Preoperative atrial fibrillation is an independent risk factor for mid-term mortality after concomitant aortic valve replacement and coronary artery bypass graft surgery

The outcomes of concomitant catheter ablation in non-mitral valve cardiac surgery-a systematic review and meta-analysis of the literature

Background

Atrial fibrillation (AF) is the most common form of cardiac arrythmia, with a key importance in the perioperative setting of cardiac surgery. In recent years, the question as to whether pre-existent AF should be treated concomitantly when undergoing cardiac surgery has been heatedly debated. This systematic review and meta-analysis sought to delineate the outcomes of patients undergoing concomitant AF ablation procedures alongside cardiac surgery.

Methods

The methods for this systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Four databases were searched, ultimately yielding 22 papers for inclusion, using appropriate search terminology. Meta-analysis using proportions or means, as appropriate, were applied. Kaplan-Meier curves were digitized and aggregated using previously reported and validated techniques.

Results

A total of 9,428 patients (67% male) were identified across the study period as having received non-mitral cardiac surgery and concomitant AF ablation procedures. On actuarial assessment, freedom from AF was found to be 93%, 88%, 85%, 82%, and 79% at 1 through to 5 years, respectively. Freedom from mortality was found to be 94%, 93%, 91%, 90%, and 87% at 1 through to 5 years, respectively.

Conclusions

This review demonstrated excellent freedom from AF out to a long-term follow-up of 5 years. Freedom from mortality was also encouraging. Emerging data are increasingly illustrating that in this patient cohort, concurrent treatment of pre-existent AF with cardiac and/or valvular disease at the point of operation should be the standard of care. Robust data in the form of randomized control trials will hopefully solidify this assertion.

Clinical Outcome of Rheumatic Mitral Valve Repair and Replacement Surgery in Indonesia; A Comparison with Non-Rheumatic Aetiology

Introduction

Mitral valve repair (MVr) has been shown to achieve better outcomes than mitral valve replacement (MVR) in degenerative aetiology. However, that cannot be applied in rheumatic mitral valve disease. Therefore, this study aims to evaluate early and late clinical outcomes and mid-term survival in RHD compared to the non-RHD group and whether mitral valve repair is a better surgical approach in RHD patients.

Methods

Patients who underwent mitral valve surgery with or without coronary artery bypass grafting were included in this study. All patients were divided into the RHD and non-RHD group by the type of mitral surgery performed. Early and late outcomes were evaluated, and mid-term cumulative survival was reported.

Results

A total of 1382 patients post MV surgeries were included. The 30-day mortality was significantly higher in the RHD group compared to the non-RHD group (8.7% vs. 4.4%, p = 0.003). There was no difference in 30-day mortality between repair and replacement in each respective group. During follow-up (12-54 months), all-cause mortality between RHD and non-RHD groups (16.7% vs. 16.2%) was not different. In the RHD group, the survival of MVr was 85.6% (95% CI 82.0%-88.5%), and MVR was 78.3% (95% CI 75.8%-80.6%), p-value log rank 0.26 However, in the non-RHD group, patients who underwent MVr had better survival than MVR, with cumulative survival of 81.7% (95% CI 72.3%-88.2%) vs. 71.1% (95% CI 56.3%-81.7%) p-value log rank 0.007.

Conclusion

Early mortality rate in rheumatic mitral valve surgery was higher than in non-rheumatic valve surgery. Although in rheumatic MV disease MV repair did not show a significant survival advantage over MV replacement, a trend towards more favourable survival in the repair group was observed.

The completeness of the left atrial appendage amputation during routine cardiac surgery

BACKGROUND

Left atrial appendage (LAA) is the origin of most heart thrombi which can lead to stroke or other cerebrovascular event in patients with non-valvular atrial fibrillation (AF). This study aimed to prove safety and low complication rate of surgical LAA amputation using cut and sew technique with control of its effectiveness.

METHODS

303 patients who have undergone selective LAA amputation were enrolled in the study in a period from 10/17 to 08/20. The LAA amputation was performed concomitant to routine cardiac surgery on cardiopulmonary bypass with cardiac arrest with or without previous history of AF. The operative and clinical data were evaluated. Extent of LAA amputation was examined intraoperatively by transoesophageal echocardiography (TEE). Six months in follow up, the patients were controlled regarding clinical status and episodes of strokes.

RESULTS

Average age of study population was 69.9 ± 19.2 and 81.9% of patients were male. In only three patients was residual stump after LAA amputation larger than 1 cm with average stump size 0.28 ± 0.34 cm. 3 patients (1%) developed postoperative bleeding. Postoperatively 77 (25.4%) patients developed postoperative AF (POAF), of which 29 (9.6%) still had AF at discharge. On 6 months follow up only 5 patients had NYHA class III and 1 NYHA class IV. Seven patients reported with leg oedema and no patient experienced any cerebrovascular event in early postoperative follow up.

CONCLUSION

LAA amputation can be performed safely and completely leaving minimal to no LAA residual stump.

Reaching Frail Elderly Patients to Optimize Diagnosis and Management of Atrial Fibrillation (REAFEL): A Feasibility Study of a Cross-Sectoral Shared-Care Model

Introduction: Atrial fibrillation (AF) management in primary care often requires a referral to cardiology clinics, which can be strenuous for frail patients. We developed “cardio-share” (CS), a new cross-sector collaboration model, to ease this process. General practitioners (GPs) can use a compact Holter monitor (C3 from Cortrium) to receive remote advice from the cardiologist. Objective: To test the feasibility and acceptability of the CS model to manage suspected AF in frail elderly patients. Methods: We used a mixed methods design, including the preparation of qualitative semistructured interviews of GPs and nurses. Results: Between MAR-2019 and FEB-2020, 54 patients were consulted through the CS model, of whom 35 underwent C3 Holter monitoring. The time from referral to a final Holter report was shortened from a mean (SD) of 117 (45) days in usual care to 30 days (13) with the CS model. Furthermore, 90% of the patients did not need to attend visits at the cardiology clinic. The GPs and nurses highlighted the ease of using the C3 monitor. Their perception was that patients were confident in the GPs’ collaboration with cardiologists. Conclusions: The CS model using a C3 monitor for AF is both feasible and seems acceptable to GPs. The elapsed time from referral to the Holter report performed for the diagnosis was significantly reduced.

Temporal trends and predictors of surgical ablation for atrial fibrillation across a multistate healthcare system

Background

Multiple class I and class IIa recommendations exist related to surgical ablation (SA) of atrial fibrillation (AF) in patients undergoing cardiac surgery.

Objective

Examine temporal trends and predictors of SA for AF in a large US healthcare system.

Methods

We retrospectively analyzed data from the Society for Thoracic Surgery (STS) Adult Cardiac Surgery Database for 21 hospitals in the Providence St. Joseph Health system. All patients with preoperative AF who underwent isolated coronary artery bypass graft (CABG) surgery, isolated aortic valve replacement (AVR), AVR with CABG surgery (AVR+CABG), isolated mitral valve repair or replacement (MVRr), and MVRr with CABG surgery (MVRr+CABG) from July 1, 2014, to March 31, 2020 were included. Temporal trends in SA were evaluated using the Cochran-Armitage trends test. A multilevel logistic regression model was used to examine patient-, hospital-, and surgeon-level predictors of SA.

Results

Among 3124 patients with preoperative AF, 910 (29.1%) underwent SA. This was performed most often in those undergoing isolated MVRr (n = 324, 44.8%) or MVRr+CABG (n = 75, 35.2%). Rates of SA increased over time and were highly variable between hospitals. Years since graduation from medical school for the primary operator was one of the few predictors of SA: odds ratio (95% confidence interval) = 0.71 (0.56–0.90) for every 10-year increase. Annual surgical (both hospital and operator) and AF catheter ablation volumes were not predictive of SA.

Conclusion

Wide variability in rates of SA for AF exist, underscoring the need for greater preoperative collaboration between cardiologists, electrophysiologists, and cardiac surgeons.

Association between new-onset postoperative atrial fibrillation and 1-year mortality in elderly patients after hip arthroplasty

BACKGROUND

The purpose of this study is to determine whether new-onset postoperative atrial fibrillation (NOPAF) among patients after hip arthroplasty can predict 1-year mortality.

METHODS

All patients over 65 years who underwent hip arthroplasty from January 2013 to December 2017 in a Chinese tertiary hospital were retrospectively analyzed. Patients with paroxysmal and persistent atrial fibrillation were ruled out. 2438 patients were identified to be eligible. The primary endpoint was 1-year mortality after the arthroplasty.

RESULTS

Among the 2438 patients, 101 (4.1%) had NOPAF and 2337 (95.9%) had not. Only the current use of beta blocker could predict the occurrence of NOPAF after hip arthroplasty. 1-year mortality for patients with NOPAF was significantly higher than that for patients without NOPAF (70.3% vs 19.0%; p < 0.001). Anti-arrhythmic and anticoagulant treatments were related to 1-year mortality, respectively. With multivariate analysis, NOPA was the most significant variable related to 1-year mortality (hazard ratio 7.8, 95% CI 2.9-24.6).

CONCLUSIONS

Among elderly patients after hip arthroplasty, 1-year mortality is increased significantly for patients with NOPAF.

Preoperative paroxysmal atrial fibrillation predicts high cardiovascular mortality in patients undergoing surgical aortic valve replacement with a bioprosthesis: CAREAVR study

Background

Preoperative permanent atrial fibrillation (AF) is associated with impaired outcome after surgical aortic valve replacement (SAVR). The impact of preoperative paroxysmal AF, however, has remained elusive.

Purpose

We assessed the impact of preoperative paroxysmal AF on outcome in patients undergoing SAVR with bioprosthesis.

Methods

A total of 666 patients undergoing isolated AVR with a bioprosthesis were included. Survival data was obtained from the national registry Statistics Finland. Patients were divided into three groups according to the preoperative rhythm: sinus rhythm (n = 502), paroxysmal AF (n = 90), and permanent AF (n = 74).

Results

Patients in the sinus rhythm and paroxysmal AF groups did not differ with respect to age (P = .484), gender (P = .402) or CHA₂DS₂‐VASc score (P = .333). At 12‐month follow‐up, AF was present in 6.2% of sinus rhythm patients and in 42.4% of paroxysmal AF patients (P < .001). During follow‐up, incidence of fatal strokes in the paroxysmal AF group was higher compared to sinus rhythm group (1.9 vs 0.4 per 100 patient‐years, HR 4.4 95% Cl 1.8‐11.0, P = .001). Cardiovascular mortality was higher in the paroxysmal AF group than in the sinus rhythm group (5.0 vs 3.0 per 100 patient‐years, HR 1.70 95% CI 1.05‐2.76, P = .03) and equal to patients in the permanent AF (5.0 per 100 patient‐years).

Conclusion

Patients undergoing SAVR with bioprosthesis and history of paroxysmal AF had higher risk of developing permanent AF, cardiovascular mortality and incidence of fatal strokes compared to patients with preoperative sinus rhythm. Life‐long anticoagulation should be considered in patients with a history of preoperative paroxysmal AF.

The Factors Affecting Rhythm Control for Cryoablation of Atrial Fibrillation in Mitral Valve Surgery

OBJECTIVE

To evaluate the factors impacting on the conversion to sinus rhythm and on the postoperative rhythm findings in the six-month follow-up period of a mitral valve surgery combined with cryoablation Cox-Maze III procedure, in patients with atrial fibrillation.

METHODS

In this study, we evaluated 80 patients who underwent structural valve disease surgery in combination with cryoablation. Indications for the surgical procedures were determined in the patients according to the presence of rheumatic or non-rheumatic structural disorders in the mitral valve as evaluated by echocardiography. Cox-Maze III procedure and left atrial appendix closure were applied.

RESULTS

The results of receiver operating characteristics analysis indicated that the rate of conversion to the sinus rhythm was significantly higher in patients with left atrial diameters ≥ 45.5 mm and with ejection fraction (EF) ≥ 48.5%. However, the statistical differences disappeared in the sixth month. Thromboembolic (TE) events were seen only in three patients in the early period and no more TE events occurred in the six-month follow-up period.

CONCLUSION

The EF and the preoperative left atrial diameter were determined to be the factors impacting on the conversion to sinus rhythm in patients who underwent mitral valve surgery in combination with cryoablation. Mitral valve surgery in combination with ablation for atrial fibrillation does not affect mortality and morbidity in the experienced health centers; however, it remains controversial whether it will provide additional health benefits to the patients compared to those who underwent only mitral valve surgery.

Does Left Atrial Appendage Amputation During Routine Cardiac Surgery Reduce Future Atrial Fibrillation and Stroke?

Purpose of Review

Stroke is the most feared complication of atrial fibrillation. To prevent stroke, left atrial appendage exclusion has been targeted, as it is the prevalent site for formation of heart thrombi during atrial fibrillation.

We review the historic development of methods for exclusion of the left atrial appendage and the evidence to support its amputation during routine cardiac surgery.

Recent Findings

Evidence is not yet sufficient to routinely recommend left atrial exclusion during heart surgery, despite a high prevalence of postoperative atrial fibrillation. Observational studies indicate that electrical isolation of scarring from clip or suture techniques reduces the arrhythmogenic substrate.

Summary

Randomized studies comparing different methods of closure of the left atrial appendage before amputation do not exist. Such studies are therefore warranted, as well as studies that can elucidate whether amputation is superior to leaving the left atrial appendage stump. Potentially, thrombogenic remaining pouch after closure should be addressed.

Adding left atrial appendage closure to open heart surgery provides protection from ischemic brain injury six years after surgery independently of atrial fibrillation history: the LAACS randomized study

Background

Open heart surgery is associated with high occurrence of atrial fibrillation (AF), subsequently increasing the risk of post-operative ischemic stroke. Concomitant with open heart surgery, a cardiac ablation procedure is commonly performed in patients with known AF, often followed by left atrial appendage closure with surgery (LAACS). However, the protective effect of LAACS on the risk of cerebral ischemia following cardiac surgery remains controversial. We have studied whether LAACS in addition to open heart surgery protects against post-operative ischemic brain injury regardless of a previous AF diagnosis.

Methods

One hundred eighty-seven patients scheduled for open heart surgery were enrolled in a prospective, open-label clinical trial and randomized to concomitant LAACS vs. standard care. Randomization was stratified by usage of oral anticoagulation (OAC) planned to last at least 3 months after surgery. The primary endpoint was a composite of post-operative symptomatic ischemic stroke, transient ischemic attack or imaging findings of silent cerebral ischemic (SCI) lesions.

Results

During a mean follow-up of 3.7 years, 14 (16%) primary events occurred among patients receiving standard surgery vs. 5 (5%) in the group randomized to additional LAACS (hazard ratio 0.3; 95% CI: 0.1–0.8, p = 0.02). In per protocol analysis (n = 141), 14 (18%) primary events occurred in the control group vs. 4 (6%) in the LAACS group (hazard ratio 0.3; 95% CI: 0.1–1.0, p = 0.05).

Conclusions

In a real-world setting, LAACS in addition to elective open-heart surgery was associated with lower risk of post-operative ischemic brain injury. The protective effect was not conditional on AF/OAC status at baseline.

Trial registration

LAACS study, clinicaltrials.gov NCT02378116, March 4th 2015, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13019-018-0740-7) contains supplementary material, which is available to authorized users.

Hybrid treatment combining robotic coronary artery bypass grafting and percutaneous catheter radiofrequency ablation

Isolated coronary artery bypass grafting associated with atrial fibrillation is routinely performed through a sternotomy, and cardiac arrest. Advancements in this surgical approach have led to better cosmesis, a quick postoperative recovery, with the same postoperative results. We report a case of a novel, less invasive hybrid treatment combining robot-assisted coronary artery bypass grafting and percutaneous radiofrequency catheter ablation.

Long-term results of radiofrequency maze procedure for persistent atrial fibrillation with concomitant mitral surgery

Background

The radiofrequency (RF) maze procedure can effectively restore sinus rhythm in most patients with persistent atrial fibrillation (AF) and mitral disease. However, long-term results and predictors for late AF recurrence are still under investigation.

Methods

From December 1995 to November 2011, 207 consecutive patients with persistent AF and mitral disease underwent RF maze procedure and concomitant mitral surgery. The mean age was 54±12.4 year-old. Mitral surgery was performed in all patients and concomitant procedures including tricuspid surgery, aortic valve surgery, and atrial septal defect closure were carried on 164 patients.

Results

The in-hospital mortality was 3.9% (n=8) and late mortality was 8.2% (n=17). After a mean follow-up period of 101±50.9 months, 154 patients (74.4%) had long-term sinus conversion. A permanent pacer was implanted in 8 patients (3.9%). By Cox multivariate survival regression analysis, predictors for long-term sinus conversion were identified to be the duration of persistent AF, preoperative left atrial (LA) diameter, preoperative right atrial (RA) area, and preoperative beta-blocker use. The receiver operating characteristic (ROC) curve analysis showed that the best cutoff value for persistent AF duration, preoperative LA diameter, and preoperative RA area were 59.5 months, 59.85 mm, and 25.65 cm².

Conclusions

Longer persistent AF duration, larger preoperative LA diameter, larger preoperative RA area and preoperative beta-blocker use were the predictors for negative long-term outcome of RF maze procedure for the patients with persistent AF underwent concomitant mitral surgery. Timely referral of patients for surgery is mandatory.

Should We Ablate Atrial Fibrillation During Coronary Artery Bypass Grafting and Aortic Valve Replacement?

BACKGROUND

This study evaluates the safety and efficacy of concomitant atrial fibrillation (AF) ablation in patients with AF undergoing coronary artery bypass grafting (CABG) or aortic valve replacement (AVR) or both.

METHODS

This is a single-center retrospective study of patients with AF presenting for CABG or AVR or both between 2009 and 2013. They were divided into an ablation group that underwent concomitant AF ablation and a control group that did not. Follow-up data were obtained using telephone interviews. The data were 100% complete with a median follow-up of 30 months.

RESULTS

A total of 375 patients with AF presented for CABG (44%), AVR (27%), or CABG and AVR (29%). The ablation (129 patients) and control (246 patients) groups had similar baseline characteristics. The ablation group had significantly longer cardiopulmonary bypass and cross-clamp times, adding a mean of 31 ± 3 and 22 ± 3 minutes (p < 0.01 for both), respectively. There were similar unadjusted rates of hospital mortality (4.7% versus 5.3%, p = 0.79), stroke (3.1% versus 3.3%, p = 0.94), and reopening (4.7% versus 6.5%, p = 0.46) between the groups. The intensive care and hospital length of stays were similar. The ablation group had a lower incidence of postoperative AF (27% versus 78%, p < 0.01). Adjusted operative mortality was similar, but the intervention group had significantly lower odds of postoperative AF (odds ratio 0.11, p < 0.01). Although there was no difference in mid-term survival, the ablation group had higher mid-term AF-free survival (p < 0.01) and a trend toward higher anticoagulation-free (p = 0.09) and stroke-free survival (p = 0.08).

CONCLUSIONS

Concomitant AF ablation in patients with AF undergoing CABG or AVR or both does not increase perioperative rates of mortality or morbidity. Moreover, concomitant AF ablation is effective at reducing postoperative AF burden and increases mid-term AF-free survival.

Results of Cryoablation for Atrial Fibrillation Concomitant With Video-Assisted Minimally Invasive Mitral Valve Surgery

Interest in minimally invasive video-assisted mitral valve surgery (MIMVS) is rapidly growing. Data on concomitant atrial fibrillation (AF) ablation to MIMVS are still lacking. The present study investigates the long-term results of AF cryoablation concomitant to MIMVS. From October 2006-September 2014, 68 patients with mitral valve disease (age 65.9 ± 11.1 years, 34 men out of 68 patients, Euroscore log 5.4 ± 4.5) and drug-resistant AF underwent MIMVS via right minithoracotomy and concomitant left-sided AF endocardial cryoablation (Cryoflex Medtronic, Minneapolis, MN). Patients were independently followed up by cardiological outpatient visits and underwent electrophysiological study when indicated. In total, 44 out of 68 patients (64.7%) underwent mitral valve repair and 8 patients (11.8%) also received concomitant tricuspid valve surgery. One procedure was electively converted to full sternotomy (1.5%). Total clamp time was 97.6 ± 22.8 minutes. In March 2015, 60 patients were alive and completed the follow-up after a mean of 3.4 ± 2.0 years following the procedure. In all, 48 patients (80%) presented sinus rhythm throughout the whole follow-up. Freedom from AF was respectively 95%, 87%, and 72% at 1, 3, and 5 years, respectively. We recorded 2 pacemaker implants (3.3%). A total of 3 patients suffered symptomatic recurrences (2 atypical atrial flutter and 1 atrial fibrillation) and underwent transcatheter ablation-all the 3 patients remained in stable sinus rhythm for the remaining follow-up. In conclusions, given the favorable long-term sinus rhythm maintenance rates of concomitant cryoablation, MIMVS can also be offered to patients with symptomatic AF. AF transcatheter ablation may easily avoid further symptomatic recurrences.

Atrial Fibrillation Is Associated With Increased Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement: Insights From the Placement of Aortic Transcatheter Valve (PARTNER) Trial

BACKGROUND

This study sought to evaluate the impact of atrial fibrillation (AF) on clinical outcomes in patients undergoing transcatheter aortic valve replacement.

METHODS AND RESULTS

Data were evaluated in 1879 patients with baseline and discharge ECGs who underwent transcatheter aortic valve replacement in the Placement of AoRTic TraNscathetER Valve (PARTNER) trial. A total of 1262 patients manifested sinus rhythm (SR) at baseline/SR at discharge, 113 SR baseline/AF discharge, and 470 AF baseline/AF discharge. Patients who converted from SR to AF by discharge had the highest rates of all-cause mortality at 30 days (P<0.0001 across all groups; 14.2% SR/AF versus 2.6% SR/SR; adjusted hazard ratio [HR]=3.41; P=0.0002) and over 2-fold difference at 1 year (P<0.0001 across all groups; 35.7% SR/AF versus 15.8% SR/SR; adjusted HR=2.14; P<0.0001). The presence of AF on baseline or discharge ECG was a predictor of 1-year mortality (adjusted HR=2.14 for SR/AF group and HR=1.88 for AF/AF groups; P<0.0001 for both groups versus SR/SR). For patients discharged in AF, those with lower ventricular response (ie, <90 bpm) experienced less 1-year all-cause mortality (HR=0.74; P=0.04).

CONCLUSIONS

After transcatheter aortic valve replacement, the presence of AF at discharge, and particularly, the conversion to AF by discharge and higher ventricular response are associated with increased mortality. These data underscore the deleterious impact of AF, as well as the need for targeted interventions to improve clinical outcomes, in patients undergoing transcatheter aortic valve replacement.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00530894.

Pre- and postoperative atrial fibrillation in CABG patients have similar prognostic impact

OBJECTIVES

To study pre- and postoperative atrial fibrillation and its long-term effects in a cohort of aortocoronary bypass surgery patients.

DESIGN

Altogether 615 patients undergoing aortocoronary bypass graft surgery in 1999-2000 were studied. Forty-four (7%) had preoperative atrial fibrillation. Postoperative atrial fibrillation occurred in 165/615 patients (27%) while 406/615 patients (66%) had no atrial fibrillation. After a median follow-up of 15 years, symptoms and medication in survivors were recorded, and cause of death in the deceased was obtained.

RESULTS

Death due to cerebral ischaemia was most common in the pre- and postoperative atrial fibrillation groups (7% and 5%, respectively, v. 2% among those without atrial fibrillation, p = .038), as were death due to heart failure (18% and 14%, v. 7%, p = .007) and sudden death (9% and 5%, v. 2%, p = .029). The presence of pre- or postoperative atrial fibrillation was an independent risk factor for late mortality (hazard ratios 1.47 (1.02-2.12) and 1.28 (1.01-1.63), respectively).

CONCLUSIONS

Patients with pre- or postoperative atrial fibrillation undergoing aortocoronary bypass surgery have increased long-term mortality and risk of cerebral ischemic and cardiovascular death compared with patients in sinus rhythm.

Ascending aortic aneurysm repair and surgical ablation for atrial fibrillation

BACKGROUND

Although surgical ablation of atrial fibrillation is commonly performed during concomitant coronary or valve surgery, it is still only performed in a fraction these cases when indicated, and less often in patients undergoing aneurysm surgery. We describe our experience in patients undergoing ascending aneurysm repair and concomitant atrial fibrillation ablation.

METHODS

From January 2004 until November 2011, 40 patients underwent ascending aneurysm repair and atrial fibrillation ablation at our institution and were retrospectively analyzed.

RESULTS

Average age was 67.6 years (43-85). Root replacement was performed in 23 (57.5 %) and arch replacement with circulatory arrest in 18 (45 %). At an average of 41.8 months, 81 % of patients were in sinus rhythm. Operative survival was 100 %, with 1 and 5 year survival of 97.5 and 93.1 %, respectively. Kaplan-Meier analysis revealed improved overall survival in patients with rhythm success (log-rank test p = 0.037).

CONCLUSIONS

Aortic aneurysm repair with concomitant atrial fibrillation ablation is safe and efficacious despite the requirement for an already extensive procedure with rhythm success rates similar to those quoted in the setting of other procedures. Successful restoration of sinus rhythm improves long term survival and should be considered in patients presenting with aortic aneurysm and atrial fibrillation.

Determinants and prognosis of atrial fibrillation in patients with aortic stenosis

Atrial fibrillation (AF) is frequently encountered in patients with aortic stenosis (AS) and its incidence also increases with age. In the general population, AF is known to increase cardiovascular risk. We sought to investigate the prognostic importance of AF associated with AS in the context of routine clinical practice. This analysis was based on 809 patients (75 ± 12 years) diagnosed with AS (aortic valve area <2 cm(2)) and normal (≥50%) ejection fraction (EF). Patients were grouped according to the presence of sinus rhythm (SR) or AF at study enrollment. The AF group comprised 141 patients (17.5%) with AF, whereas 668 patients (82.5%) were in SR at inclusion. Four-year estimates of all-cause mortality with medical and surgical management were 60 ± 5% for the AF group compared with 24 ± 2% for the SR group (p = 0.0001). On multivariate analysis, the risk of all-cause mortality was higher in the AF group than in the SR group (adjusted hazard ratio [HR] 2.47 [1.83 to 3.33], p = 0.0001). AF remained associated with excess mortality risk when the analysis was limited to asymptomatic patients (adjusted HR 2.31 [1.38 to 3.89], p = 0.002) and, respectively, patients with severe AS (adjusted HR 2.22 [1.41 to 3.49], p = 0.001). Among patients managed medically, AF was independently associated with increased risk of death in the overall study population (adjusted HR 2.52 [1.81 to 3.51], p = 0.0001), in asymptomatic AS (adjusted HR 2.12 [1.19 to 3.76], p = 0.01), and in severe AS (adjusted HR 2.23 [1.30 to 3.81], p = 0.004). In conclusion, AF is a major predictor of mortality, in both medically and surgically managed patients with AS, irrespective of the functional status and the severity. AF is, therefore, a strong marker of risk in AS and should be considered for clinical decision making.

Atrial fibrillation in patients undergoing liver transplantation-a single-center experience

BACKGROUND

As the prevalence of atrial fibrillation rises with age and older patients increasingly receive transplants, the perioperative management of this common arrhythmia and its impact on outcomes in liver transplantation is of relevance.

METHODS

Retrospective review of 757 recipients of liver transplantation from January 2002 through December 2011.

RESULTS

Nineteen recipients (2.5%) had documented pre-transplantation atrial fibrillation. Sixteen patients underwent liver and 3 a combined liver-kidney transplantation. Three patients died within 30 days (84.2% 1-month survival) and another 3 within 1 year of transplantation (68.4% 1-year survival). Compared with patients without atrial fibrillation, the relative risk of death in the atrial fibrillation group was 5.29 at 1 month (P = .0034; 95% confidence interval [CI], 1.73-16.18) and 3.28 at 1 year (P = .0008; 95% CI, 1.63-6.59). Time to extubation and intensive care unit (ICU) and hospital readmissions were not different from the control cohort. Rapid ventricular response requiring treatment occurred in 4 patients during surgery and 7 after surgery, resulting in 3 ICU and 3 hospital readmissions.

CONCLUSIONS

The results suggest that patients with atrial fibrillation may be at increased risk of mortality after liver transplantation. Optimization of medical therapy may decrease ICU and hospital readmission due to rapid ventricular response.

The impact of coronary artery disease severity on late survival after combined aortic valve replacement and coronary artery bypass grafting - experience of a single cardiac surgery center

Introduction

The severity of coronary artery disease (CAD) may have an impact on the outcomes of patients (pts) after aortic valve replacement (AVR) and coronary artery bypass grafting (CABG).

Aim

The aim of the study was to analyze survival after simultaneous AVR and CABG with respect to CAD severity.

Material and methods

The study involved 143 consecutive pts (40 women and 103 men) with a mean age of 65.1 ± 7.7 years treated between 2006 and 2009. The indication for surgery was aortic stenosis accompanied by left main or three-vessel disease (group A; n = 43) and by single- or two-vessel disease (group B; n = 100). In-hospital and late mortality were analyzed. Post-discharge survival was estimated using the Kaplan-Meier method. Moreover, selected preoperative clinical and echocardiographic data as well as intraoperative variables were compared between the groups.

Results

In-hospital mortality was 4.7% in group A and 3.0% in group B (NS). The 12-month and 48-month survival probability rates were 0.88 ± 0.05 and 0.83 ± 0.06 in group A, and 0.97 ± 0.01 and 0.92 ± 0.03 in group B, respectively (p < 0.05). Patients in group A and B differed (p < 0.05) with respect to the preoperative prevalence of arterial hypertension (65.1% vs. 42.0%) and atrial fibrillation (18.6% vs. 6.0%) as well as with regard to the rate of complete revascularization (20.9% vs. 85.0%, group A and B, respectively).

Conclusions

Coronary artery disease severity impacts long-term survival after combined AVR and CABG. Patients with left main or three-vessel disease more often undergo incomplete surgical revascularization, and this fact may be one of the predictors of an unfavorable outcome.

Systematic review and meta-analysis of surgical ablation for atrial fibrillation during mitral valve surgery

BACKGROUND

Surgical ablation has emerged as an acceptable treatment modality for patients with atrial fibrillation (AF) undertaking concomitant cardiac surgery. However, the efficacy of surgical ablation in patient populations undergoing mitral valve surgery is not well established. The present meta-analysis aims to establish the current randomized evidence on clinical outcomes of surgical ablation versus no ablative treatment in patients with AF undergoing mitral valve surgery.

METHODS

Electronic searches were performed using six databases from their inception to September 2013, identifying all relevant randomized controlled trials (RCTs) comparing surgical ablation versus no ablation in AF patients undergoing mitral valve surgery. Data were extracted and analyzed according to predefined clinical endpoints.

RESULTS

Nine relevant RCTs were identified for inclusion in the present analysis. The number of patients in sinus rhythm (SR) was significantly improved in the surgical ablation group compared to the non-ablation group at discharge. This effect on SR remained at all follow-up periods until >1 year. Results indicated that there was no significant difference between surgical ablation and no ablation in terms of 30-day mortality, all-cause mortality, pacemaker implantation, stroke, thromboembolism, cardiac tamponade, reoperation for bleeding and myocardial infarction.

CONCLUSIONS

Results from the present meta-analysis demonstrate that the addition of surgical ablation for AF leads to a significantly higher rate of sinus rhythm in mitral valve surgical patients, with no increase in the rates of mortality, pacemaker implantation, stroke and thromboembolism. Further research should be directed at correlating different surgical ablation subtypes to cardiac and cerebrovascular events at long-term follow-up.