Safety and efficacy of concomitant ablation for atrial fibrillation in rheumatic mitral valve surgery: A meta-analysis.

OBJECTIVES: This review aimed to evaluate the safety and efficacy of concomitant surgical ablation (SA) for patients with atrial fibrillation (AF) undergoing rheumatic mitral valve (MV) surgery. METHODS: A systematic search of relevant studies focusing on SA for patients with AF undergoing rheumatic MV surgery was performed. The primary outcomes included mortality, efficacy, and complications. RESULTS: Four randomized controlled trials (RCTs) and four observational studies covering 1931 patients met the inclusion criteria. In RCTs, no significant differences in reoperation for bleeding, low cardiac output syndrome, thromboembolic events, and early (risk ratio [RR], 2.07; 95% confidence intervals [CI], 0.37-11.40; p = .41) and midterm all-cause death (RR, 1.07; 95% CI, 0.40-2.88; p = .89) were noted between the SA group and the nonablation group. These results were similar to those obtained from observational studies. However, ablation was associated with a higher incidence of permanent pacemaker implantation (RR, 2.44; 95% CI, 1.15-5.18; p = .02) in observational studies but not in RCTs (RR, 2.03; 95% CI, 0.19-21.26; p = .56). Furthermore, additional SA was significantly more effective in sinus rhythm (SR) restoration than MV surgery alone at discharge and at the 12-month and 3-year follow-ups. CONCLUSIONS: Concomitant SA during rheumatic MV surgery does not increase perioperative adverse events. In addition, SA promotes considerable restoration of SR. Although some evidence exists that permanent pacemaker implantation is more common after ablation, not all studies support this notion.

Quadrangular resection versus chordal replacement for degenerative posterior mitral leaflet prolapse.

BACKGROUND: The aims of the present study was to compare midterm results of quadrangular leaflet resection versus chordal replacement for the repair of degenerative posterior mitral leaflet (PML) prolapse, and to explore the risk factors for recurrent severe mitral regurgitation (MR). METHODS: From January 2012 to December 2018, 1,423 consecutive patients underwent mitral valve (MV) repair. A total of 317 had degenerative PML prolapse and constituted the study population. Of these, 74 (23.3%) underwent quadrangular leaflet resection, and 243 (76.7%) underwent chordal replacement. Outcomes were compared by using unadjusted data and propensity score-matched analyses. RESULTS: Patients with multiple leaflet prolapse were more likely to undergo chordal replacement (18.4% vs. 41.9%, P<0.001), and performed as a minimally invasive approach (47.3% vs. 61.7%, P=0.027). Of the entire cohort, 1 death (0.3%) occurred due to intraoperative aortic dissection, and 1 patient who had undergone chordal replacement required reoperation before discharge for posterior leaflet tearing. There was no significant difference in the probability of freedom from recurrent severe MR at 82 months between the resection and neochordae groups in both the pre-matched (95.6% vs. 88.8%, P=0.105) and matched (95.2% vs. 88.5%, P=0.170) cohorts, which was consistent across all of the examined subgroups (P>0.05). Multivariate Cox regression indicated that dilated left ventricular end-systolic diameter (LVESD) was an independent risk factor for recurrent severe MR [<40 vs. >40 mm, hazards ratio (HR): 3.17, 95% confidence interval (CI): 1.20-8.39, P=0.020]; however, surgical technique was not (resection vs. neochordae, HR: 0.31, 95% CI: 0.07-1.37, P=0.122). CONCLUSIONS: Chordal replacement for the repair of degenerative posterior MV prolapse yields similar satisfactory outcomes when compared with quadrangular resection, and is promising in minimally invasive cardiac surgery for various lesions. However, it is also associated with more recurrent severe MR, albeit non-significant, for which patients with dilated LVESD are at high risk.