Hybrid atrial fibrillation ablation in patients with persistent atrial fibrillation or failed catheter ablation.

BACKGROUND: Combined 'hybrid' thoracoscopic and percutaneous atrial fibrillation (AF) ablation is a strategy used to treat AF in patients with therapy-resistant symptomatic AF. We aimed to study efficacy and safety of single-stage hybrid AF ablation in patients with symptomatic persistent AF, or paroxysmal AF with failed endocardial ablation, and assess determinants of success and quality of life. METHODS: We included consecutive patients undergoing single-stage hybrid AF ablation. First, we performed epicardial ablation, via thoracoscopic access, to isolate the pulmonary veins and superior caval vein and to create a posterior left atrial box. Thereafter, isolation was assessed endocardially and complementary endocardial ablation was performed, followed by cavotricuspid isthmus ablation. Efficacy was assessed by 12-lead electrocardiography and 72-hour Holter monitoring after 3, 6 and 12 months. Recurrence was defined as AF/atrial flutter/tachycardia recorded by electrocardiography or Holter monitoring lasting >30 s during 1­year follow-up. RESULTS: Fifty patients were included, 57 ± 9 years, 38 (76%) men, 5 (10%) paroxysmal, 34 (68%) persistent and 11 (22%) long-standing persistent AF. At 1­year 38 (76%) maintained sinus rhythm off antiarrhythmic drugs. Majority of recurrences were atrial flutter (9/12 patients). Success was associated with type of AF (p = 0.039). Patients with paroxysmal AF had highest success, patients with longstanding persistent AF had lowest success. Seven (14%) patients had procedure-related complications. Quality of life improved after ablation in patients who maintained sinus rhythm. CONCLUSION: Success of single-stage hybrid AF ablation was 76% off antiarrhythmic drugs, being associated with type of AF. Quality of life improved significantly, Procedure-related complications occurred in 14%.

Early results with bilateral internal mammary artery grafting in coronary reoperations.

In recent years, use of the internal mammary artery (IMA) as first graft of choice has been expanded with bilateral and sequential grafts in primary myocardial revascularization. The use of bilateral IMA grafts in reoperation has seldom been reported. The experience and early results with bilateral IMA grafting in 47 patients undergoing coronary reoperation are described. Hospital mortality was 6.3%. Four patients had postoperative signs of low cardiac output, and 4 had a perioperative myocardial infarction. At follow-up (18 +/- 18 months), 2 cardiac-related, late deaths were noted. Thirteen patients (29%) improved 1 New York Heart Association class, and 28 (63%) improved > 1 class. In 1 of 44 surviving patients, operation did not result in a decrease in angina. On the basis of the early results, the bilateral use of the IMA in coronary reoperation appears justified.

Experience and early results of second reoperations for coronary artery disease. Should patent vein grafts be replaced during reoperation?

Reoperation for coronary artery disease has become a routine procedure; however, a second reoperation is exceptional. In this report we describe our experience with 16 patients undergoing a second reoperation for coronary atherosclerosis. The absence of operative mortality is certainly related to the patient selection. The number of patients is still too small to draw major conclusions. Striking, however, is that the first reoperation was usually done for angina because of progression of atherosclerosis in the native coronary system and the second reoperation was done because of graft failure. This experience supports the idea that the replacement of old, even patent, venous grafts and the choice of the best available conduits are of great importance at the first reoperation and may prevent a second reoperation.

Delayed sequelae of penetrating chest trauma: a plea for early sternotomy.

Penetrating wounds of the anterior chest wall are often associated with cardiac tamponade. Eighty to ninety percent of stab wounds to the heart result in acute tamponade, whereas delayed cardiac tamponade or hemothorax are rare, but hurtful for the patient. Of the cases reviewed, fifty percent of the patients who underwent sternotomy required repair of cardiac injuries. The presented case report adds further justification for early sternotomy in case of precordial penetrating chest injury in the danger zone.

[The biopsying of at least 5 mediastinal lymph node stations for presurgical staging in patients with a non-small-cell lung carcinoma]. / Minstens 5 mediastinale lymfeklierstations biopteren voor de preoperatieve stadiëring van patiënten met een niet-kleincellig bronchuscarcinoom.

OBJECTIVE: To determine the additional value of mediastinoscopy/tomy in the pre-surgical staging of non-small-cell lung carcinoma. DESIGN: Retrospective. METHODS: Patients who underwent mediastinoscopy/tomy for staging of non-small-cell lung carcinoma from 1994 to 2000 at Groningen University Hospital, the Netherlands, were evaluated. Starting with data on history, physical examination, data imaging tests and bronchoscopy, the additional value of the mediastinoscopy was then evaluated using a logistic regression model. Not only was the additional value of a limited, routinely performed mediastinoscopy (whereby only lymph nodes at the site of the primary tumour are biopsied) examined, but also that of the comprehensive standard mediastinoscopy (conforming to the minimal requirements regarding number and localization of biopsied lymph nodes, i.e. lymph-node stations 2L, 2R, 4R, 4L, 7). The outcome against which all the test results were measured was the result of final pathological tumour staging. RESULTS: A total of 176 evaluable patients were included. History, physical examination and bronchoscopy played a small but significant role in predicting the percentage of patients in which resection was possible, 58% (95% CI: 50-67). Age was an important predictor. The subsequent addition of the limited and routinely performed mediastinoscopy to the model increased the correct prediction to 69% (95% CI: 61-77), while adding the standard mediastinoscopy to the model showed a significantly higher correct prediction of 81% (95% CI: 75-88). CONCLUSION: The standard mediastinoscopy involving a minimum of five different lymph node stations was of greater diagnostic value than limited mediastinoscopy.

Oesophageal endoscopic ultrasound with fine needle aspiration improves and simplifies the staging of lung cancer.

BACKGROUND: Positron emission tomography (PET) is accurate for mediastinal staging of lung cancer but has a moderate positive predictive value, necessitating pathological verification. Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) is a technique for tissue verification of mediastinal and upper retroperitoneal abnormalities. The use of EUS-FNA may decrease the number of surgical procedures and thereby staging costs. METHODS: EUS-FNA was used prospectively for the cytological assessment of mediastinal and/or upper retroperitoneal PET hot spots in patients with suspected lung cancer. Only if EUS-FNA was positive for malignancy was subsequent mediastinoscopy or exploratory thoracotomy cancelled. The cost effectiveness of EUS-FNA was determined. RESULTS: Of 488 consecutive patients with suspected lung cancer, 81 were enrolled with mediastinal and/or upper retroperitoneal PET hot spots. EUS-FNA was positive in 50 (62%) patients, negative in six, and inconclusive in 25. Of the 31 negative or inconclusive patients, 26 underwent surgical staging (resulting in 14 patients with and 12 without mediastinal malignancy), while five patients had mediastinal metastases during follow up. No EUS-FNA related morbidity or mortality was encountered. The accuracy of the decision to proceed to surgery (or not) on the basis of EUS-FNA was 77% (95% CI 68 to 86). EUS-FNA detected more mediastinal abnormalities than PET except for the upper mediastinal region. Addition of EUS-FNA to conventional lung cancer staging reduced staging costs by 40% per patient, mainly due to a decrease in surgical staging procedures. CONCLUSION: EUS-FNA can replace more than half of the surgical staging procedures in lung cancer patients with mediastinal and/or upper retroperitoneal PET hot spots, thereby saving 40% of staging costs.