Surgical options for atrial fibrillation treatment during concomitant cardiac procedures.

Current guidelines recommend concomitant surgical ablation (SA) of atrial fibrillation (AF) in the context of mitral valve disease. A variety of energy sources have been tested for SA to perform effective transmural lesions reliably. To date, only radiofrequency and cryothermy energies are considered viable options. The gold standard for SA is the Cox-Maze ablation set, especially for non-paroxysmal AF (nPAF), with the aim of interrupting macro-reentrant drivers perpetuating AF, without hampering the sinus node activation of both atria, and to maintain the atrioventricular synchrony. Although the efficacy of SA in terms of early and late sinus rhythm restoration has been clearly demonstrated over the years, concomitant AF ablation is still underperformed in patients with AF undergoing cardiac surgery. From a surgical standpoint, concerns have been raised about whether a single (left) or double atriotomy would be justified in AF patients undergoing a "non-atriotomy" surgical procedure, such as aortic valve or revascularization surgery. Thus, an array of simplified lesion sets have been described in the last decade, which have unavoidably hampered procedural efficacy, somewhat jeopardizing the standardization process of ablation surgery. As a matter of fact, the term "Maze" has improperly become a generic term for SA. Surgical interventions that do not align with the principles of forming conduction-blocking lesions according to the Maze pattern, cannot be classified as Maze procedures. In this complex scenario, a tailored approach according to the different AF patterns has been proposed: for patients with concomitant nPAF, a biatrial Cox-Maze ablation is recommended. Conversely, it might be reasonable to limit lesions to the left atrium or the pulmonary veins in patients with paroxysmal AF (PAF) in some clinical scenarios. The aim of this review is to provide an overview of the current ablation strategies for patients with AF undergoing concomitant cardiac surgery.

Hybrid strategies for stand-alone surgical ablation of atrial fibrillation.

Atrial fibrillation (AF) has been reported as a major cause of cardiac morbidity and mortality, and significantly reduces the quality of life in symptomatic patients. Current guidelines recommend antiarrhythmic drugs and catheter ablation (CA) as first-line therapy. Despite CA showed to be associated with lower incidence of peri-procedural complications, rhythm outcomes are far from optimal. Indeed, patients undergoing CA frequently require multiple AF ablation procedures, especially in those with persistent and long-standing persistent AF. While surgical ablation can provide transmural lesions, surgical invasiveness has limited the widespread use of this approach due to the increased perioperative complications. The development of minimally invasive thoracoscopic approaches has renewed the interest towards surgical ablation, thus favoring more simplified ablation sets. Therefore, the concept of "hybrid" ablation has emerged in order to theoretically enhance advantages of both minimally invasive and CA procedures while seeking to improve rhythm outcomes and reduce invasiveness and incidence of perioperative complications. On one hand, it provides the effectiveness of a surgical ablation, on the other, electrical mapping during CA can identify and treat any ablation gap or provide additional ablation lines, thus improving the chance of a stable sinus rhythm restoration at long-term follow-up. Three main thoracoscopic strategies are currently available. All of them can be performed in conjunction with the "catheter ablation procedure": the "Fusion" technique, the bipolar clamp technique, and the most recent "convergent" technique. CA can be performed either simultaneously or with a staged approach after a blanking period in order to allow the ablation lesion to stabilize. Excellent results of the hybrid procedures have been reported in terms of rhythm outcomes and incidence of perioperative complications. This narrative review aims to discuss the rationale behind the concept of hybrid ablation for the treatment of AF regarding different available strategies, results and expert opinions.

Mitral valve surgery in acute infective endocarditis: long-term outcomes of mitral valve repair versus replacement.

AIMS: Timing and surgical strategies in acute infective endocarditis are still questionable. We sought to investigate clinical outcomes of patients undergoing mitral valve repair (MVR) compared with mitral valve replacement [mitral valve prosthesis (MVP)] for acute infective endocarditis. METHODS: From 2004 to 2019, 109 consecutive patients with acute mitral valve infective endocarditis were retrospectively investigated. Patients were divided into two groups according to surgical strategy: MVR 53/109 (48.6%) versus MVP 56/109 (51.4%). Primary end points were in-hospital mortality and overall survival at 10 years. Secondary end point was the freedom from infective endocarditis relapse. RESULTS: Our institutional surgical approach for infective endocarditis allowed us to achieve MVR in 48.6% of patients. Hospital mortality was comparable between the two groups [MVR: 1/53 (1.9%) versus MVP: 2/56 (3.6%), P  = 1.000]. Overall 10-year survival was 80.0 ±â€Š14.1 and 77.2 ±â€Š13.5% for MVR and MVP, respectively ( P  = 0.648). MVR showed a lower incidence of infective endocarditis relapse compared with MVP (MVR: 93.6 ±â€Š7.1 versus MVP: 80.9 ±â€Š10.8%, P  = 0.041). At Cox regression, infective endocarditis relapse was an independent risk factor for death (hazard ratio 4.03; 95% confidence interval 1.41-11.52; P  = 0.009). CONCLUSION: The tendency to postpone surgery in stable patients with mitral infective endocarditis allowed achievement of MVR in almost 50% of patients. Although repair remains the approach of choice in our institution, no differences between MVR and MVP were reported in terms of early/late survival. However, MVP had a higher incidence of infective endocarditis relapse that represents an independent risk of mortality.

Del Nido cardioplegia in adult cardiac surgery: Clinical outcomes in a single center all-comer study.

INTRODUCTION: The use of Del Nido Cardioplegia (DNC) has been extended in the latest years from pediatrics to adult cardiac surgery with encouraging results. We sought to investigate clinical and biochemical outcomes in adult patients who underwent cardiac surgery with different degrees of complexity who received DNC for myocardial protection. METHODS: Data on one-thousand patients were retrospectively collected from 2020 to 2022. The only exclusion criteria was off-pump adult cardiac surgery. Surgical procedures weight was categorized according EuroSCORE II in six groups: Single-CABG(G1), isolated non-CABG(mitral) (G2), isolated non-CABG(aortic) (G3), isolated non-CABG(any) (G4), 2-procedures(G5), 3/more-procedures(G6). Primary endpoint was to identify a binomial correlation between hs-TnT/CK-MB and the cross-clamp time (X-Clamp). A secondary endpoint was the comparison between the treatment groups of the vasoactive-inotropic score (VIS) and the need of mechanical circulatory support (MCS). RESULTS: A linear correlation was identified between hs-TnT and X-clamp in the overall population (rho:0.447, p< .001) and in the treatment groups (G1:rho=0.357, p< .001/G2:rho=0.455, p< .001/G3:rho=0.307, p= .001/G4:rho=0.165, p= .257/G5:rho=0.157, p= .031/G6:rho=0.226, p= .015). Similarly, a linear correlation between CK-MB and X-clamp in the overall population (rho=0.457, p< .001) and treatment group (G1:rho=0.282, p< .001/G2:rho=0.287, p= .025/G3:rho=0.211, p= .009/G4:rho=0.0878, p= .548/G5:rho=0.309, p< .001/G6: rho=0.212, p= .024) was identified. As regard for the secondary endpoint, no differences were reported between the treatment groups in terms of VIS and MCS (VIS G1:7; G2:4; G3:7; G4:7, G5:5.5, G6:6, p-value= .691) (MCS G1: 4.5%; G2:4.8%; G3:3.3%; G4:3.1%; G5:1.4%; G6:5.3%; p-value= .372). CONCLUSIONS: Del Nido Cardioplegia is a safe and useful tool in adult cardiac surgery allowing operators to achieve a stable and durable cardioplegic arrest. Despite accounting with different types of surgery, the six subgroups of our study population showed similar perioperative results.

Left Atrium Volume Reduction Procedure Concomitant With Cox-Maze Ablation in Patients Undergoing Mitral Valve Surgery: A Meta-Analysis of Clinical and Rhythm Outcomes.

BACKGROUND: The management of an enlarged left atrium (LA) in mitral valve (MV) disease with atrial fibrillation (AF) is still being debated. It has been postulated that a reduction in LA size may improve patient outcomes. This meta-analysis aimed to assess rhythm and clinical outcomes of combined surgical AF treatment with or without LA volume reduction (LAVR) in patients undergoing MV surgery. METHODS: A systematic review was performed and all available literature to May 2022 was included. The primary endpoint was analysis of early and late mortality and rhythm outcomes. Secondary outcomes included early and late cerebrovascular accident (CVA) and permanent pacemaker implantation. RESULTS: The search strategy yielded 2,808 potentially relevant articles, and 19 papers were eventually included. The pooled estimated rate of 30-day mortality was 3.76% (95% CI 2.52-5.56). The incidence rate of late mortality and late cardiac-related mortality was 1.75%/year (95% CI 0.63-4.84) and 1.04%/year (95% CI 0.31-3.53), respectively. At subgroup analysis when comparing the surgical procedure with and without AF ablation, the ablation subgroup showed a significantly lower rate of postoperative CVA (p<0.0001) and higher restoration to sinus rhythm at discharge (p=0.0124), with only a trend of lower AF recurrence at 1 year (p=0.0608). At univariable meta-regression, reintervention was significantly associated with higher late mortality (p=0.0033). CONCLUSION: In enlarged LA undergoing MV surgery, LAVR combined with AF ablation showed a trend of improved rhythm outcomes when compared with AF ablation without LAVR. Each LAVR technique has its advantages and disadvantages, which must be managed accordingly.

Sutureless versus transcatheter valves in patients with aortic stenosis at intermediate risk: A multi-institutional European study.

BACKGROUND: Recent randomized controlled trials showed comparable short-term outcomes of transcatheter aortic valve implantation versus surgical aortic valve replacement in intermediate and low-risk patients. However, independent studies comparing transcatheter aortic valve implantation results versus surgical aortic valve replacement at 5 years showed worsening outcomes in patients treated with transcatheter aortic valve implantation. The aim of this study was to analyze mid- to long-term outcomes of patients with isolated aortic stenosis and an intermediate-risk profile who underwent aortic valve replacement using a sutureless valve versus transcatheter aortic valve implantation. METHODS: This retrospective multi-institutional European study investigated 2,123 consecutive patients with isolated aortic stenosis at intermediate risk profile treated with sutureless aortic valve replacement (824 patients) or transcatheter aortic valve implantation (1,299 patients) from 2013 to 2020. After 1:1 propensity score matching, 2 balanced groups of 517 patients were obtained. Primary endpoints were as follows: 30 days, late all-cause, and cardiac-related mortality. Secondary endpoints included major adverse cardiocerebrovascular events (all-cause death, stroke/transient ischemic attack, endocarditis, reoperation, permanent pacemaker implantation, and paravalvular leak grade ≥2). RESULTS: Median follow-up was 4.3 years (interquartile range 1.1-7.4 years). Primary endpoints were as follows-30-day mortality sutureless aortic valve replacement: 2.13% versus transcatheter aortic valve implantation: 4.64% (P = .026), all-cause mortality sutureless aortic valve replacement: 36.7% ± 7.8% vs transcatheter aortic valve implantation: 41.8% ± 8.2% (P = .023), and cardiac-related mortality sutureless aortic valve replacement: 10.2% ± 2.8% vs transcatheter aortic valve implantation: 19.2% ± 3.5%;(P = .00043) at follow-up. Secondary endpoints were as follows-major adverse cardiocerebrovascular events in the sutureless aortic valve replacement group: 47.2% ± 9.0% versus transcatheter aortic valve implantation: 57.3% ± 7.5% (P < .001). In particular, the incidence of permanent pacemaker implantation (sutureless aortic valve replacement: 6.38% versus transcatheter aortic valve implantation: 11.8% [P = .002]) and paravalvular leak ≥2 (sutureless aortic valve replacement: 0.97% versus transcatheter aortic valve implantation: 4.84% [P = .001]) was significantly higher in transcatheter aortic valve implantation group. At Multivariable Cox regression analysis, paravalvular leak ≥2 (hazard ratio: 1.63%; 95% confidence interval: 1.06-2.53, P = .042) and permanent pacemaker implantation (hazard ratio: 1.49%; 95% confidence interval: 1.02-2.20, P = .039) were identified as predictors of mortality. CONCLUSION: Sutureless aortic valve replacement showed a significantly lower incidence of all-cause mortality, cardiac-related death, permanent pacemaker implantation, and paravalvular leak than transcatheter aortic valve implantation. Moreover, permanent pacemaker implantation and paravalvular leak negatively affected survival in patients treated for isolated aortic stenosis.

Sutureless and Rapid Deployment vs. Transcatheter Valves for Aortic Stenosis in Low-Risk Patients: Mid-Term Results.

BACKGROUND: Recent trials showed that TAVI is neither inferior nor superior to surgical aortic valve replacement. The aim of this study was to evaluate the outcomes of Sutureless and Rapid Deployment Valves (SuRD-AVR) when compared to TAVI in low surgical risk patients with isolated aortic stenosis. METHODS: Data from five European Centers were retrospectively collected. We included 1306 consecutive patients at low surgical risk (EUROSCORE II < 4) who underwent aortic valve replacement by means of SuRD-AVR (n = 636) or TAVI (n = 670) from 2014 to 2019. A 1:1 nearest-neighbor propensity-score was performed, and two balanced groups of 346 patients each were obtained. The primary endpoints of the study were: 30-day mortality and 5-year overall survival. The secondary endpoint was 5-year survival freedom from major adverse cardiovascular and cerebrovascular events (MACCEs). RESULTS: Thirty-day mortality was similar between the two groups (SuRD-AVR:1.7%, TAVI:2.0%, p = 0.779), while the TAVI group showed a significantly lower 5-year overall survival and survival freedom from MACCEs (5-year matched overall survival: SuRD-AVR: 78.5%, TAVI: 62.9%, p = 0.039; 5-year matched freedom from MACCEs: SuRD-AVR: 64.6%, TAVI: 48.7%, p = 0.004). The incidence of postoperative permanent pacemaker implantation (PPI) and paravalvular leak grade ≥ 2 (PVL) were higher in the TAVI group. Multivariate Cox Regression analysis identified PPI as an independent predictor for mortality. CONCLUSIONS: TAVI patients had a significantly lower five-year survival and survival freedom from MACCEs with a higher rate of PPI and PVL ≥ 2 when compared to SuRD-AVR.

Cerebral Perfusion and Neuromonitoring during Complex Aortic Arch Surgery: A Narrative Review.

Complex ascending and aortic arch surgery requires the implementation of different cerebral protection strategies to avoid or limit the probability of intraoperative brain damage during circulatory arrest. The etiology of the damage is multifactorial, involving cerebral embolism, hypoperfusion, hypoxia and inflammatory response. These protective strategies include the use of deep or moderate hypothermia to reduce the cerebral oxygen consumption, allowing the toleration of a variable period of absence of cerebral blood flow, and the use of different cerebral perfusion techniques, both anterograde and retrograde, on top of hypothermia, to avoid any period of intraoperative brain ischemia. In this narrative review, the pathophysiology of cerebral damage during aortic surgery is described. The different options for brain protection, including hypothermia, anterograde or retrograde cerebral perfusion, are also analyzed, with a critical review of the advantages and limitations under a technical point of view. Finally, the current systems of intraoperative brain monitoring are also discussed.

Thoracoscopic Surgical Ablation of Lone Atrial Fibrillation: Long-term Outcomes at 7 Years.

BACKGROUND: Antiarrhythmic drugs and transcatheter ablation in atrial fibrillation (AF) provide suboptimal rhythm control with a not negligible rate of failure in paroxysmal AF (PAF) and nonparoxysmal AF (n-PAF) at midterm and long-term follow-up. This study evaluated the safety profile and long-term efficacy of thoracoscopic ablation in patients with lone AF. METHODS: A consecutive 153 patients with lone AF were prospectively enrolled and underwent thoracoscopic surgical ablation. Inclusion criteria were symptomatic AF refractory to pharmacologic therapy (Vaughan-Williams class I-III), age >18 years, and absence of left atrial thrombosis. Exclusion criteria were long-standing AF >5 years, left atrial diameter >55 mm, and contraindication to oral anticoagulation. The "box lesion set" (encircling of pulmonary veins) was always used. Exclusion of the left atrial appendage was performed only in selected cases. The primary study end point was freedom from AF. Secondary end points were overall survival and cumulative incidence function of cardiac event-related death, cerebrovascular accidents, and pacemaker implantation. RESULTS: There was no in-hospital mortality. Early postoperative complications were pacemaker implantation (4/153 [2.6%]), cerebrovascular accident (2/153 [1.3%]) with full recovery of both, and bleeding requiring surgical revision (2/153 [1.3%]). Overall freedom from AF at 7 years was 86% ± 4% (76.9% in n-PAF, 96.1% in PAF). Survival freedom from AF in patients without antiarrhythmic drugs in PAF and n-PAF groups was 79.1% and 52.2%, respectively. CONCLUSIONS: Thoracoscopic surgical ablation of lone AF by means of an isolated left atrial box lesion provided an excellent long-term rhythm outcome, even in long-standing persistent AF. The isolated left atrial ablation showed an excellent safety profile with low incidence of pacemaker implantation and postoperative complications.

Perceval valve intermediate outcomes: a systematic review and meta-analysis at 5-year follow-up.

OBJECTIVES: New technologies for the treatment of Aortic Stenosis are evolving to minimize risk and treat an increasingly comorbid population. The Sutureless Perceval Valve is one such alternative. Whilst short-term data is promising, limited mid-term outcomes exist, until now. This is the first systematic review and meta-analysis to evaluate mid-term outcomes in the Perceval Valve in isolation. METHODS: A systematic literature review of 5 databases was performed. Articles included evaluated echocardiographic and mortality outcomes beyond 5 years in patients who had undergone Perceval Valve AVR. Two reviewers extracted and reviewed the articles. Weighted estimates were performed for all post-operative and mid-term data. Aggregated Kaplan Meier curves were reconstructed from digitised images to evaluate long-term survival. RESULTS: Seven observational studies were identified, with a total number of 3196 patients analysed. 30-day mortality was 2.5%. Aggregated survival at 1, 2, 3, 4 and 5 years was 93.4%, 89.4%, 84.9%, 82% and 79.5% respectively. Permanent pacemaker implantation (7.9%), severe paravalvular leak (1.6%), structural valve deterioration (1.5%), stroke (4.4%), endocarditis (1.6%) and valve explant (2.3%) were acceptable at up to mid-term follow up. Haemodynamics were also acceptable at up mid-term with mean-valve gradient (range 9-13.6 mmHg), peak-valve gradient (17.8-22.3 mmHg) and effective orifice area (1.5-1.8 cm2) across all valve sizes. Cardiopulmonary bypass (78 min) and Aortic cross clamp times (52 min) were also favourable. CONCLUSION: To our knowledge, this represents the first meta-analysis to date evaluating mid-term outcomes in the Perceval Valve in isolation and demonstrates good 5-year mortality, haemodynamic and morbidity outcomes. KEY QUESTION: What are the mid-term outcomes at up to 5 years follow up in Perceval Valve Aortic Valve Replacement? KEY FINDINGS: Perceval Valve AVR achieves 80% freedom from mortality at 5 years with low valve gradients and minimal morbidity. KEY OUTCOMES: Perceval Valve Aortic Valve Replacement has acceptable mid-term mortality, durability and haemodynamic outcomes.

Rhythm outcomes of minimally-invasive off-pump surgical versus catheter ablation in atrial fibrillation: A meta-analysis of reconstructed time-to-event data.

BACKGROUND: Mid- and long-term rhythm outcomes of catheter ablation (CA) for atrial fibrillation (AF) are reported to be suboptimal. Minimally invasive surgical off-pump ablation (MISOA), including both thoracoscopic and trans-diaphragmatic approaches, has been developed to reduce surgical invasiveness and overcome on-pump surgery drawbacks. We sought to compare the efficacy and safety of MISOA and CA for AF treatment. METHODS: A systematic review and meta-analysis of the literature was performed including studies comparing MISOA and CA. The primary endpoint was survival freedom from AF at follow-up after a 3-month blanking period. Subgroup analysis of the primary endpoint was performed according to the type of surgical incision and hybrid approach. RESULTS: Freedom from AF at 4 years was 52.1% ± 3.2% vs 29.1% ± 3.5%, between MISOA and CA respectively (log-rank p < 0.001; Hazard Ratio: 0.60 [95%Confidence Interval (CI):0.50-0.72], p < 0.001). At landmark analysis, a significant improvement in rhythm outcomes was observed in the MISOA group after the 5th month of follow-up (2 months from the blanking period). The Odds Ratio between MISOA and CA of postoperative cerebrovascular accident incidence and postoperative permanent pacemaker implant (PPM) were 2.00 (95%CI:0.91-4.40, p = 0.084) and 1.55 (95%CI:0.61-3.95, p = 0.358), respectively. The incidence rate ratio of late CVA between MISOA and CA was 0.86 (95%CI:0.28-2.65, p = 0.787), while for late PPM implant was 0.45 (95%CI:0.11-1.78, p = 0.256). CONCLUSIONS: The current meta-analysis suggests that MISOA provides superior rhythm outcomes when compared to CA in terms of sinus rhythm restoration. Despite the rhythm outcome superiority of MISOA, it is associated to higher postoperative complications compared to CA.

Deep learning to detect significant coronary artery disease from plain chest radiographs AI4CAD.

BACKGROUND: The predictive role of chest radiographs in patients with suspected coronary artery disease (CAD) is underestimated and may benefit from artificial intelligence (AI) applications. OBJECTIVES: To train, test, and validate a deep learning (DL) solution for detecting significant CAD based on chest radiographs. METHODS: Data of patients referred for angina and undergoing chest radiography and coronary angiography were analysed retrospectively. A deep convolutional neural network (DCNN) was designed to detect significant CAD from posteroanterior/anteroposterior chest radiographs. The DCNN was trained for severe CAD binary classification (absence/presence). Coronary angiography reports were the ground truth. Stenosis severity of ≥70% for non-left main vessels and ≥ 50% for left main defined severe CAD. RESULTS: Information of 7728 patients was reviewed. Severe CAD was present in 4091 (53%). Patients were randomly divided for algorithm training (70%; n = 5454) and fine-tuning/model validation (10%; n = 773). Internal clinical validation (model testing) was performed with the remaining patients (20%; n = 1501). At binary logistic regression, DCNN prediction was the strongest severe CAD predictor (p < 0.0001; OR: 1.040; CI: 1.032-1.048). Using a high sensitivity operating cut-point, the DCNN had a sensitivity of 0.90 to detect significant CAD (specificity 0.31; AUC 0.73; 95% CI DeLong, 0.69-0.76). Adding to the AI chest radiograph interpretation angina status improved the prediction (AUC 0.77; 95% CI DeLong, 0.74-0.80). CONCLUSION: AI-read chest radiographs could be used to pre-test significant CAD probability in patients referred for suspected angina. Further studies are required to externally validate our algorithm, develop a clinically applicable tool, and support CAD screening in broader settings.

Every cloud has a silver lining: COVID-19 chest-CT screening prevents unnecessary cardiac surgery.

BACKGROUND: Unenhanced chest CT can identify incidental findings (IFs) leading to management strategy change. We report our institutional experience with routine chest-CT as preoperative screening tool during the COVID-19 pandemic, focusing on the impact of IFs. METHODS: All patients scheduled for cardiac surgery from May 1st to December 31st 2020, underwent preoperative unenhanced chest-CT according to COVID-19 pandemic institutional protocol. We have analyzed IFs incidence, reported consequent operative changes, and identified IFs clinical determinants. RESULTS: Out of 447, 278 patients were included. IFs rate was 7.2% (20/278): a solid mass (11/20, 55%), lymphoproliferative disease (1/20, 5%), SARS-CoV-2 pneumonia (2/20, 10%), pulmonary artery chronic thromboembolism (1/20, 5%), anomalous vessel anatomy (2/20, 10%), voluminous hiatal hernia (1/20, 5%), mitral annulus calcification (1/20, 5%), and porcelain aorta (1/20, 5%) were reported. Based on IFs, 4 patients (20%-4/278, 1.4%) were not operated, 8 (40%-8/278, 2.9%) underwent a procedure different from the one originally planned one, and 8 (40%-8/278, 2.9%) needed additional preoperative investigations before undergoing the planned surgery. At univariate regression, coronary artery disease, atrial fibrillation, and history of cancer were significantly more often present in patients presenting with significant IFs. History of malignancy was identified as the only independent determinant of significant IFs at chest-CT (OR=4.27 IQR: [1.14-14.58], P=0.0227). CONCLUSIONS: Unenhanced chest-CT as a preoperative screening tool in cardiac surgery led to incidental detection of significant clinical findings, which justified even procedures cancellation. Malignancy history is a determinant for CT incidental findings and could support a tailored screening approach for high-risk patients.

Atrioventricular node ablation and pacing for atrial tachyarrhythmias: A meta-analysis of postoperative outcomes.

BACKGROUND: Atrioventricular node ablation (AVNA) and pacemaker (PM) is performed in symptomatic atrial fibrillation (AF) unresponsive to medical treatment and percutaneous ablation. This meta-analysis evaluated results after AVNA and PM. METHODS: Primary and secondary endpoints were early/late overall/cardiac-related mortality and early/late postoperative complications. Meta-regression explored mortality and preoperative characteristics relation. RESULTS: We selected 93 studies with 11,340 patients: 9105 right ventricular (RV)-PM, and 2235 biventricular PM (cardiac resynchronization therapy, CRT). Malignant arrhythmia (2.5%), heart failure (2.4%), and lead dislodgement (2.0%) were most common periprocedural complications. Pooled estimated 30-day mortality was 1.08% (95%CI:0.65-1.77). At 19.9 months median follow-up (IQR: 10.3-34 months), rehospitalization (0.79%/month) and heart failure (0.48%/month) were the most frequent complications. Overall mortality incidence rate (IR) was 0.43%/month (95%CI:0.36-0.51), and cardiac death IR 0.27%/month (95%CI:0.22-0.32). No mortality determinants emerged in the AVNA CRT subgroup. AVNA RV-PM subgroup univariable meta-regression showed inverse relationship between age, ejection fraction (EF), and late cardiac death (Beta = -0.0709 ± 0.0272; p = 0.0092 and Beta = -0.0833 ± 0.0249; p = 0.0008). Coronary artery disease (CAD) was directly associated to follow-up overall/cardiac mortality at univariable (Beta = 0.0550 ± 0.0136, p < 0.0001; Beta = 0.0540 ± 0.0130, p < 0.0001) and multivariable (Beta = 0.0460 ± 0.0189, p = 0.152; Beta = 0.0378 ± 0.0192, p = 0.0491) meta-regression. CONCLUSIONS: Solid long-term evidence supporting AVNA and pace is lacking. Younger patients with reduced LVEF% have increased follow-up cardiac mortality after AVNA RV and may require CRT. Alternative strategies to maintain sinus rhythm and ventricular synchronism should be compared to AVNA to support future treatment strategies.

Sutureless versus transcatheter aortic valves in elderly patients with aortic stenosis at intermediate risk: A multi-institutional study.

OBJECTIVE: This multi-institutional study compares the long-term outcome of elderly patients with severe aortic stenosis and an intermediate risk profile undergoing sutureless versus transcatheter aortic valve implantation. METHODS: From 2008 to 2015, 967 elderly patients (>75 years) with intermediate risk (Society of Thoracic Surgeons score 4%-8%) and isolated aortic stenosis were included in the study (sutureless valve = 481; transcatheter aortic valve implantation = 486). After propensity score matching, 2 matched groups of 291 patients were obtained. Transcatheter valves implanted in patients were the CoreValve (Medtronic, Minneapolis, Minn), Edwards SAPIEN-XT (Edwards Lifesciences, Irvine, Calif), and Acurate-TA (Symetis, Lausanne, Switzerland). Primary end points included all-cause death at 30 days and 5 years. Secondary end points included early and 5-year incidence of composite adverse events (major adverse cardiovascular events: all-cause death, stroke, pacemaker implant, myocardial infarction, paravalvular leak ≥II, and reoperation). RESULTS: After matching, there were no substantial differences between groups. The 30-day mortality was significantly lower in the sutureless valve group (sutureless valve = 1.7% vs transcatheter aortic valve implantation = 5.5%; P = .024) and the rate of permanent pacemaker implantation (sutureless valve = 5.5% vs transcatheter aortic valve implantation = 10.7%, P = .032). Stroke/transient ischemic attack cumulative incidence at 5 years was 1.4% in the sutureless valve group and 5.3% in the transcatheter aortic valve implantation group (P = .010). The incidence of perivalvular leak grade II or greater was 1.3% in the sutureless valve group and 9.8% in the transcatheter aortic valve implantation group (P < .001). At 60 months follow-up, the all-cause death rate was lower in the sutureless valve group than in the transcatheter aortic valve implantation group (sutureless valve = 16.1% ± 4.1% vs transcatheter aortic valve implantation = 28.9% ± 5.3%, P = .006), and the major adverse cardiovascular event rate was lower in the sutureless valve group (sutureless valve = 23.5% ± 4.1% vs transcatheter aortic valve implantation = 39.0% ± 5.6%, P = .002). Multivariable Cox regression identified transcatheter aortic valve implantation as an independent predictor for 5-year mortality and major adverse cardiovascular events (hazard ratio, 1.86; confidence interval, 1.09-3.18; P = .022) (hazard ratio, 1.73; confidence interval, 1.13-2.73; P = .010). CONCLUSIONS: Sutureless valves improved the outcomes of aortic stenosis in elderly patients with an intermediate risk profile when compared with transcatheter aortic valve implantation. The use of transcatheter aortic valve implantation in this subset population should be evaluated in further controlled randomized trials with sutureless valve use in a comparative cohort.

A multicentre roadmap to restart elective cardiac surgery after COVID-19 peak in an Italian epicenter.

BACKGROUND: During the Italian Phase-2 of the coronavirus pandemic, it was possible to restart elective surgeries. Because hospitals were still burdened with coronavirus disease 2019 (COVID-19) patients, it was focal to design a separate "clean path" for the surgical candidates and determine the possible effects of major surgery on previously infected patients. METHODS: From May to July 2020 (postpandemic peak), 259 consecutive patients were scheduled for elective cardiac surgery in three different centers. Our original roadmap with four screening steps included: a short item questionnaire (STEP-1), nasopharyngeal swab (NP) (STEP-2), computed tomography (CT)-scan using COVID-19 reporting and data system (CO-RADS) scoring (STEP-3), and final NP swab before discharge (STEP-4). RESULTS: Two patients (0.8%) resulted positive at STEP-2: one patient was discharged home for quarantine, the other performed a CT-scan (CO-RADS: <2), and underwent surgery for unstable angina. Chest-CT was positive in 6.3% (15/237) with mean CO-RADS of 2.93 ± 0.8. Mild-moderate lung inflammation (CO-RADS: 2-4) did not delay surgery. Perioperative mortality was 1.15% (3/259), and cumulative incidence of pulmonary complications was 14.6%. At multivariable analysis, only age and cardiopulmonary bypass (CPB) time were independently related to pulmonary complications composite outcome (age >75 years: odds ratio [OR]: 2.6; 95% confidence interval [CI]: 1.25-5.57; p = 0.011; CPB >90 min. OR: 4.3; 95% CI: 1.84-10.16; p = 0.001). At 30 days, no periprocedural contagion and rehospitalization for COVID-19 infections were reported. CONCLUSIONS: Our structured roadmap supports the safe restarting of an elective cardiac surgery list after a peak of a still ongoing COVID-19 pandemic in an epicenter area. Mild to moderate CT residuals of coronavirus pneumonia do not justify elective cardiac surgery procrastination.