angle after surgery for atrial functional mitral regurgitation

OBJECTIVE

The optimal surgical strategy for atrial functional mitral regurgitation remains uncertain. Preoperative mitral-septal angle ≤ 70° has been reported as a risk factor for an abnormal vortex pattern in mitral valve repair. This study aimed to elucidate the change in the mitral-septal angle after surgery for atrial functional mitral regurgitation and its effect on the mid-term outcomes.

METHODS

Forty patients underwent mitral valve repair for atrial functional mitral regurgitation. The mitral-septal angle was defined as the angle between the mitral annulus and the anteroseptal wall of the left ventricular mid-portion in the parasternal long-axis view on transthoracic echocardiography. All patients underwent mitral ring annuloplasty. Left atrial plication was performed in nine patients. The mean clinical follow-up period was 42 ± 24 months.

RESULTS

The ratio of left atrial volume to left ventricular end-systolic volume was negatively correlated with the preoperative mitral-septal angle. The postoperative mitral-septal angles were significantly smaller than the preoperative ones. The mitral-septal angle decreased with a decrease in the mitral annuloplasty ring size. Patients who underwent left atrial plication tended to show an increase in the mitral-septal angle postoperatively. There were no significant differences in mid-term morbidities, including heart failure, requiring re-hospitalization and mortalities between patients with postoperative MSA > 70° and those with postoperative MSA ≤ 70°.

CONCLUSIONS

Mitral ring annuloplasty negatively changed the mitral-septal angle, while left atrial plication may induce a positive change to the mitral-septal angle. An association between the mitral-septal angle and mid-term outcomes was not revealed in this study.

Clinical significance of right atrial volume in patients with repaired tetralogy of Fallot

OBJECTIVES

Atrial arrhythmia and right ventricular (RV) diastolic dysfunction are associated with increased morbidity and mortality in patients with repaired tetralogy of Fallot (TOF). This study was performed to determine whether the preoperative right atrial (RA) volume can predict the development of atrial arrhythmia after pulmonary valve replacement (PVR) in patients with TOF.

METHODS

Forty-seven consecutive adult patients with repaired TOF underwent PVR from 2003 to 2018. Seventeen patients showed preoperative atrial arrhythmia and underwent the Maze procedure concomitantly. The preoperative RA volume was evaluated with computed tomography and image analysis software.

RESULTS

The median follow-up period after PVR was 6.8 years. Among 17 patients who underwent the Maze procedure, recurrent atrial arrhythmia developed in 8 patients. Among 30 patients without preoperative atrial arrhythmia, novel atrial arrhythmia developed in 2 patients. The RA volume index was a significant predictor according to the multivariate analysis (P = 0.003). The RA volume index showed a significant positive correlation with the RV end-diastolic pressure (P < 0.001).

CONCLUSIONS

The RA volume predicts the development of atrial arrhythmia after PVR in patients with repaired TOF. RA volume measurement is strongly recommended in the management of this patient population.

Improvement in Polysomnographic Objective Sleep Quality in Adults with Pectus Excavatum After the Nuss Procedure

BACKGROUND

Patients with pectus excavatum have a poorer subjective sleep quality and quality of life than the general population. The Nuss procedure has been shown to improve these patients' quality of life, but data regarding their postoperative sleep quality are lacking. We aimed to evaluate the objective sleep quality of adults with pectus excavatum before and after the Nuss procedure.

METHODS

Twenty-eight participants completed this study. Epworth Sleepiness Scale (ESS) scores for daytime sleepiness, Pittsburgh Sleep Quality Index (PSQI) scores for subjective sleep quality, and overnight polysomnography for objective sleep quality were evaluated before and 6 months after the Nuss procedure.

RESULTS

Subjective sleep quality improved after the Nuss procedure. The median PSQI score decreased from 7 [interquartile range (IQR): 5; 9] to 5 (IQR: 4; 7, p = 0.029); the median percentage of poor PSQI sleep quality decreased from 64.3 to 35.7% (p = 0.048). The median percentage of rapid eye movement sleep significantly increased after surgery [15.6% (IQR: 12.2%; 19.8%) vs. 20.4% (IQR: 14.5%; 24.9%), p = 0.016]. Sleep interruptions also improved, with the median arousal index decreasing from 9.5 (IQR: 4.8; 18.2) to 8.2 (IQR: 4.3; 12.1; p = 0.045). However, there was no significant change in ESS scores after surgery (p = 0.955).

CONCLUSIONS

Pectus excavatum may be associated with poor subjective and objective sleep quality in adults, and the condition may improve after the Nuss procedure. For adults with pectus excavatum who report poor subjective sleep quality, polysomnography should be considered to assess their preoperative and postoperative sleep condition.

Pectus excavatum repair using bridge fixation system

Background

The stability of the pectus bar is an important determinant of the success of pectus excavatum repair surgery. In practice, several different types of fixation method are in use for stabilizing pectus bars. The aim of this study was to compare the performance of the bridge fixation system with previous fixation systems for stabilizing pectus bars.

Methods

We performed a retrospective review of 1760 pectus excavatum repair cases conducted in the Thoracic Department of Choray Hospital and its satellite hospitals, between 2007 and 2017. We compared the results of 560 patients who had the bridge fixation system with the previous 1200 patients who had other fixation techniques.

Results

The bridge fixation system with 2 bars in 560 patients gave better results in terms of bar stabilization, operative time, and postoperative complications, compared to the previous 1200 patients who had other stabilization techniques. The average skin-to-skin surgery time using the bridge fixation system was 55 min. Of the 560 cases, only one patient showed trivial one bar dislocation, and one had a postoperative complication (pneumothorax).

Conclusions

We found the bridge fixation system to be superior not only in terms of stabilizing the bars but also for minimizing the time of surgery and postoperative complications, compared to other fixation systems. The bridge fixation system with 2 bars showed excellent results. Use of 3 bars is not necessary. One bar was used in the other fixation techniques and the results were found to be inferior compared to those using 2 bars.

Impact of volume reduction in giant left atrium during surgical ablation of atrial fibrillation

Background

An enlarged left atrium (LA) is a well-known risk factor for ablation failure of atrial fibrillation (AF). We analyzed the result of concomitant AF ablation in patients with a giant LA and evaluated the effect of LA volume reduction.

Methods

Between 2000 and 2011, 116 patients with a giant LA (antero-posterior dimension ≥70 mm) who underwent surgical AF ablation during MV surgery were retrospectively reviewed. Among these, 28 patients received aggressive LA volume reduction procedure (reduction group) while the other 88 patients received the surgery without LA volume reduction (non-reduction group). Mean follow-up duration was 6.8±3.0 years.

Results

Aortic clamping and cardio-pulmonary bypass times were significantly longer in reduction group than non-reduction group (P<0.001 and 0.025, respectively). There were no significant differences in early mortality rates (3.7% vs. 5.7%, P>0.99) and major complication rates. Rates of freedom from AF at 1, 3 and 5 years were 84.2%, 74.3% and 54.5%, respectively in reduction group and 49.0%, 33.2% and 28.4%, respectively in non-reduction group (P=0.013). Multivariable analysis revealed severe pulmonary hypertension as an independent risk factor for AF recurrence (HR, 15.9; 95% CI, 1.69-149.54, P=0.015) while LA volume reduction (HR, 0.50; 95% CI, 0.28-0.89, P=0.018) and the use of cryoablation instead of radiofrequency (HR, 0.11; 95% CI, 0.01-0.95, P=0.045) were found to be protective against AF recurrence.

Conclusions

Aggressive LA volume reduction was found to improve rhythm outcomes in patients with a giant LA undergoing surgical AF ablation.

Pulmonary function in pectus excavatum patients before repair with the Nuss procedure

OBJECTIVES

Whether the origin of symptoms in pectus excavatum patients (Pex) is related to reduced pulmonary function or impaired cardiovascular performance is debatable. However, pulmonary function testing (PFT) is still part of the evaluation prior to surgical repair in Pex. The purpose of this study was to corroborate our hypothesis that the majority of Pex that qualified for surgery present preoperatively with normal or close to normal PFT.

METHODS

After institutional review board approval, preoperative PFT data of Pex who underwent surgical repair were analyzed retrospectively: total lung capacity (TLC), vital capacity (VC), functional residual capacity, forced expiratory volume in 1 second (FEV1) and maximal expiratory flow at 25% of FVC (MEF25).

RESULTS

82 patients aged from 9 to 27 years (average, 15 years) underwent PFT. A restrictive pattern (VC<80%) was observed in 45%, an obstructive pattern (FEV1 < 75 %) in 35%, and a normal total lung capacity in 62% of the Pex. No significant correlation was noted between the increasing severity of the Haller index and the PFT.

CONCLUSION

Adolescent Pex without relevant respiratory symptoms have nearly a normal lung function. We suggest to skip PFT from the routine preoperative assessment in asymptomatic Pex.

Cardiac function in adults following minimally invasive repair of pectus excavatum

OBJECTIVES

To study if minimally invasive repair of pectus excavatum (PE) in adult patients would improve cardiopulmonary function at rest and during exercise as we have found previously in young and adolescent patients with PE.

METHODS

Nineteen adult patients (>21 year of age) were studied at rest and during bicycle exercise before surgery and 1 year postoperatively. Lung spirometry was performed at rest. Cardiac output, heart rate and aerobic exercise capacity were measured using a photo-acoustic gas-rebreathing technique during rest and exercise. Data are shown as mean ± standard deviation.

RESULTS

Fifteen patients completed the 1-year follow-up. No significant differences were found in neither cardiac output (14.0 ± 0.9 l min at baseline vs 14.8 ± 1.1 l min after surgery; P = 0.2029), nor maximum oxygen uptake (30.4 ± 1.9 and 33.3 ± 1.6 ml/kg/min; P = 0.0940 postoperatively). The lung spirometry was also unchanged, with no difference in forced expiratory capacity during the first second.

CONCLUSIONS

Correction of PE in adult patients does not improve the cardiopulmonary function 1 year after surgery as seen in children and adolescents.

Surgical Treatment of Atrial Fibrillation

Atrial fibrillation (AF) is the most common chronic arrhythmia in the adult population. Ablation lines have largely replaced the historical and challenging cut and sew techniques. Surgical ablation of AF is commonly performed in cases with other indications for cardiac surgery and less commonly as a stand-alone therapy. Pulmonary vein isolation is the cornerstone of this procedure. Extended left atrial ablation lines may increase efficacy in cases with longstanding persistent or permanent AF. Additional efficacy by adding right atrial ablation is controversial but is often performed in cases undergoing right atrial or atrial septal surgery. Left atrial volume reduction is recommended in cases with large left atria and AF undergoing another cardiac surgery. Arrhythmia recurrence is not uncommon after surgical ablation of AF and varies among studies due to heterogeneity in patient population, lesion set and endpoints. Freedom from AF recurrence was 65-87% at 12 months and 58-70% at 2 years follow-up. Long-term monitoring is recommended due to an increased prevalence of asymptomatic recurrences. The strongest predictors of AF recurrence are longstanding or persistent AF and a large left atrium. The most common mechanisms of recurrence are pulmonary vein reconnection, nonpulmonary vein triggers, and gaps in the ablation lines. About 20% of atrial tachyarrhythmia recurrences are atrial flutter or atrial tachycardia. There are not enough data in the surgical literature to support withdrawal of anticoagulation after surgical AF ablation. Patients selected for stand-alone surgical ablation usually have low risk profiles and low postoperative mortality rates (0.2%).

How pulmonary function changes after pectus excavatum correction surgery

AIM

We aimed to determine the effects of minimally invasive repair of pectus excavatum on pulmonary function and quality of life.

METHODS

Minimally invasive pectus excavatum repair was undertaken in 80 patients with a mean age of 16.91 ± 4.37 years (range 7-30 years) and a mean Haller index of 4.07 ± 1.39; 85% of the patients were male. They and their parents completed the Nuss Questionnaire Modified for Adults, and pulmonary function tests were performed on the patients before and 6 months after the operation.

RESULTS

The mean Nuss score was 31.06 ± 6.78 before the operation and it increased to 37.1 ± 8.31 (p = 0.000) 6 months after the operation. Forced vital capacity decreased from 3.70 ± 1.23 to 3.48 ± 1.03 L (p = 0.05) postoperatively. The percentage of expected forced vital capacity decreased from 83.21% ± 16.97% to 76.52% ± 20.98% (p = 0.01). There was no significant change in forced expiratory volume in 1 s. The mean ratio of forced expiratory volume in 1 s to forced vital capacity was 86% preoperatively and it increased to 91% postoperatively (p = 0.000).

CONCLUSIONS

Minimally invasive pectus excavatum repair has a positive impact on the quality of life of pectus excavatum patients, but a negative impact on forced vital capacity. Follow-up studies are needed to assess the long-term changes in pulmonary function after this operation.

Pectus excavatum in adult women: repair and the impact of prior or concurrent breast augmentation

BACKGROUND

Women present with pectus excavatum five times less frequently than men. Adult women may have additional, associated cosmetic factors, including hypoplastic or asymmetric breasts, or prior augmentation. The authors evaluated the impact of prior or concurrent cosmetic breast surgery in an adult female cohort undergoing repair of pectus excavatum deformity.

METHODS

A retrospective review was performed of women (≥18 years old) who underwent pectus excavatum repair at a single institution from January of 2010 to September of 2013.

RESULTS

Pectus excavatum repair was performed on 47 women with a median age of 35 years (range, 18 to 63 years). Mean pectus severity index was 6.2 (range, 3.1 to 16). All patients had physiologic symptoms as the primary purpose for seeking repair. Twenty patients (43 percent) presented with existing implants or the desire for implants at the time of repair. Fifteen patients (32 percent) had a history of implant placement including prior breast augmentation (n = 14) and/or pectus implant (n = 4). Concurrent augmentation (n = 5), breast implant exchange (n = 8), and/or removal of chest wall implants (n = 4) was performed during repair. Morbidity included one implant-related hematoma. Complications and hospital stay were not significantly different for patients undergoing primary repair alone versus those with prior or concurrent augmentation.

CONCLUSIONS

Breast cosmesis was a concern in nearly half of adult women presenting for pectus excavatum repair. The authors' experience suggests neither prior nor concurrent breast augmentation increases the risk of complications in repair. The authors recommend that cosmetic breast surgery be performed concurrently with pectus excavatum repair.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum

This compares outcome measures of current pectus excavatum (PEx) treatments, namely the Nuss and Ravitch procedures, in pediatric and adult patients. Original investigations that stratified PEx patients based on current treatment and age (pediatric=0-21; adult 17-99) were considered for inclusion. Outcome measures were: operation duration, analgesia duration, blood loss, length of stay (LOS), outcome ratings, complications, and percentage requiring reoperations. Adult implant patients (18.8%) had higher reoperation rates than adult Nuss or Ravitch patients (5.3% and 3.3% respectively). Adult Nuss patients had longer LOS (7.3 days), more strut/bar displacement (6.1%), and more epidural analgesia (3 days) than adult Ravitch patients (2.9 days, 0%, 0 days). Excluding pectus bar and strut displacements, pediatric and adult Nuss patients tended to have higher complication rates (pediatric - 38%; adult - 21%) compared to pediatric and adult Ravitch patients (12.5%; 8%). Pediatric Ravitch patients clearly had more strut displacements than adult Ravitch patients (0% and 6.4% respectively). These results suggest significantly better results in common PEx surgical repair techniques (i.e. Nuss and Ravitch) than uncommon techniques (i.e. Implants and Robicsek). The results suggest slightly better outcomes in pediatric Nuss procedure patients as compared with all other groups. We recommend that symptomatic pediatric patients with uncomplicated PEx receive the Nuss procedure. We suggest that adult patients receive the Nuss or Ravitch procedure, even though the long-term complication rates of the adult Nuss procedure require more investigation.

Guideline for the surgical treatment of atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its prevalence is ∼1-2% of the general population, but higher with increasing age and in patients with concomitant heart disease. The Cox-maze III procedure was a groundbreaking development and remains the surgical intervention with the highest cure rate, but due to its technical difficulty alternative techniques have been developed to create the lesions sets. The field is fast moving and there are now multiple energy sources, multiple potential lesion sets and even multiple guidelines addressing the issues surrounding the surgical treatment of AF both for patients undergoing this concomitantly with other cardiac surgical procedures and also as stand-alone procedures either via sternotomy or via videothoracoscopic techniques. The aim of this document is to bring together all major guidelines in this area into one resource for clinicians interested in surgery for AF. Where we felt that guidance was lacking, we also reviewed the evidence and provided summaries in those areas. We conclude that AF surgery is an effective intervention for patients with all types of AF undergoing concomitant cardiac surgery to reduce the incidence of AF, as demonstrated in multiple randomized studies. There is some evidence that this translates into reduced stroke risk, reduced heart failure risk and longer survival. In addition, symptomatic patients with AF may be considered for surgery after failed catheter intervention or even as an alternative to catheter intervention where either catheter ablation is contraindicated or by patient choice.

Efficacy of the maze procedure for atrial fibrillation associated with atrial septal defect

Background

Atrial fibrillation (AF) is a common complication in elderly patients with atrial septal defect (ASD). The purpose of this study was to examine the efficacy of the maze procedure in these patients.

Materials and Methods

Between February 2000 and May 2011, 46 patients underwent the maze procedure as a concomitant operation with ASD closure. Three patients who underwent a right-sided maze were excluded, and one patient was lost to follow-up. The mean follow-up duration was 3.2±2.5 years. Electrocardiography was performed 1 month, 3 months, 6 months, and 1 year after surgery, and checked annually after that.

Results

AF persisted in 4 patients after surgery. One year after surgery, among 38 patients, 55.3% remained in sinus rhythm without antiarrhythmic drugs. However, when including the patients who took antiarrhythmic drugs, 92.1% were in sinus rhythm. Freedom from AF recurrence at 3 months, 6 months, 1 year, 2 years, 3 years, and 5 years after surgery were 97.4±2.6, 94.4±3.8, 91.2±4.9, 87.8±5.8, 79.5±7.6, and 68.2±12.4, respectively. There was no early mortality after operation.

Conclusion

Concomitant treatment with the maze procedure and ASD closure is safe and effective for restoring the sinus rhythm.

Circumferential left atrium resection for treating a giant left atrium

BACKGROUND

An enlarged left atrium (LA) is a major risk factor for atrial fibrillation (AF) recurrence after a maze operation.

METHODS

Between 2000 and 2009, 35 patients underwent circumferential left atrium resection (CLAR), during mitral valve surgery. All patients had continuous AF.

RESULTS

Hospital mortalities occurred in two patients (5.7%). Postoperative bleeding occurred in two patients (5.7%). The average follow-up was 64 months. The mean New York Heart Association (NYHA) functional class had significantly decreased to 1.16 ± 0.37 from 2.77 ± 0.65 (p < 0.01). The mean LA dimension and the cardiothoracic ratio had significantly decreased to 52.8 ± 7.9 mm, and 0.55 ± 0.06 from 72.6 ± 11.0 mm, and 0.66 ± 0.11, respectively (p < 0.01). The mean early postoperative LA volume had decreased to 178 ± 68 mL (102-343 mL) from 332 ± 133 mL (124-655 mL) (p < 0.001). These LA volume reductions had been maintained until the last echocardiogram, which was done at an average of 29 months. In patients who underwent the maze procedure, the rate of sinus rhythm restoration was 82.1%, 81.5%, and 74% at three to six months, one year, and the last visit, respectively.

CONCLUSION

CLAR significantly reduced the LA volume. CLAR had an additional beneficial effect with the maze procedure of a relative rate of sinus rhythm restoration. To clarify the role of CLAR in marked symptom improvements after mitral valve surgery in patients with a giant LA, well-designed comparative studies are required.

The effects of magnesium on the course of atrial fibrillation and coagulation in patients with atrial fibrillation undergoing mitral valve annuloplasty

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia. Magnesium has been reported to be effective in reducing the incidence or prophylaxis of AF. Magnesium is also an essential constituent of many enzyme systems and plays a physiological role in coagulation regulation. The aim of the present study was to examine the effects of magnesium, whether magnesium infusion might decrease the incidence of AF and induce hypocoagulable state in patients with AF, who were undergoing mitral valve annuloplasty.

Methods

This prospective laboratory study was performed using blood from patients with AF undergoing mitral valve annuloplasty. The radial artery was punctured with a 20 gauge catheter and used for monitoring continuous arterial pressure and blood sampling. After anesthesia induction, 4 g of magnesium was mixed with 100 ml normal saline and infused for 5 minutes. Magnesium, calcium, activated clotting time (ACT) and thromboelastographic parameters were checked before and 60 minutes after the magnesium infusion. The electrocardiography changes after magnesium infusion were also checked before commencing cardiopulmonary bypass.

Results

After magnesium infusion, the serum level of magnesium increased significantly but serum calcium did not change significantly. ACT did not change significantly before or after magnesium infusion. The thromboelastographic parameters showed no significant changes before or after magnesium infusion. None of the patients converted to sinus rhythm from AF after the magnesium infusion.

Conclusions

A magnesium infusion did not influence the course of AF and coagulation in patients during prebypass period with AF undergoing mitral valve annuloplasty.