Cardiovascular outcomes in solid organ transplant recipients undergoing cardiac surgery: A matched pair analysis.

INTRODUCTION: This study aimed to compare postoperative outcomes after cardiac surgery in solid-organ transplant recipients and nontransplant patients. METHODS: We performed a retrospective analysis of 78 consecutive transplant recipients who underwent cardiac surgery at Asan Medical Center between 2000 and 2022 and were matched with 312 nontransplant patients who underwent cardiac surgery at a 1:4 ratio. The outcomes included 30-day mortality, all-cause death, cardiac death, readmission, and cardiac readmission. RESULTS: There was no significant difference in baseline characteristics between the two groups. The most common type of cardiac surgery performed in solid organ transplant recipients was isolated valve surgery, followed by isolated CABG. The 30-day mortality was not significantly different between transplant recipients and nontransplant patients (3.9% vs. 3.5%; P > .99). Solid organ transplant recipients showed a higher all-cause mortality compared to nontransplant patients (29.1% vs. 14.3% at 5 years; P = .001); however, there was no significant difference in cardiac death between the two groups (2.6% vs. 3.2% at 5 years; P = .80). In addition, the readmission and cardiac readmission rates showed comparable findings to that of mortality. CONCLUSION: Cardiac surgery can be performed safely in solid organ transplant recipients, with postoperative cardiovascular outcomes comparable to those observed in nontransplant patients.

Minimally Invasive Approach versus Sternotomy for Cardiac Surgery in Jehovah's Witness Patients.

OBJECTIVE: To evaluate the outcomes of minimally invasive cardiac surgery (MICS) compared with the sternotomy approach for Jehovah's Witness (JW) patients who cannot receive blood transfusions DESIGN: This was a retrospective observational study. SETTING: The study was conducted at a specialized cardiovascular intervention and surgery institute. PARTICIPANTS: The study cohort comprised JW patients undergoing cardiac surgery between September 2016 and July 2022. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Patients (n = 63) were divided into MICS (n = 19) and sternotomy (n = 44) groups, and clinical outcomes were analyzed. There was no difference in types of operation except coronary bypass grafting (n = 1 [5.3%] in the MICS group v n = 20 [45.5%] in the sternotomy group; p = 0.005). There were no between-group differences in early mortality and morbidities. Overall survival did not differ significantly during the follow-up period (mean, 43.9 ± 24.4 months). The amount of chest tube drainage was significantly lower in the MICS group on the first postoperative day (mean, 224.0 ± 122.7 mL v 334.0 ± 187.0 mL in the sternotomy group; p = 0.022). The mean hemoglobin level was significantly higher in the MICS group on the day of operation (11.7 ± 1.3 mg/dL v 10.6 ± 2.0 mg/dL in the sternotomy group; p = 0.042) and the first postoperative day (12.3 ± 1.8 mg/dL v 11.2 ± 1.9 mg/dL; p = 0.032). CONCLUSIONS: MICS for JW patients showed favorable early outcomes and mid-term survival compared to conventional sternotomy. MICS may be a viable option for JW patients who decline blood transfusions.

Aortic Valve Replacement in the Era of Transcatheter Aortic Valve Implantation: Current Status in Korea.

BACKGROUND: In the era of transcatheter aortic valve implantation, this study was conducted to investigate the current trend of aortic valve procedures in Korea and to evaluate the early and mid-term outcomes of isolated surgical aortic valve replacement (SAVR) using bioprosthetic valves in contemporary Korea. METHODS: Contemporary outcomes of isolated bioprosthetic SAVR in Korea were analyzed using the datasets on a multicenter basis. Patients who underwent isolated SAVR using bioprostheses from June 2015 to May 2019 were included, and those with concomitant cardiac procedures, SAVR with mechanical valve, or SAVR for infective endocarditis were excluded. A total of 456 patients from 4 large-volume centers were enrolled in this study. Median follow-up duration was 43.4 months. Early postoperative outcomes, mid-term clinical outcomes, and echocardiographic outcomes were evaluated. RESULTS: Mean age of the patients was 73.1 ± 7.3 years, and EuroSCORE II was 2.23 ± 2.09. The cardiopulmonary bypass time and aortic cross-clamp times were median 106 and 76 minutes, respectively. SAVR was performed with full median sternotomy (81.8%), right thoracotomy (14.7%), or partial sternotomy (3.5%). Operative mortality was 1.8%. The incidences of stroke and permanent pacemaker implantation were 1.1% and 1.1%, respectively. Paravalvular regurgitation ≥ mild was detected in 2.6% of the patients. Cumulative incidence of all-cause mortality at 5 years was 13.0%. Cumulative incidences of cardiovascular mortality and bioprosthetic valve dysfunction at 5 years were 7.6% and 6.8%, respectively. CONCLUSION: The most recent data for isolated SAVR using bioprostheses in Korea resulted in excellent early and mid-term outcomes in a multicenter study.

Impact of concomitant surgical atrial fibrillation ablation in patients undergoing aortic valve replacement.

BACKGROUND: The clinical benefit of concomitant atrial fibrillation (AF) ablation at the time of aortic valve replacement (AVR) is uncertain. METHODS AND RESULTS: A total of 124 patients with AF who underwent AVR with (n=50) or without (n=74) a concomitant maze procedure, between 2000 and 2011, were evaluated. There were no significant differences in early postoperative outcomes. During a median clinical follow-up of 18.1 months (interquartile range: 6.9-47.8 months), 19 late deaths (15.3%) and 33 valve-related complications (26.6%) occurred, but the differences between groups were not statistically significant. Major event-free survival at 5 years was 60.9±9.9% vs. 57.0±10.3% (P=0.41). After adjustment, the maze group demonstrated similar risks for major adverse cardiac events (hazard ratio, 1.18; 95% confidence interval, 0.56-2.49; P=0.67). However, the rate of sinus rhythm restoration at 4 years was significantly higher in the maze group (80.6% vs. 3.6%, P<0.001). Left atrial dimension was smaller (46.9 vs. 50.4mm, P=0.017), and the ejection fraction was higher (60.6% vs. 58.0%, P=0.059) in the maze group. The rate of postoperative anticoagulation was also lower in the maze group (53.1% vs. 89.2%, P<0.001). CONCLUSIONS: Concomitant AF ablation in patients undergoing AVR resulted in increased sinus rhythm restoration, better echocardiographic results, and decreased anticoagulation requirement, without increasing surgical morbidity or mortality.

Surgical Treatment of an Aneurysmal Coronary Artery Fistula between the Left Coronary Artery and Right Atrium: A Case Report.

A coronary artery fistula (CAF) is an abnormal vascular connection between the coronary arteries and the cardiac chambers or major vessels. Although rare, CAFs can lead to substantial coronary morbidity and mortality. This study outlines the surgical management of a CAF originating from the left coronary artery and connecting to the right atrium, in a patient experiencing angina with a marked left-to-right shunt. The surgical approach involved ligation of the coronary artery and reduction of the aneurysmal portion, resulting in the patient's uneventful recovery.

Mechanical versus Bioprosthetic Aortic Valve Replacement in Patients Aged 50 to 70 Years.

Background: This study compared the outcomes of surgical aortic valve replacement (AVR) in patients aged 50 to 70 years based on the type of prosthetic valve used. Methods: We compared patients who underwent mechanical AVR to those who underwent bioprosthetic AVR at our institution between January 2000 and March 2019. Competing risk analysis and the inverse probability of treatment weighting (IPTW) method based on propensity score were employed for comparisons. Results: A total of 1,580 patients (984 patients with mechanical AVR; 596 patients with bioprosthetic AVR) were enrolled. There was no significant difference in early mortality between the mechanical AVR and bioprosthetic AVR groups (0.9% vs. 1.7%, p=0.177). After IPTW adjustment, the risk of all-cause mortality was significantly higher in the bioprosthetic AVR group than in the mechanical AVR group (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.07-1.80; p=0.014). Competing risk analysis revealed lower risks of stroke (sub-distributional hazard ratio [sHR], 0.44; 95% CI, 0.28-0.67; p<0.001) and anticoagulation- related bleeding (sHR, 0.35; 95% CI, 0.23-0.53; p<0.001) in the bioprosthetic AVR group. Conversely, the risk of aortic valve (AV) reintervention was higher in the bioprosthetic AVR group (sHR, 6.14; 95% CI, 3.17-11.93; p<0.001). Conclusion: Among patients aged 50 to 70 years who underwent surgical AVR, those receiving mechanical valves showed better survival than those with bioprosthetic valves. The mechanical AVR group exhibited a higher risk of stroke and anticoagulation-related bleeding, while the bioprosthetic AVR group showed a higher risk of AV reintervention.

Volumetric and functional assessment using cardiac magnetic resonance imaging in young children exposed to acute pulmonary regurgitation: is pulmonary regurgitation just a long-term matter?

BACKGROUND: The early effect of pulmonary regurgitation (PR) on both ventricular volume and function has not been well established in children. We evaluated the early effect of PR on both ventricular volume and function in young children. METHODS: Among patients who underwent total repair of pulmonary atresia with ventricular septal defect between January 2007 and December 2008, cardiac magnetic resonance imaging (CMRI) was performed in 12 patients at a median interval of 15.6 months (6-22 months). Valveless right ventricular outflow tract (RVOT) reconstruction was performed in five patients (valveless group) and RVOT reconstruction using valved conduit in seven patients (valve group). Age and weight at operation, and the interval between the operation and CMRI were not different between the groups. RESULTS: We observed a higher pulmonary regurgitant fraction (p = 0.003), a higher right ventricular end-diastolic volume index (RVEDVI) (p = 0.003), a higher right ventricular end-systolic volume index (p = 0.003), a higher left ventricular end-diastolic volume index (p = 0.010), a higher left ventricular end-systolic volume index (p = 0.018), and a lower left ventricular ejection fraction (LVEF; p = 0.048) in the valveless group. Right ventricular ejection fraction (RVEF) was not different between two groups. The RVEDVI was negatively correlated with RVEF (rho = -0.601, p = 0.039) and LVEF (rho = -0.580, p = 0.048). CONCLUSIONS: Both ventricular volumes increased and left ventricular function was compromised, but right ventricular function was preserved early after the exposure to PR in children. Right ventricular volume was associated with both ventricular functions.

Chordae Tendineae Approximation Technique for Severe Tricuspid Regurgitation with Severe Leaflet Tethering Using a Totally Endoscopic Beating-Heart Strategy: A Case Report.

Untreated severe tricuspid regurgitation (TR) is associated with poor outcomes. Functional TR occurs secondary to dilatation of the annulus and tethering of the leaflets. Ring annuloplasty alone can correct most cases, but is insufficient in cases of severe annular dilatation due to severe leaflet tethering. In such cases, a tricuspid edge-to-edge technique may be an option. However, stitching of the leaflet tips alone is likely to result in tearing of the leaflets. Approximation of the durable chordae tendineae is considered helpful for this problem. Herein, we present the case of a 39-year-old man who had undergone openheart surgery for acute type A aortic dissection 13 months earlier. A right mini-thoracotomy approach with a beating-heart strategy was used, which did not require unnecessary pericardial adhesiolysis and dissection. This technique had the advantage of reducing the operation time and the risk of bleeding. To summarize, we present a case of tricuspid valve repair in a high-risk patient with severe leaflet tethering that was successfully managed using these methods.

Easy surgical explantation technique for sutureless Perceval S prosthesis, 'lasso technique': a case report.

BACKGROUND: Due to structural valve deterioration of sutureless aortic prosthesis, there is a need for explantation of the prothesis. We introduce a surgical technique to explant sutureless aortic prosthesis, which has a self-expanding stent incorporated into the aortic wall. CASE PRESENTATION: An 82-year-old man who had undergone sutureless aortic valve replacement 6 years previously underwent redo-aortic and mitral valve replacement because of severe prosthetic aortic valve stenosis and mitral regurgitation. The sutureless prosthesis was explanted using 'lasso technique'. The patient was discharged after 7 days without complications. CONCLUSIONS: We presented a useful technique to explant a sutureless aortic prosthesis.

Left Coronary Ostial Obstruction by a Dislocated Sutureless Aortic Valve Prosthesis: Redo Aortic Valve Replacement with Hybrid Coronary Revascularization: A Case Report.

Coronary ostium obstruction due to dislodgement of the prosthetic valve is a rare and life-threatening complication, and particular caution is required for sutureless aortic valve replacement (AVR) with concomitant valvular surgery. In general, coronary artery bypass surgery is performed when coronary ostium obstruction occurs after AVR, but other options may need to be considered in some cases. Herein, we present a case of coronary artery occlusion in an 82-year-old female patient who had undergone AVR and mitral valve replacement for aortic valve stenosis and mitral valve stenosis at the age of 77 years. A hybrid procedure involving redo AVR and percutaneous coronary intervention after left main coronary ostium endarterectomy was performed. To summarize, we present a case of hybrid AVR in a patient with coronary artery obstruction after AVR that was successfully managed using this method.

Midterm outcomes of isolated tricuspid valve surgery with a mini-thoracotomy and beating heart strategy.

Background: Isolated tricuspid valve (TV) operation is considered high-risk surgery; thus, early surgical referral is frequently discouraged. Our study aims to evaluate the outcomes of isolated TV surgery with a mini-thoracotomy and beating heart strategy. Methods: We retrospectively reviewed 25 patients [median age, 65.0 years (Q1-Q3, 59.0-72.0 years)] who had undergone mini-thoracotomy beating heart isolated TV surgery from January 2017 to May 2021. TV repair was performed in 16 patients (64.0%), and TV replacement in 9 patients (36.0%). Among them, 18 patients (72.0%) had previous cardiac surgery, including TV replacement (n=4, 16.0%) and TV repair (n=4, 16.0%). Results: The median cardiopulmonary bypass time was 75.0 minutes (Q1-Q3, 61.0-98.0 minutes). There was 1 early mortality (4.0%) due to low cardiac output syndrome. Acute kidney injury requiring dialysis occurred in 3 patients (12.0%), and a permanent pacemaker was required in 1 patient (4.0%). The median lengths of stay in the intensive care unit and hospital were 1.0 day (Q1-Q3, 1.0-2.0) and 9.0 days (Q1-Q3, 6.0-18.0), respectively. The median follow-up duration was 30.3 months (Q1-Q3, 19.2-43.8). Freedoms from overall mortality, severe tricuspid regurgitation (TR), and significant tricuspid stenosis [i.e., trans-tricuspid pressure gradient (TTPG) ≥5 mmHg] at 4 years were 89.1%, 94.4%, and 83.3%, respectively. There was no TV reoperation. Conclusions: Mini-thoracotomy beating heart strategy for isolated TV surgery showed favorable early and midterm outcomes. This strategy may be a valuable option for isolated TV operations.

Surgical edge-to-edge repair for tricuspid regurgitation: Impact of the concomitant annuloplasty.

BACKGROUND: Surgical edge-to-edge repair has been suggested for tricuspid regurgitation (TR) with complex tricuspid valve (TV) pathologies. Nevertheless, the impact of concomitant TAP has not been well established. This study aimed to compare the outcomes of tricuspid edge-to-edge repair according to the implementation of concomitant TAP. METHODS: A total of 264 patients who underwent tricuspid edge-to-edge repair between January 2001 and December 2020 were enrolled in the study, and 23 patients who had undergone previous TV repair were excluded. The remaining 241 patients were categorized into two groups: TAP (n = 190) and non-TAP (n = 51). Inverse probability of treatment weighting (IPTW) was used to adjust the baseline differences between the two groups. RESULTS: Early mortality and morbidity did not differ between the two groups. The mean follow-up duration was 111.5 ± 72.4 months. IPTW-adjusted survival analysis did not reveal a difference between the two groups in late significant tricuspid stenosis (trans-tricuspid pressure gradient ≥5 mmHg) and TV reoperations. However, freedom from overall mortality and late severe TR were significantly higher in the TAP group (p = 0.033 and 0.006, respectively). The sensitivity analysis, including propensity score matching, showed consistent results. CONCLUSION: The long-term outcomes of surgical tricuspid edge-to-edge repair were better when performed with concomitant TAP.

Tricuspid Edge-to-Edge Repair Versus Tricuspid Valve Replacement for Severe Tricuspid Regurgitation.

BACKGROUND AND OBJECTIVES: Tricuspid valve (TV) repair techniques other than annuloplasty remain challenging and frequently end in tricuspid valve replacement (TVR) in complicated cases. However, the results of TVR are suboptimal compared with TV repair. This study aimed to evaluate the clinical effectiveness of TV edge-to-edge repair (E2E) compared to TVR for severe tricuspid regurgitation (TR). METHODS: We retrospectively reviewed 230 patients with severe TR who underwent E2E (n=139) or TVR (n=91) from 2001 to 2020. Clinical and echocardiographic results were analyzed using inverse probability of treatment weighting analysis and propensity score matching. RESULTS: The two groups showed no significant differences in early mortality and morbidities. During the mean follow-up of 106.2±68.8 months, late severe TR and TV reoperation rates were not significantly different between groups. E2E group, however, showed better outcomes in overall survival (p=0.023), freedom from significant tricuspid stenosis (TS) (trans-tricuspid pressure gradient ≥5 mmHg, p=0.021), and freedom from TV-related events (p<0.001). Matched analysis showed consistent results. CONCLUSIONS: E2E for severe TR presented more favorable clinical outcomes than TVR. Our study supports that E2E might be a valuable option in severe TR surgery, avoiding TVR.

Impact of valve repair on mild tricuspid insufficiency in rheumatic mitral surgery.

OBJECTIVE: Tricuspid valve repair for mild tricuspid regurgitation during rheumatic mitral valve surgery is controversial. We evaluated the benefit of tricuspid valve repair for mild tricuspid regurgitation in rheumatic mitral valve surgery. METHODS: Among 1208 consecutive patients (52.6 ± 11.9 years) with mild tricuspid regurgitation who underwent rheumatic mitral valve surgery from 2000 to 2018 in 2 referral centers, 419 received concomitant tricuspid valve repair and 789 did not. The primary end point was the development of severe tricuspid regurgitation. Deaths were regarded as competing events. Secondary end points were death and heart failure. Inverse probability of treatment weighting was performed to reduce selection bias. Multivariable competing risk analysis was performed to determine the predictive factors of severe tricuspid regurgitation. RESULTS: There was no significant difference in early mortality rates between patients with and without tricuspid valve repair (P = .26). During a median follow-up of 71.6 (interquartile range: 25.3-124.2) months, the primary end point was detected in 7 of 419 patients (0.25%/patient-years) and 28 of 789 patients (0.57%/patient-years) with and without tricuspid valve repair, respectively (P = .04). There were no significant differences in the secondary end points. After baseline adjustment, the primary end point was not significantly different depending on the addition of tricuspid valve repair (hazard ratio, 0.64; 95% confidence interval, 0.23-1.77; P = .39). In multivariable analysis, only the omission of surgical atrial fibrillation ablation (hazard ratio, 4.52; 95% confidence interval, 2.07-9.87) was significantly associated with the development of severe tricuspid regurgitation. CONCLUSIONS: Tricuspid valve repair for mild tricuspid regurgitation in rheumatic mitral valve surgery provides no overt clinical benefit.

Patterns of genetic mutations explored by systematic screening of patients with aortopathy and their family members.

Objective: Genetic aortopathy, if left untreated, leads to aortic catastrophe in most affected individuals. We sought to determine the genetic mutation patterns and detection rates in patients with aortopathy and their families with a systematic screening protocol. Methods: In 2016 to 2020, patients with aortic dissection or root aneurysm (Z score ≥2) and their first-degree relatives were enrolled in a prospective registry at a tertiary referral center. The individuals underwent systematic single- or multi-gene panel testing depending on clinical presentations. Results: Among 575 enrolled individuals (mean age, 46.6 ± 14.5 years; 203 women), 346 (60.2%) underwent genetic testing. Rates of relevant gene mutations identified were 39.4% (91/231), 27.1% (54/199) and 72.4% (n = 105) in aneurysm, dissection, and family screening groups, respectively (P < .001). Mutated genes frequently identified were FBN1 (n = 199; Marfan), TGFBR1/2 or SMAD3 (n = 14; Loeys-Dietz), COL3A1/COL5A2 (n = 15; Ehlers-Danlos), and ACTA2 (n = 10). After enrollment, 123 aortic surgeries were performed in 117 patients (20.3%) including 15 family members, with resultant operative mortality of 0.8% (n = 1). In logistic regression analysis, systemic score in Ghent nosology was the only significant factor associated with positive gene mutation (odds ratio, 14.81; 95% confidence interval, 6.87-31.96), and its 3.5 point cutoff showed the best predictive value with 78.2% sensitivity and 87.2% specificity. Conclusions: Genetic aortopathy was identified in a considerable proportion of patients with aortopathy and their family members by systematic genetic testing. This strategy is recommended for timely diagnosis and proactive management of genetic aortopathy.

Impact of Optimal Medical Therapy on Long-Term Outcomes After Myocardial Revascularization for Multivessel Coronary Disease.

Although optimal medical therapy (OMT) after coronary revascularization is advocated for intensive secondary prevention, its criteria and effect on long-term outcomes are uncertain. Using data from the ASAN-Multivessel (Asan Medical Center-Multivessel Revascularization) registry, we identified 8,311 patients who underwent coronary artery bypass grafting (CABG) (n = 3,115) or percutaneous coronary intervention (PCI) (n = 5,196). OMT was defined as the combination of minimum of 3 medications in 4 drug classes (antiplatelet drugs, statins, ß blockers, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers). Two primary outcomes were all-cause mortality and serious composite outcome of death, spontaneous myocardial infarction, or stroke at 10 years. Of 8,311 patients, 4,321 (52.0%) followed OMT. In the 3,397 propensity-score-matched cohort, OMT status compared with non-OMT status was significantly associated with a lower risk of all-cause mortality (10.7% vs 18.7%; hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.47 to 0.65) and serious composite outcome (14.5% vs 22.5%, HR 0.635, 95% CI 0.55 to 0.73) at 10 years. The association on 10-year mortality was more prominent in the PCI group (HR 0.45, 95% CI 0.36 to 0.56) than in the CABG group (HR 0.72, 95% CI 0.58 to 0.90) with a significant interaction (p = 0.001). Overall findings were consistent using different OMT criteria (all 4 types of medications). In conclusion, OMT significantly lowered the risks of mortality and major cardiovascular events at 10 years in patients with multivessel revascularization. The OMT impact on mortality was more remarkable in the PCI group than in the CABG group. This work was registered at http://ClinicalTrials.gov (Identifier: NCT02039752).

Easy surgical explantation technique for self-expanding transcatheter aortic valve: 'lasso technique'.

A prosthesis with a self-expanding nitinol frame firmly incorporates into the aortic wall and thus is difficult to explant. We introduce a novel technique that simplifies explantation.

Effects of early postoperative shower after cardiac surgery.

BACKGROUND: Little is known regarding the effects of early showers after cardiac surgery. We evaluated the influence of early showers on postoperative wound complications following cardiac surgery. METHODS: This was a prospective observational study of 100 cardiac surgery patients (mean age, 63.0±13.5 years) who underwent early postoperative showers from September 2020 to March 2021 at our institution. Postoperative showers were initiated after the drain was removed. Postoperative wound complications were examined and patient satisfaction was evaluated using questionnaires. RESULTS: Surgery was performed through sternotomy in 48 patients (48.0%) and through minimally invasive approaches (right or left mini-thoracotomy) in 52 patients (52.0%). The mean time from surgery to shower was 6.0±1.4 days. No wound dehiscence, superficial wound infection, or deep wound infection was observed. Questionnaires showed that more than 50% of patients thought they were not allowed to shower until more than 2 weeks after the operation. Patient satisfaction score was 7.4±2.3 out of 10 for early showers after cardiac surgery. CONCLUSIONS: Our study suggests that postoperative early showers after cardiac surgery are not associated with an increased risk of wound complications. Patient satisfaction was also high. Early postoperative showering can be considered after cardiac surgery.

Surgical ablation for atrial fibrillation during aortic and mitral valve surgery: A nationwide population-based cohort study.

OBJECTIVE: There is limited evidence on the effectiveness of surgical atrial fibrillation ablation in reducing mortality or thromboembolic events during aortic/mitral valve surgery. We evaluated the association of surgical ablation versus no ablation with risks of all-cause death and ischemic stroke or systemic embolization among patients with preoperative atrial fibrillation undergoing concomitant aortic valve or mitral valve surgery. METHODS: With the use of administrative healthcare datasets from the Korean National Health Insurance Service database between 2003 and 2018, adult patients with atrial fibrillation undergoing aortic/mitral valve replacement or mitral valve repair were enrolled, and their outcomes were compared according to the performance of concomitant surgical ablation. The primary end points were all-cause death and thromboembolic event of ischemic stroke or systemic embolization. RESULTS: Among 17,247 patients with atrial fibrillation undergoing aortic/mitral valve surgery, 8716 (50.5%) received surgical ablation, whereas 8531 (49.5%) did not. During a median follow-up of 6.7 years (124,842.2 patient-years), death was less in the ablation group than in the no-ablation group (2.7 vs 4.1 patient-years; P < .001). The incidence of ischemic stroke or systemic embolization was also lower in the ablation group (0.9 vs 1.3 patient-years; P < .001). After adjustment with inverse probability of treatment weighting, surgical ablation was associated with decreased risks of all-cause death (hazard ratio, 0.86; 95% confidence interval, 0.80-0.92), ischemic stroke or systemic embolization (hazard ratio, 0.62; 95% confidence interval, 0.55-0.71), and hospitalization from heart failure (hazard ratio, 0.87; 95% confidence interval, 0.79-0.96). CONCLUSIONS: In patients with atrial fibrillation undergoing aortic/mitral valve surgery, concomitant surgical ablation was significantly associated with lower risks of mortality and thromboembolic events.

Long-term outcomes and risk factors for mortality of patients with hypertrophic obstructive cardiomyopathy undergoing septal myectomy.

Background: We aimed to evaluate the long-term surgical outcomes of patients with hypertrophic obstructive cardiomyopathy and explore the risk factors for mortality, especially those related to atrial fibrillation. Methods: We retrospectively reviewed 150 consecutive patients with hypertrophic obstructive cardiomyopathy who underwent surgical treatment between March 2003 and December 2020. Results: Fifty (33.3%, age 53.7±16.1 years) patients underwent isolated septal myectomy (SM), 79 (52.7%, age 52.3±12.6 years) underwent SM with mitral valve intervention (SM + MVI), and 21 (14.0%, age 57.1±13.5 years) underwent SM with mitral valve replacement (SM + MVR). Overall peak left ventricular outflow tract pressure gradient at rest was significantly decreased from 91.9±43.2 to 13.3±13.0 mmHg (P<0.0001). Survival rates were 96.7%, 89.1%, and 81.5% at 30 days, 5 years, and 10 years, respectively. Patients in the SM + MVI group survived longer than those in SM + MVR or isolated SM groups (94.1% vs. 75.4% vs. 88.0%, respectively, at 5 years, P=0.05). Patients with preoperative atrial fibrillation had a worse 5-year survival rate than those without atrial fibrillation (73.4% vs. 92.8%, respectively, P<0.001). Preoperative atrial fibrillation was an independent risk factor for late mortality in multivariable analysis. Notably, those whose atrial fibrillation was successfully eradicated by surgical ablation had a better 5-year survival rate than other patients (87.7% vs. 28.6%, respectively, P<0.001). Conclusions: Surgical outcomes in hypertrophic obstructive cardiomyopathy are favorable in the long-term, except in patients with preoperative atrial fibrillation. Therefore, intraoperative ablation for preoperative atrial fibrillation in hypertrophic obstructive cardiomyopathy should be actively considered to improve patient outcomes.