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Khiabani AJ, Pawale A. Extracorporeal Membrane Oxygenation in Cardiogenic Shock: Execution Is Something; Timing Is Everything? J Am Heart Assoc 2024; 13:e033348. [PMID: 38240242 PMCID: PMC11056149 DOI: 10.1161/jaha.123.033348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Affiliation(s)
- Ali J. Khiabani
- Division of Cardiothoracic Surgery, Department of SurgeryWashington University School of Medicine, Barnes‐Jewish HospitalSt LouisMOUSA
| | - Amit Pawale
- Division of Cardiothoracic Surgery, Department of SurgeryWashington University School of Medicine, Barnes‐Jewish HospitalSt LouisMOUSA
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Khiabani AJ, Kachroo P. Commentary: Starting the conversation of race and outcomes in proximal aortic surgery. J Thorac Cardiovasc Surg 2024; 167:13-14. [PMID: 36774209 DOI: 10.1016/j.jtcvs.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 12/12/2022] [Indexed: 12/29/2022]
Affiliation(s)
- Ali J Khiabani
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
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Yates TA, Vijayakumar R, McGilvray M, Khiabani AJ, Razo N, Sinn L, Schill MR, Marrouche N, Zemlin C, Damiano RJ. Delayed-enhancement cardiac magnetic resonance imaging detects disease progression in patients with mitral valve disease and atrial fibrillation. JTCVS Open 2023; 16:292-302. [PMID: 38204711 PMCID: PMC10774962 DOI: 10.1016/j.xjon.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/22/2023] [Accepted: 07/11/2023] [Indexed: 01/12/2024]
Abstract
Objectives The mechanism by which mitral valve (MV) disease leads to atrial fibrillation (AF) remains poorly understood. Delayed-enhancement cardiac magnetic resonance imaging (DE-MRI) has been used to assess left atrial (LA) fibrosis in patients with lone AF before catheter ablation; however, few studies have used DE-MRI to assess MV-induced LA fibrosis in patients with or without AF undergoing MV surgery. Methods Between March 2018 and September 2022, 38 subjects were enrolled; 15 age-matched controls, 14 patients with lone mitral regurgitation (MR), and 9 patients with MR and AF (MR + AF). Indexed LA volume, total LA wall, and regional LA posterior wall (LAPW) enhancement were defined by the DE-MRI. One-way analysis of variance was performed. Results LA volume and LA enhancement were associated (r = 0.451, P = .004). LA volume differed significantly between controls (37.1 ± 10.6 mL) and patients with lone MR (71.0 ± 35.9, P = .020 and controls and patients with MR + AF (99.3 ± 47.4, P < .001). The difference in LA enhancement was significant between MR + AF (16.7 ± 9.6%) versus controls (8.3 ± 3.9%, P = .006) and MR + AF versus lone MR (8.0 ± 4.8%, P = .004). Similarly, the was significantly more LAPW enhancement in the MR + AF (17.5 ± 8.7%) versus control (9.2 ± 5.1%, P = .011) and MR + AF versus lone MR (9.8 ± 6.0%, P = .020). Conclusions Patients with MR + AF had significantly more total and LAPW fibrosis compared with both controls and lone MR. Volume and delayed enhancement were associated, but there was no difference between MR and MR + AF.
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Affiliation(s)
- Tari-Ann Yates
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Ramya Vijayakumar
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Martha McGilvray
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Ali J. Khiabani
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Nicholas Razo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Laurie Sinn
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Matthew R. Schill
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Nassir Marrouche
- Department of Cardiology, Tulane University School of Medicine, New Orleans, La
| | - Christian Zemlin
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
| | - Ralph J. Damiano
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, Saint Louis, Mo
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Bakir NH, Khiabani AJ, MacGregor RM, Kelly MO, Sinn LA, Schuessler RB, Maniar HS, Melby SJ, Helwani MA, Damiano RJ. Concomitant surgical ablation for atrial fibrillation is associated with increased risk of acute kidney injury but improved late survival. J Thorac Cardiovasc Surg 2022; 164:1847-1857.e3. [PMID: 33653608 PMCID: PMC8608247 DOI: 10.1016/j.jtcvs.2021.01.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) after cardiac surgery remains a common complication that has been associated with increased morbidity and mortality. This study implemented Kidney Disease Improving Global Outcomes criteria to evaluate renal outcomes after concomitant surgical ablation for atrial fibrillation. METHODS Patients with a history of atrial fibrillation who underwent elective cardiac surgery at our institution from 2008 to 2018 were retrospectively reviewed. Those with preoperative renal dysfunction were excluded. Patients were classified as those who underwent concomitant Cox-Maze IV (CMP-IV) (n = 376) or no surgical ablation (n = 498). Nearest neighbor 1:1 propensity matching was conducted on fourteen covariates. AKI was evaluated by mixed effects logistic regression analysis. Long-term survival was evaluated by proportional hazards regression. RESULTS Propensity matching yielded 308 patients in each group (n = 616). All preoperative variables were similar between groups. The concomitant CMP-IV group had a greater incidence of AKI: 32% (n = 99) versus 16% (n = 49), P < .001. After accounting for bypass time and nonablation operations on mixed effects analysis, concomitant CMP-IV was associated with increased risk of AKI (odds ratio, 1.89; confidence interval, 1.12-3.18; P = .017). While AKI was associated with decreased late survival (P < .001), patients who received a concomitant CMP-IV maintained superior 7-year survival to patients who received no ablation (P < .001). No patients required permanent dialysis. CONCLUSIONS Concomitant CMP-IV was independently associated with increased risk of AKI in the acute postoperative period. However, the long-term risks of AKI were offset by the significant survival benefit of CMP-IV. Concerns regarding new-onset renal dysfunction should not prohibit recommendation of this procedure in appropriate patients.
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Affiliation(s)
- Nadia H. Bakir
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ali J. Khiabani
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Robert M. MacGregor
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Meghan O. Kelly
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Laurie A. Sinn
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Richard B. Schuessler
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Hersh S. Maniar
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Spencer J. Melby
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Mohammad A. Helwani
- Department of Anesthesiology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ralph J. Damiano
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri,Corresponding Author: Ralph J. Damiano, Jr., MD, Washington University School of Medicine, Barnes-Jewish Hospital, Department of Surgery, Division of Cardiothoracic Surgery, Campus Box 8234, 660 S. Euclid Ave., St. Louis, MO 63110, Phone: 314-362-7327, Fax: 314-361-8706,
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MacGregor RM, Khiabani AJ, Bakir NH, Kelly MO, Perez SC, Maniar HS, Schuessler RB, Moon MR, Melby SJ, Damiano RJ. Impact of Obesity on Atrial Fibrillation Recurrence Following Stand-Alone Cox Maze IV Procedure. Innovations (Phila) 2021; 16:434-440. [PMID: 34180299 DOI: 10.1177/15569845211017176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Obesity is a strong and independent factor for the development of atrial fibrillation (AF), and adversely impacts the success of catheter ablation procedures for AF. This study evaluated the impact of body mass index (BMI) on the outcomes following surgical ablation of AF. METHODS Between 2003 and 2019, 236 patients underwent a stand-alone biatrial Cox maze IV procedure (CMP-IV) for refractory AF. Obesity was defined as BMI ≥30 kg/m2. Patients were divided into two groups: BMI <30 kg/m2 (n = 100) and BMI ≥30 kg/m2 (n = 136). Freedom from atrial tachyarrhythmia (ATA) was determined using electrocardiography, Holter, or pacemaker interrogation at 1 year and annually thereafter. Recurrence was defined as any documented ATA lasting ≥30 s. Predictors of recurrence were determined using multivariable logistic regression. Preoperative and procedural outcomes were compared between groups. RESULTS Obese patients had a higher rate of diabetes (16% vs 7%, P = 0.044) and larger left atrial diameter (4.9 ± 1.1 cm vs 4.6 ± 1.0 cm, P = 0.021) when compared to non-obese patients. There was no difference in major complication rate between the groups (4% vs 7%, P = 0.389). There was no operative mortality in either group. During 4.1 ± 2.4 years of follow-up, there was no significant difference in freedom from ATA with or without antiarrhythmic drugs in obese patients when compared to the non-obese group (P > 0.05). Absence of sinus rhythm at discharge predicted AF recurrence up to 7 years postoperatively. CONCLUSIONS As opposed to catheter ablation, obesity did not adversely impact the short and long-term outcomes of stand-alone surgical ablation with CMP-IV, and BMI was not a predictor of AF recurrence. Additionally, there was no significant increase in major complications in obese patients.
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Affiliation(s)
- Robert M MacGregor
- 122757548 Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Ali J Khiabani
- 122757548 Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Nadia H Bakir
- 122757548 Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Meghan O Kelly
- 122757548 Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Samuel C Perez
- 122757548 Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Hersh S Maniar
- 122757548 Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Richard B Schuessler
- 122757548 Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Marc R Moon
- 122757548 Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Spencer J Melby
- 122757548 Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Ralph J Damiano
- 122757548 Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
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Khiabani AJ, Schuessler RB, Damiano RJ. Surgical ablation of atrial fibrillation in patients with heart failure. J Thorac Cardiovasc Surg 2020; 162:1100-1105. [PMID: 32948298 DOI: 10.1016/j.jtcvs.2020.05.125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Ali J Khiabani
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Richard B Schuessler
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
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Manghelli JL, Kelly MO, Carter DI, Gauthier JM, Scozzi D, Lancaster TS, MacGregor RM, Khiabani AJ, Schuessler RB, Gelman AE, Damiano RJ, Melby SJ. Pericardial Mitochondrial DNA Levels Are Associated With Atrial Fibrillation After Cardiac Surgery. Ann Thorac Surg 2020; 111:1593-1600. [PMID: 32946846 DOI: 10.1016/j.athoracsur.2020.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery, and is associated with increased morbidity and mortality. Inflammation has been implicated as an etiology of POAF. Mitochondrial DNA (mtDNA) has been shown to initiate inflammation. This study analyzed inflammatory mechanisms of POAF by evaluating mtDNA, neutrophils, and cytokines/chemokines in the pericardial fluid and blood after cardiac surgery. METHODS Blood and pericardial fluid from patients who underwent coronary artery bypass or heart valve surgery, or both, were collected intraoperatively and at 4, 12, 24, and 48 hours postoperatively. Real-time polymerase chain reaction was used to quantify mtDNA in the pericardial fluid and blood. A Luminex (Luminex Corp, Austin, TX) assay was used to study cytokine and chemokine levels. Flow cytometry was used to analyze neutrophil infiltration and activation in the pericardial fluid. RESULTS Samples from 100 patients were available for analysis. Postoperatively, mtDNA and multiple cytokine levels were higher in the pericardial fluid versus blood. Patients who had POAF had significantly higher levels of mtDNA in the pericardial fluid compared with patients who did not (P < .001, area under the curve 0.74). There was no difference in the mtDNA concentration in the blood between the POAF group and non-POAF group (P = .897). Neutrophil concentration increased in the pericardial fluid over time from a baseline of 0.8% to 56% at 48 hours (P < .01). CONCLUSIONS The pericardial space has a high concentration of inflammatory mediators postoperatively. Mitochondrial DNA in the pericardial fluid was strongly associated with the development of POAF. This finding provides insight into a possible mechanism of inflammation that may contribute to POAF, and may offer novel therapeutic targets.
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Affiliation(s)
- Joshua L Manghelli
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Meghan O Kelly
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Daniel I Carter
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Jason M Gauthier
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Davide Scozzi
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Timothy S Lancaster
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Robert M MacGregor
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Ali J Khiabani
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Richard B Schuessler
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Andrew E Gelman
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri
| | - Spencer J Melby
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Missouri.
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Khiabani AJ, MacGregor RM, Manghelli JL, Ruaengsri C, Carter DI, Melby SJ, Schuessler RB, Damiano RJ. Bipolar Radiofrequency Ablation on Explanted Human Hearts: How to Ensure Transmural Lesions. Ann Thorac Surg 2020; 110:1933-1939. [PMID: 32522634 DOI: 10.1016/j.athoracsur.2020.04.079] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/25/2020] [Accepted: 04/11/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Bipolar radiofrequency (RF) clamps have been shown to be capable of reproducibly creating transmural lesions with a single ablation in animal models. Unfortunately in clinical experience the bipolar clamps have not been as effective and often require multiple ablations to create conduction block. This study created a new experimental model using fresh, cardioplegically arrested human hearts turned down for transplant to evaluate the performance of a nonirrigated bipolar RF clamp. METHODS Nine human hearts turned down for transplant were harvested, and the Cox-Maze IV lesion set was performed with a nonirrigated bipolar RF clamp. In the first 7 hearts a single ablation was performed for each lesion. In the last 2 hearts a set of 2 successive ablations without unclamping were performed. The heart tissue was stained with 2,3,5-triphenyl-tetrazolium chloride. Each ablation lesion was cross-sectioned to assess lesion depth and transmurality. RESULTS A single ablation with the bipolar RF clamp resulted in 89% (469/529) of the histologic sections and 65% (42/65) of the lesions being transmural. Of the nontransmural sections, 92% occurred in areas with epicardial fat. Performing 2 successive ablations without unclamping resulted in 100% of the cross-sections (201/201) and lesions (25/25) being transmural. CONCLUSIONS A single ablation failed to create a transmural lesion 35% of the time, and this was associated with the presence of epicardial fat. Two successive ablations without unclamping resulted in 100% lesion transmurality using the bipolar RF clamp.
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Affiliation(s)
- Ali J Khiabani
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Robert M MacGregor
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Joshua L Manghelli
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Chawannuch Ruaengsri
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Daniel I Carter
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Spencer J Melby
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Richard B Schuessler
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Ralph J Damiano
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri.
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MacGregor RM, Khiabani AJ, Bakir NH, Manghelli JL, Sinn LA, Carter DI, Maniar HS, Moon MR, Schuessler RB, Melby SJ, Damiano RJ. Impact of age on atrial fibrillation recurrence following surgical ablation. J Thorac Cardiovasc Surg 2020; 162:1516-1528.e1. [PMID: 32389465 DOI: 10.1016/j.jtcvs.2020.02.137] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 02/03/2020] [Accepted: 02/23/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The incidence of atrial fibrillation (AF) in patients older than 75 years of age is expected to increase, and its treatment remains challenging. This study evaluated the impact of age on the outcomes of surgical ablation of AF. METHODS A retrospective review was performed of patients who underwent the Cox-maze IV procedure at a single institution between 2005 and 2017. The patients were divided into a younger (age <75 years, n = 548) and an elderly cohort (age ≥75 years, n = 148). Rhythm outcomes were assessed at 1 year and annually thereafter. Predictors of first atrial tachyarrhythmia (ATA) recurrence were determined using Fine-Gray regression, allowing for death as the competing risk. RESULTS The mean age of the elderly group was 78.5 ± 2.8 years. The majority of patients (423/696, 61%) had nonparoxysmal AF. The elderly patients had a lower body mass index (P < .001) and greater rates of hypertension (P = .011), previous myocardial infarction (P = .017), heart failure (P < .001), and preoperative pacemaker (P = .008). Postoperatively, the elderly group had a greater rate of overall major complications (23% vs 14%, P = .017) and 30-day mortality (6% vs 2%, P = .026). The percent freedom from ATAs and antiarrhythmic drugs was lower in the elderly patients at 3 (69% vs 82%, P = .030) and 4 years (65% vs 79%, P = .043). By competing risk analysis, the incidence of first ATA recurrence was greater in elderly patients (33% vs 20% at 5 years; Gray test, P = .005). On Fine-Gray regression adjusted for clinically relevant covariates, increasing age was identified as a predictor of ATAs recurrence (subdistribution hazard ratio, 1.03; 95% confidence interval, 1.02-1.05, P < .001). CONCLUSIONS The efficacy of the Cox-maze IV procedure was worse in elderly patients; however, the majority of patients remained free of ATAs at 5 years. The lower success rate in these greater-risk patients should be considered when deciding to perform surgical ablation.
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Affiliation(s)
- Robert M MacGregor
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Ali J Khiabani
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Nadia H Bakir
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Joshua L Manghelli
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Laurie A Sinn
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Daniel I Carter
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Hersh S Maniar
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Richard B Schuessler
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Spencer J Melby
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
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Manghelli JL, Carter DI, Khiabani AJ, Gauthier JM, Moon MR, Munfakh NA, Damiano RJ, Corvera JS, Melby SJ. A 20-year multicenter analysis of dialysis-dependent patients who had aortic or mitral valve replacement: Implications for valve selection. J Thorac Cardiovasc Surg 2019; 158:805-813.e2. [PMID: 30685160 PMCID: PMC6709586 DOI: 10.1016/j.jtcvs.2018.10.168] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 10/23/2018] [Accepted: 10/28/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Valve selection in dialysis-dependent patients can be difficult because long-term survival is diminished and bleeding risks during anticoagulation treatment are greater in patients with renal failure. In this study we analyzed long-term outcomes of dialysis-dependent patients who underwent valve replacement to help guide optimal prosthetic valve type selection. METHODS Dialysis-dependent patients who underwent aortic and/or mitral valve replacement at 3 institutions over 20 years were examined. The primary outcome was long-term survival. A Cox regression model was used to estimate survival according to 5 ages, presence of diabetes, and/or heart failure symptoms. RESULTS Four hundred twenty-three available patients were analyzed; 341 patients had biological and 82 had mechanical valves. Overall complication and 30-day mortality rates were similar between the groups. Thirty-day readmission rates for biological and mechanical groups were 15% (50/341) and 28% (23/82; P = .005). Five-year survival was 23% and 33% for the biological and mechanical groups, respectively. After adjusting for age, New York Heart Association (NYHA) class, and diabetes using a multivariable Cox regression model, survival was similar between groups (hazard ratio, 0.93; 95% confidence interval, 0.66-1.29; P = .8). A Cox regression model on the basis of age, diabetes, and heart failure, estimated that patients only 30 or 40 years old, with NYHA class I-II failure without diabetes had a >50% estimated 5-year survival (P < .001). CONCLUSIONS Dialysis-dependent patients who underwent valve replacement surgery had poor long-term survival. Young patients without diabetes or NYHA III or IV symptoms might survive long enough to justify placement of a mechanical valve; however, a biological valve is suitable for most patients.
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Affiliation(s)
- Joshua L Manghelli
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Mo
| | - Daniel I Carter
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Mo
| | - Ali J Khiabani
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Mo
| | - Jason M Gauthier
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Mo
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Mo
| | - Nabil A Munfakh
- Division of Cardiothoracic Surgery, Christian Northeast Hospital, Washington University School of Medicine, St Louis, Mo
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Mo
| | - Joel S Corvera
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Methodist Hospital, Indianapolis, Ind
| | - Spencer J Melby
- Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Mo.
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Aquino A, Khiabani AJ, Henn MC, Zajarias A, Melby SJ, Sintek M, Lasala J, Kachroo P, Novak E, Maniar HS. Radiation Exposure During Transcatheter Valve Replacement: What Cardiac Surgeons Need to Know. Ann Thorac Surg 2019; 109:118-122. [PMID: 31288016 DOI: 10.1016/j.athoracsur.2019.05.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/10/2019] [Accepted: 05/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve replacement expose operators to radiation. These procedures differ primarily in whether they are performed via a transfemoral (TF) or an alternative access (AA) approach. This study compared operator radiation exposure during transcatheter valve implantation when performed via a TF vs an AA approach, when performed in a catheterization lab vs a hybrid operating room (OR), and investigated the potential benefit of disposable shielding. METHODS Dosimeters were worn during TAVR-TF (n = 50) and TAVR-AA (n = 31) procedures by operators. All TAVR-AA procedures were performed in a hybrid OR and TF procedures were performed in either catheterization labs (n = 16) or a hybrid OR (n = 34). Disposable radiation shielding pads (RADPAD; Worldwide Innovations and Technologies, Inc, Kansas City) or a placebo were added in a randomized, blinded fashion. RESULTS Team radiation exposure was higher after TAVR-AA vs TAVR-TF (median 15.1 mRad [interquartile range: IQR 8.6, 32.4] vs 5.5 mRad [IQR 2.4, 9.8], P < .001). TAVR-TF procedures required the same amount of fluoroscopy time regardless of where they were performed (20.3 ± 7.4 min in hybrid OR vs 19.0 ± 6.4 min in catheterization lab, P = .55). However, radiation exposure for TAVR-TF remained higher when performed in a hybrid OR (median 9.0 mRad [IQR 4.5, 11.9] vs 2.2 mRad [IQR 1.3, 2.8], P < .001). Radiation exposure was greatest for TAVR-AA (median 15.1 mRad [IQR 8.6, 32.4]). The use of RADPAD did not decrease radiation exposure (median 9.0 mRad [IQR 4.5, 14.7] vs 9.4 mRad [IQR 2.8, 19.5], P = .82). CONCLUSIONS Procedures performed in the hybrid OR were associated with higher operator radiation exposure. In comparison with the TF approach, AA cases had the highest levels of operator radiation. This is particularly important in cases of transcatheter mitral valve replacement that can only be done via an AA approach. The use of disposable radiation shielding in this series did not attenuate operator radiation exposure. Radiation shielding within hybrid ORs should be scrutinized in an effort to remain on par with that found within catheterization labs.
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Affiliation(s)
- Alejandro Aquino
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Ali J Khiabani
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Matthew C Henn
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Alan Zajarias
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Spencer J Melby
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Marc Sintek
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - John Lasala
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Eric Novak
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri
| | - Hersh S Maniar
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri.
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12
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Khiabani AJ, Greenberg JW, Hansalia VH, Schuessler RB, Melby SJ, Damiano RJ. Late Outcomes of Surgical Ablation for Inappropriate Sinus Tachycardia. Ann Thorac Surg 2019; 108:1162-1168. [PMID: 31077661 DOI: 10.1016/j.athoracsur.2019.03.103] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 02/09/2019] [Accepted: 03/25/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Inappropriate sinus tachycardia (IST) is a rare clinical disorder characterized by an elevated resting heart rate and an exaggerated rate response to exercise or autonomic stress. Pharmacologic therapy and catheter ablation are considered first-line treatments for IST but can yield suboptimal relief of symptoms. The results of surgical ablation at our center were reviewed for patients with refractory IST. METHODS Between 1987 and 2018, 18 patients underwent surgical sinoatrial (SA) node isolation for treatment-refractory IST. All 18 patients had previously failed pharmacologic therapy, and 15 patients had failed catheter ablation of the SA node. RESULTS Ten patients underwent a median sternotomy, and 8 patients underwent a minimally invasive right thoracotomy. The SA node was isolated with the use of surgical incisions, cryoablation, or bipolar radiofrequency ablations. Sinus tachycardia was eliminated in 100% of patients in the immediate postoperative period. Long-term follow-up data were available for 17 patients, with a mean follow-up of 11.4 ± 7.9 years. At last follow-up, 100% of patients were free from recurrent symptomatic IST. More than 80% of patients were completely asymptomatic, whereas 3 patients reported occasional palpitations. Four patients were on β-blockers, and 5 patients required subsequent pacemaker implantation. All 8 patients who underwent minimally invasive isolation were in normal sinus rhythm at last follow-up, and only 1 patient complained of palpitations. CONCLUSIONS Surgical isolation of the SA node is a feasible treatment for IST refractory to pharmacologic therapy and catheter ablation. A minimally invasive surgical approach offers a less morbid alternative to traditional median sternotomy.
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Affiliation(s)
- Ali J Khiabani
- Division of Cardiothoracic Surgery, Department of Surgery, Washinton University School of Medicine in St Louis, St Louis, Missouri
| | - Jason W Greenberg
- Division of Cardiothoracic Surgery, Department of Surgery, Washinton University School of Medicine in St Louis, St Louis, Missouri
| | - Vivek H Hansalia
- Division of Cardiothoracic Surgery, Department of Surgery, Washinton University School of Medicine in St Louis, St Louis, Missouri
| | - Richard B Schuessler
- Division of Cardiothoracic Surgery, Department of Surgery, Washinton University School of Medicine in St Louis, St Louis, Missouri
| | - Spencer J Melby
- Division of Cardiothoracic Surgery, Department of Surgery, Washinton University School of Medicine in St Louis, St Louis, Missouri
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washinton University School of Medicine in St Louis, St Louis, Missouri.
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13
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Adademir T, Khiabani AJ, Schill MR, Sinn LA, Schuessler RB, Moon MR, Melby SJ, Damiano RJ. Surgical Ablation of Atrial Fibrillation in Patients With Tachycardia-Induced Cardiomyopathy. Ann Thorac Surg 2019; 108:443-450. [PMID: 30928552 DOI: 10.1016/j.athoracsur.2019.01.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 12/10/2018] [Accepted: 01/20/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common cause of tachycardia-induced cardiomyopathy (TIC). This study evaluated the outcomes of the Cox-Maze IV procedure in patients with TIC and significant left ventricular dysfunction. METHODS Between January 2002 and January 2017, 37 consecutive patients with a left ventricular ejection fraction (LVEF) of 0.40 or less underwent stand-alone surgical ablation of AF. After dilated and ischemic cardiomyopathies were excluded, 34 of 37 patients met the criteria for the diagnosis of TIC. RESULTS Patients were a mean age of 56 ± 11 years, and 24 (70%) had long-standing persistent AF. The median AF duration was 72 months (interquartile range, 9 to 276 months). Seventeen patients (50%) had at least one catheter-based ablation that failed. Mean LVEF was 0.32 ± 0.08. There were 11 patients (32%) with New York Heart Association Functional Classification III/IV symptoms. There was one (3%) 30-day mortality caused by a pulmonary embolus, despite full anticoagulation. At 12 months, freedom from atrial tachyarrhythmias on or off antiarrhythmic drugs was 94% and 89%, respectively. Postoperative echocardiograms were available for 27 of 33 patients (82%). The LVEF improved to a mean of 0.55 ± 0.08 (95% confidence interval, 0.51 to 0.58; p < 0.001). Of the 11 patients with New York Heart Association Functional Classification III/IV symptoms, 8 patients were in class I/II at the last follow-up (p = 0.02). CONCLUSIONS Restoration of sinus rhythm with the Cox-Maze IV was associated with significant improvement in the LVEF in patients with AF and TIC. This retrospective study illustrates the efficacy of the Cox-Maze IV in this patient population both at restoring sinus rhythm and improving ventricular function. Patients with TIC and poor left ventricular function in whom other treatments have failed should be strongly considered for surgical ablation.
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Affiliation(s)
- Taylan Adademir
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ali J Khiabani
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Matthew R Schill
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Laurie A Sinn
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Richard B Schuessler
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Spencer J Melby
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri.
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15
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Ruaengsri C, Schill MR, Lancaster TS, Khiabani AJ, Manghelli JL, Carter DI, Greenberg JW, Melby SJ, Schuessler RB, Damiano RJ. The hemodynamic and atrial electrophysiologic consequences of chronic left atrial volume overload in a controllable canine model. J Thorac Cardiovasc Surg 2018; 156:1871-1879.e1. [PMID: 30336917 DOI: 10.1016/j.jtcvs.2018.05.078] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 05/18/2018] [Accepted: 05/21/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the effects of chronic left atrial volume overload on atrial anatomy, hemodynamics, and electrophysiology using a titratable left ventriculoatrial shunt in a canine model. METHODS Canines (n = 16) underwent implantation of a shunt between the left ventricle and the left atrium. Sham animals (n = 8) underwent a median sternotomy without a shunt. Atrial activation times and effective refractory periods were determined using 250-bipolar epicardial electrodes. Biatrial pressures, systemic pressures, left atrial and left ventricle diameters and volumes, atrial fibrillation inducibility, and durations were recorded at the initial and at 6-month terminal study. RESULTS Baseline shunt fraction was 46% ± 8%. The left atrial pressure increased from 9.7 ± 3.5 mm Hg to 13.8 ± 4 mm Hg (P < .001). At the terminal study, the left atrial diameter increased from a baseline of 2.9 ± 0.05 cm to 4.1 ± 0.6 cm (P < .001) and left ventricular ejection fraction decreased from 64% ± 1.5% to 54% ± 2.7% (P < .001). Induced atrial fibrillation duration (median, range) was 95 seconds (0-7200) compared with 0 seconds (0-40) in the sham group (P = .02). The total activation time was longer in the shunt group compared with the sham group (72 ± 11 ms vs 62 ± 3 ms, P = .003). The right atrial and not left atrial effective refractory periods were shorter in the shunt compared with the sham group (right atrial effective refractory period: 156 ± 11 ms vs 141 ± 11 ms, P = .005; left atrial effective refractory period: 142 ± 23 ms vs 133 ± 11 ms, P = .35). CONCLUSIONS This canine model of mitral regurgitation reproduced the mechanical and electrical remodeling seen in clinical mitral regurgitation. Left atrial size increased, with a corresponding decrease in left ventricle systolic function, and an increased atrial activation times, lower effective refractory periods, and increased atrial fibrillation inducibility. This model provides a means to understand the remodeling by which mitral regurgitation causes atrial fibrillation.
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Affiliation(s)
- Chawannuch Ruaengsri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo; Division of Cardiothoracic Surgery, Department of Surgery, Mahidol University, Ramathibodi Hospital, Bangkok, Thailand
| | - Matthew R Schill
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Timothy S Lancaster
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Ali J Khiabani
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Joshua L Manghelli
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Daniel I Carter
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Jason W Greenberg
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Spencer J Melby
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Richard B Schuessler
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo.
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Ruaengsri C, Schill MR, Khiabani AJ, Schuessler RB, Melby SJ, Damiano RJ. The Cox-maze IV procedure in its second decade: still the gold standard? Eur J Cardiothorac Surg 2018; 53:i19-i25. [PMID: 29590383 PMCID: PMC6018688 DOI: 10.1093/ejcts/ezx326] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/28/2017] [Accepted: 08/11/2017] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and the treatment options include medical treatment and catheter-based or surgical interventions. AF is a major cause of stroke, and its prevalence is increasing. The surgical treatment of AF has been revolutionized over the past 2 decades through surgical innovation and improvements in endoscopic imaging, ablation technology and surgical instrumentation. The Cox-maze (CM) procedure, which was developed by James Cox and introduced clinically in 1987, is a procedure in which multiple incisions are created in both the left and the right atria to eliminate AF while allowing the sinus impulse to reach the atrioventricular node. This procedure became the gold standard for the surgical treatment of AF. Its latest iteration is termed the CM IV and was introduced in 2002. The CM IV replaced the previous cut-and-sew method (CM III) by replacing most of the incisions with a combination of bipolar radiofrequency and cryoablation. The use of ablation technologies, made the CM IV technically easier, faster and more amenable to minimally invasive approaches. The aims of this article are to review the indications and preoperative planning for the CM IV, to describe the operative technique and to review the literature including comparisons of the CM IV with the previous cut-and-sew method. Finally, this review explores future directions for the surgical treatment of patients with AF.
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Affiliation(s)
- Chawannuch Ruaengsri
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Matthew R Schill
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ali J Khiabani
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Richard B Schuessler
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Spencer J Melby
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Ralph J Damiano
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, MO, USA
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