Routine left atrial appendage ligation during cardiac surgery may prevent postoperative atrial fibrillation-related cerebrovascular accident.

OBJECTIVE: The aim of the study was to determine whether routine left atrial appendage ligation in cardiac surgery would reduce the risk of postoperative atrial fibrillation-related cerebrovascular accident. METHODS: We performed an institutional review board-approved, case-control, retrospective chart review of adult patients who underwent cardiac surgery by a single surgeon between January 1, 2001, and December 31, 2010. Preoperative CHADS(2) score criteria were collected, and outcomes through postoperative day 30 were analyzed. RESULTS: A total of 2067 patients were reviewed. Propensity score matching was used to create matched groups based on left atrial appendage ligation, and 631 patients were matched in each group. Subjects with postoperative atrial fibrillation were 2.4 times (95% confidence interval, 1.51-2.82) more likely to undergo valve surgery, 2.11 times (95% confidence interval, 1.56-2.86) more likely to be aged more than 75 years, and 1.36 times (95% confidence interval, 1.03-1.80) more likely to have undergone left atrial appendage ligation. In the left atrial appendage ligation group with postoperative atrial fibrillation (n = 145), there were zero subjects (0%) with a postoperative cardiovascular accident. In the non-left atrial appendage ligation group with postoperative atrial fibrillation (n = 115), there were 7 subjects (6.1%) with a postoperative cardiovascular accident (0.0% vs 6.1%, P = .003). CONCLUSIONS: Although postoperative atrial fibrillation remains a common complication of cardiac surgery, there was a significant decrease in the incidence of postoperative cerebrovascular accidents since routine ligation of the left atrial appendage was undertaken. This has been found to be a safe adjunct to a wide variety of cardiac procedures and therefore deserves further study by a larger randomized controlled trial.

Outcomes of the RESTOR-MV Trial (Randomized Evaluation of a Surgical Treatment for Off-Pump Repair of the Mitral Valve).

OBJECTIVES: we sought to determine whether patients with functional mitral regurgitation (FMR) would benefit from ventricular reshaping by the Coapsys device (Myocor, Inc., Maple Grove, Minnesota). BACKGROUND: FMR occurs when ventricular remodeling impairs valve function. Coapsys is a ventricular shape change device placed without cardiopulmonary bypass to reduce FMR. It compresses the mitral annulus and reshapes the ventricle. We hypothesized that Coapsys for FMR would improve clinical outcomes compared with standard therapies. METHODS: RESTOR-MV (Randomized Evaluation of a Surgical Treatment for Off-Pump Repair of the Mitral Valve) was a randomized, prospective, multicenter study of patients with FMR and coronary disease with core laboratory analysis. After enrollment, patients were stratified to the standard indicated surgery: either coronary artery bypass graft alone or coronary artery bypass graft with mitral valve repair. In each stratum, randomization was to either control (indicated surgery) or treatment (coronary artery bypass graft with Coapsys ventricular reshaping). RESULTS: the study was terminated when the sponsor failed to secure ongoing funding; 165 patients were randomized. Control and Coapsys both produced decreases in left ventricular (LV) end-diastolic dimension and MR at 2 years (p < 0.001); Coapsys provided a greater decrease in LV end-diastolic dimension (p = 0.021). Control had lower MR grades during follow-up (p = 0.01). Coapsys showed a survival advantage compared with control at 2 years (87% vs. 77%) (hazard ratio: 0.421; 95% confidence interval: 0.200 to 0.886; stratified log-rank test; p = 0.038). Complication-free survival (including death, stroke, myocardial infarction, and valve reoperation) was significantly greater with Coapsys at 2 years (85% vs. 71%) (hazard ratio: 0.372; 95% confidence interval: 0.185 to 0.749; adjusted log-rank test; p = 0.019). CONCLUSIONS: analysis of RESTOR-MV indicates that patients with FMR requiring revascularization treated with ventricular reshaping rather than standard surgery had improved survival and a significant decrease in major adverse outcomes. This trial validates the concept of the ventricular reshaping strategy in this subset of patients with heart failure. (Randomized Evaluation of a Surgical Treatment for Off-Pump Repair of the Mitral Valve [RESTOR-MV]; NCT00120276).