A Swedish consensus on the surgical treatment of concomitant atrial fibrillation.

Atrial fibrillation (AF) is a common arrhythmia among patients scheduled for open heart surgery and is associated with increased morbidity and mortality. According to international guidelines, symptomatic and selected asymptomatic patients should be offered concomitant surgical AF ablation in conjunction with valvular or coronary surgery. The gold standard in AF surgery is the Cox Maze III ("cut-and-sew") procedure, with surgical incisions in both atria according to a specified pattern, in order to prevent AF reentry circuits from developing. Over 90% of patients treated with the Cox Maze III procedure are free of AF after 1 year. Recent developments in ablation technology have introduced several energy sources capable of creating nonconducting atrial wall lesions. In addition, simplified lesion patterns have been suggested, but results with these techniques have been unsatisfactory. There is a clear need for standardization in AF surgery. The Swedish Arrhythmia Surgery Group, represented by surgeons from all Swedish units for cardiothoracic surgery, has therefore reached a consensus on surgical treatment of concomitant AF. This consensus emphasizes adherence to the lesion pattern in the Cox Maze III procedure and the use of biatrial lesions in nonparoxysmal AF.

Transseptal Access Through an Atrial Septal Defect Closure Device Resulting in Open Heart Surgery.

A pulmonary vein isolation procedure in a patient with an atrial septal defect (ASD) closure device was complicated by entrapment of a mapping catheter in the device. The procedure was converted to open heart surgery, the device with the trapped catheter was explanted, the ASD was covered with a bovine patch, and a cryomaze procedure was performed. (Level of Difficulty: Intermediate.).

The biatrial cryo-maze procedure for treatment of atrial fibrillation: a single-center experience.

OBJECTIVES: The Cox-maze III procedure is the benchmark for atrial fibrillation (AF) surgery but has been replaced by surgical ablation. We evaluated our experience with biatrial cryoablation using the full Cox-maze III lesion pattern, and adhering follow-up to current guidelines. DESIGN: Forty-three patients underwent the biatrial cryo-maze procedure as a concomitant (n = 37) or stand-alone procedure (n = 6). Mean age was 64.8 ± 9.5 years. Overall, AF was paroxysmal/persistent/permanent in 28/14/58%. Mean AF duration was 5.2 ± 6.5 years. Follow-up included prospective evaluation at 1, 3 and 12 months, long-term monitoring and transthoracic echocardiography. RESULTS: No mortality and no complications related to the ablation procedure occurred. One patient suffered a stroke at 12 months. In the concomitant group, rhythm was sinus/pacing without AF/AF in 65/16/19% at three months, and 59/22/19% at 12 months. Five patients received new pacemakers (12%). In the stand-alone group, 5/6 (83%) patients had sinus rhythm with no AF at three and 12 months. Overall, 35/43 patients (81%) had sinus/paced rhythm at 12 months with no AF and no anti-arrhythmic drugs. Echocardiography showed satisfactory results in all patients. CONCLUSIONS: The biatrial cryo-maze procedure is safe and effective in surgical patients with concomitant AF, and could be considered for selected patients with lone AF.

Percutaneous femoral cannulation and decannulation using a plug-based vascular closure device in minimally invasive cardiac surgery.

Minimally invasive cardiac surgery such as a mitral valve procedure requires femoral arterial cannulation for extracorporeal circulation. To avoid complications associated with surgical groin incisions, such as seromas and infections, percutaneous cannulation techniques can be used. This video tutorial illustrates percutaneous femoral cannulation and decannulation using a plug-based vascular closure device.

Percutaneous Vascular Closure Device in Minimally Invasive Mitral Valve Surgery.

BACKGROUND: Minimally invasive mitral valve surgery requires femoral artery cannulation for extracorporeal circulation, predominantly performed through surgical cutdown. Surgical groin incision is frequently associated with complications such as seroma and infection. We evaluated the safety and efficacy of a percutaneous plug-based large-bore vascular closure device (VCD) for femoral artery closure in minimally invasive mitral valve surgery. METHODS: This was a single-center prospective study comparing patients undergoing minimally invasive mitral valve surgery with femoral cannulation performed either through surgical cutdown or percutaneously with access site closure using a plug-based VCD (MANTA; Teleflex/Essential Medical, Malvern, PA). RESULTS: From 2016 to 2018, a total of 268 (147 surgical cutdown, 121 VCD) patients underwent minimally invasive mitral valve surgery with femoral arterial cannulation of catheters sized 19-F or 21-F. Propensity score matching resulted in 109 matched pairs. In both the overall series and the propensity-matched cohort, VCD patients had a significantly higher incidence of Valve Academic Research Consortium-2 major access site vascular complications (overall cohort: 0% vs 4.1%; P = .013; propensity score-matched cohort: 0% vs 4.6%; P = .024). Bleeding did not occur in any group. In the overall series, surgical cutdown patients had a higher incidence of seroma (10.9% vs 0%; P < .001). Infection and seroma did not occur in the VCD group. CONCLUSIONS: Percutaneous femoral artery cannulation using a novel plug-based VCD in minimally invasive mitral valve surgery eliminates traditional complications frequently seen with surgical cutdown with no femoral access site seroma and infection though at the expense of an increased risk for vascular complications.

Minimally invasive versus sternotomy mitral valve surgery when initiating a minimally invasive programme.

OBJECTIVES: An increasing number of mitral valve operations are performed using minimally invasive procedures. The initiation of a minimally invasive mitral valve surgery programme constitutes a unique opportunity to study outcome differences in patients with similar characteristics operated on through a sternotomy versus a minimally invasive procedure. The goal of this study was to compare short-term outcomes of patients undergoing mitral valve surgery before versus those having surgery after the introduction of a minimally invasive programme. METHODS: The single-centre study included mitral valve procedures performed through a sternotomy or with a minimally invasive approach between January 2012 and May 2019. Propensity score matching was performed to reduce selection bias. RESULTS: A total of 605 patients (294 sternotomy, 311 minimally invasive) who underwent mitral valve surgery were included in the analysis. Propensity score matching resulted in 251 matched pairs. In the propensity score-matched analysis, minimally invasive procedures had longer extracorporeal circulation duration (149 ± 52 vs 133 ± 57 min; P = 0.001) but shorter aortic occlusion duration (97 ± 36 vs 105 ± 40 min, P = 0.03). Minimally invasive procedures were associated with a lower incidence of reoperation for bleeding (2.4% vs 7.2%; P = 0.012), lower need for transfusion (19.1% vs 30.7%; P = 0.003) and shorter in-hospital stay (5.0 ± 2.7 vs 7.2 ± 4.6 days; P < 0.001). The 30-day mortality was low in both groups (0.4% vs 0.8%; P = 0.56). CONCLUSIONS: Minimally invasive mitral valve surgery was associated with short-term outcomes comparable to those with procedures performed through a sternotomy. Initiating a minimally invasive mitral valve programme with a limited number of surgeons and a well-executed institutional selection strategy did not confer an increased risk for adverse events.

[Minimally invasive mitral valve surgery]. / Minimalinvasiv mitraliskirurgi bra alternativ till konventionell kirurgi - Mindre kirurgiskt trauma kan ge färre komplikationer och snabbare återhämtning.

Minimally invasive mitral valve surgery Conventional mitral valve surgery is performed through a full median sternotomy. Minimal invasive mitral valve surgery was introduced in the mid 1990s and is performed through a right mini-thoracotomy. Minimal access mitral valve surgery has grown in popularity and by reducing surgical trauma potential benefits include decreased postoperative bleeding and pain, reduced incidence of sternal wound infections and shortened recovery period after surgery. We report our experience in 97 patients operated during one year where mitral valve surgery was performed through a minimally invasive technique.

The assessment of acute load and contractility changes by left ventricular pressure measurements.

The aim of this study was to establish whether analysis of the left ventricular pressure waveform provides indicative information about cardiac load and contractility and to develop an algorithm for computer-based assessment of changes in these variables. In eight healthy standard breed anaesthetized open-chest pigs, a high frequency response guide-wire mounted pressure sensor was introduced into the left ventricle. Preload reduction was induced by vena cava occlusion, afterload increase by an i.v. injection of phenylephrine and increased contractility by an i.v. injection of adrenalin. Left ventricular pressure waveform analysis was performed by plotting the slope of the pressure curve during the systolic ejection period versus maximal systolic pressure. The analysis revealed characteristic changes in left ventricular pressure and pressure waveform and identified easily discernible reaction patterns in the slope versus maximal pressure plot, specific for each provocation. Analysis of the left ventricular waveform provides indicative information about loading conditions and contractility. The proposed algorithm can easily be implemented in pressure monitoring systems allowing real-time assessment and discrimination of acute changes in preload, afterload and myocardial performance.

Long-Term Follow-Up of Cardiac Rhythm in 320 Patients After the Cox-Maze III Procedure for Atrial Fibrillation.

BACKGROUND: The Cox-maze III (CM-III) procedure is the gold standard for surgical treatment of atrial fibrillation (AF). Excellent short-term results have been reported, but long-term outcomes are lesser known. The aim was to evaluate current cardiac rhythm in a nationwide cohort of CM-III patients with very long follow-up. METHODS: Perioperative characteristics were retrospectively analyzed in 536 "cut-and-sew" CM-III patients operated on from 1994 to 2009 in 4 centers. Of these, 54 patients had died and 20 were unavailable at follow-up. The remaining 462 patients received a survey concerning arrhythmia symptoms, rhythm, and medication; of these, 320 patients (69%), comprising 252 men, with a mean age of 67 years (range, 47 to 87 years), and 83% with stand-alone CM-III, returned a current 12-lead electrocardiogram. Long-term monitoring was evaluated in 40 sinus rhythm patients. Postoperative stroke/transient ischemic attack was evaluated by register analysis. RESULTS: Mean follow-up was 111 ± 44 months (range, 36-223 months). Electrocardiogram analysis showed sinus rhythm in 219 of 320 patients (68%), and regular supraventricular rhythm (sinus, nodal, or atrial pacing) in 262 (82%), with 75% off class I/III antiarrhythmic medication. This group had lower arrhythmia symptom scores and medication use. Rhythm outcome did not differ by gender, age, type of AF, or stand-alone vs concomitant operation. Patients with more than 10 years of follow-up had a lower rate of regular supraventricular rhythm (69% vs 91%, p = 0.02). Long-term monitoring showed freedom from AF/atrial flutter in 38 of 40 patients (95%). The incidence of stroke/transient ischemic attack was 0.37% per year (11 patients). CONCLUSIONS: In a single-moment electrocardiogram evaluation 9 years after the cut-and-sew CM-III, 82% of patients were in sinus rhythm or other regular supraventricular rhythm. These findings support a long-lasting positive effect of the CM-III procedure, which is relevant when evaluating current nonpharmacologic therapies for AF.

Ventricular Septal Perforation Caused by the Strut of a Mitral Valve Bioprosthesis.

Ventricular rupture is a well-known complication of mitral valve replacement. We report a rare complication in which the strut of a recently implanted mitral bioprosthesis eroded through the ventricular septum. We present the strategy of the reoperation in which the sutures holding the repair patch were also used to support the new prosthesis. In addition to ventricular rupture and obstruction of the left ventricular outflow tract by a mitral bioprosthesis, the risk of iatrogenic ventricular septal defect (VSD) should be considered when choosing, sizing, and implanting a mitral bioprosthesis.

Interrelation between the extent of atherosclerosis in the thoracic aorta, carotid intima-media thickness and the extent of coronary artery disease.

Intima-media thickness (IMT) of the common carotid artery and atherosclerosis of the thoracic aorta have been shown to correlate with coronary artery disease (CAD). This study compares the relation between wall changes in the thoracic aorta and the carotid arteries and the angiographic severity and extent of atherosclerotic lesions in the coronary arteries in patients with verified CAD. Atherosclerotic wall changes in the carotid arteries and the thoracic aorta were measured by B-mode ultrasonography and transesophageal echocardiography (TEE), respectively, in 37 subjects aged 65+/-10 years with angiographically verified CAD. The mean value of the common carotid IMT of the right and left sides was 0.87+/-0.21 mm. All subjects had carotid plaques. TEE detected grades II-IV atherosclerotic plaques in the thoracic aorta in 32 of the 37 (86%) patients. A significant correlation was seen between the extent of coronary artery stenosis and aortic plaques score (r=0.46, p=0.008). Mean carotid IMT was also significantly correlated with coronary artery stenosis extent score (r=0.44, p=0.007). Moreover, a significant correlation was seen between the aortic plaque score and the mean carotid IMT (r=0.39, p=0.02). In conclusion, we found a clear and significant relationship between wall changes in the thoracic aorta, common carotid IMT and the angiographic extent of coronary artery stenosis in patients with severe CAD. These findings indicate a potential of B-mode ultrasonography of the carotid arteries and transesophageal echocardiographic aortic examination in the diagnostic and prognostic evaluation of patients with suspected CAD.

Morphological changes rather than flow-mediated dilatation in the brachial artery are better indicators of the extent and severity of coronary artery disease.

OBJECTIVES: The aim of this study was to examine the relationship between morphological and functional parameters of the brachial and carotid arteries and the angiographic extent and severity of coronary artery stenosis in patients with severe coronary artery disease (CAD). DESIGN: A cross-sectional study. SETTING: University hospital. MAIN OUTCOME MEASURES: Flow-mediated dilatation (FMD), intima-media thickness (IMT) in the brachial artery and atherosclerotic wall changes in the carotid arteries were measured by B-mode high-resolution ultrasound in 58 patients who had undergone coronary angiography. RESULTS: A significant correlation was seen between the extent of coronary artery stenosis defined as the coronary angiographic score and both the mean brachial artery IMT and intima-media area (IMa; P = 0.01 and P = 0.04, respectively). There was no significant correlation between FMD and the extent of coronary artery stenosis. A significant correlation was seen between the mean carotid artery IMT and the mean brachial artery IMT (r = 0.30, P = 0.03). However, there was no significant correlation between FMD and the mean carotid artery IMT or IMa (r = 0.16, P = 0.23 and r = 0.17, P = 0.24, respectively). CONCLUSIONS: Morphological but not functional parameters of the brachial artery are associated with the extent of coronary artery stenosis and atherosclerotic wall changes in the carotid arteries in patients with severe CAD. These findings indicate a potential of B-mode ultrasonography of morphological parameters in the brachial artery in the diagnostic and prognostic evaluation of patients with suspected CAD.

Atrial function after left atrial epicardial cryoablation for atrial fibrillation in patients undergoing mitral valve surgery.

PURPOSE: To explore the effects on atrial and ventricular function of restoring sinus rhythm (SR) after epicardial cryoablation and closure of the left atrial appendage (LAA) in patients with mitral valve disease and atrial fibrillation (AF) undergoing surgery. METHODS: Sixty-five patients with permanent AF were randomized to mitral valve surgery combined with left atrial epicardial cryoablation and LAA closure (ABL group, n = 30) or to mitral valve surgery alone (control group, n = 35). Two-dimensional and Doppler echocardiography were performed before and 6 months after surgery. RESULTS: At 6 months, 73% of the patients in the ABL group and 46% of the controls were in SR. Patients in SR at 6 months had a reduction in their left ventricular diastolic diameter while the left ventricular ejection fraction was unchanged. In patients remaining in AF, the left ventricular ejection fraction was lower than at baseline. The left atrial diastolic volume was reduced after surgery, more in patients with SR than AF. In patients in SR, the peak velocity during the atrial contraction and the reservoir function were lower in the ABL group than in the control group. CONCLUSIONS: In patients in SR, signs of atrial dysfunction were observed in the ABL but not the control group. Atrial dysfunction may have existed before surgery, but the difference between the groups implies that the cryoablation procedure and/or closure of the LAA might have contributed.

Learning what works in surgical cryoablation of atrial fibrillation: results of different application techniques and benefits of prospective follow-up.

Atrial fibrillation (AF) in cardiac surgical patients is detrimental in the long perspective. Concomitant surgical ablation of AF is recommended in guidelines and performed in most centers. The article describes the experiences in a single institution with concomitant surgical argon-based cryoablation in 115 patients using three different application techniques (epicardial left atrium, endocardial left atrium, biatrial cryo-maze) and a structured local follow-up to one year postoperatively. Results showed cryoablation to be safe with few complications related to the ablation procedure and few thromboembolic events. In this study, a complete biatrial lesion set according to the classic Cox-maze III (CM III) lesion pattern yielded a higher success rate than left atrial procedures. At 12 months, patients in sinus or pacing rhythm, free of AF without antiarrhythmic drugs, were 27/39 (69%), 24/32 (74%) and 36/44 (82%) in the EpiLA, EndoLA and cryo-maze groups, respectively. A consistent prospective follow-up is essential not only for research purposes but also for assessing the local results of AF surgery in everyday practice. It may direct and develop the surgical ablation program, guide individual postoperative arrhythmia management and is needed to increase overall quality of surgical AF ablation.

A randomized double-blind study of epicardial left atrial cryoablation for permanent atrial fibrillation in patients undergoing mitral valve surgery: the SWEDish Multicentre Atrial Fibrillation study (SWEDMAF).

AIMS: The efficacy of epicardial left atrial (LA) cryoablation in eliminating atrial fibrillation (AF) in patients undergoing mitral valve surgery (MVS) is unknown. We hypothesized that MVS combined with LA cryoablation is superior to MVS alone. METHODS AND RESULTS: Sixty-nine patients with permanent AF, included at four centres, underwent MVS with or without epicardial LA cryoablation. The primary endpoint was regained sinus rhythm. Risk factors for failed AF cryoablation were elucidated. Sixty-five out of 69 patients reached the primary endpoint. At 6 and 12 months follow-up, 73.3% of patients who underwent cryoablation had regained sinus rhythm at both follow-ups, compared with 45.7 and 42.9% of patients, respectively, who underwent MVS alone (group differences, at 6 months P = 0.024, after 12 months P = 0.013). The in-hospital complication rate was 11.4% in the MVS group and 26.5% in the cryoablation group (P = 0.110). Risk factors for failed elimination of AF by cryoablation were duration of permanent AF (P = 0.012) and presence of coronary artery disease (P = 0.047), according to multiple logistic regression analysis. CONCLUSION: This first prospective randomized study showed that combining MVS with epicardial LA cryoablation is significantly better in eliminating pre-operative permanent AF than MVS alone.

ANP and BNP but not VEGF are regionally overexpressed in ischemic human myocardium.

Angiogenic gene therapy in angina pectoris has been disappointing so far. Reasons might be that the administered genes already are overexpressed in ischemic myocardium, or that atrial and brain natriuretic peptides (ANP and BNP) are overexpressed, as they have anti-angiogenic effects. Five stable angina pectoris patients without heart failure were studied. Left ventricular biopsies were taken during coronary by-pass surgery from a region with stress-inducible ischemia and from a normal region. Both ANP and BNP but not vascular endothelial growth factor (VEGF) and VEGF-receptor 1 and 2 were overexpressed in ischemic regions compared to non-ischemic regions as measured by real-time PCR. The expression of 15 other angiogenic genes measured by oligonucleotide arrays was not consistently increased in ischemic regions. The overexpression of ANP and BNP suggests an anti-angiogenic effect in ischemic heart disease. The lack of overexpression of angiogenic genes supports the concept of therapeutic overexpression of these genes.