The impact of surgical left atrial appendage amputation/ligation on stroke prevention in patients undergoing off-pump coronary artery bypass grafting.

Stroke is a major adverse event in patients developing atrial fibrillation (AF) after cardiac surgery. Surgical left atrial appendage amputation/ligation (LAA-A/L) during off-pump coronary artery bypass grafting (OPCAB) is routinely performed in our institution. We analyzed 578 consecutive patients (mean age 69 years, male 82%) undergoing OPCAB with or without concomitant LAA-A/L from 2011 to 2014 at our institution in a prospective observational manner. The safety and efficacy of the concomitant LAA-A/L on preventing early (<30 days) and overall postoperative stroke were examined. A total of 193 patients (33.4%) underwent LAA-A/L, consisting of amputation in 154 and ligation in 39 patients (80 and 20% of the cases, respectively). Preoperative characteristics, operative time, requirement of blood transfusion, and 30-day mortality were not significantly different between those with and without LAA-A/L. The incidences of postoperative AF and early and overall stroke were not significantly different between the groups in the analysis based on a total cohort. In a subanalysis of patients without LAA-A/L, early and overall stroke occurred more frequently in those developing postoperative AF than those without AF (2.8 vs. 0%; p = 0.005, 6.2 vs. 1.5%; p = 0.017, respectively), while in patients receiving LAA-A/L, stroke incidences did not differ between those with and without AF. Multivariate logistic regression showed postoperative AF without LAA-A/L as the only independent positive predictor of overall stroke (OR 3.69, p = 0.03). Concomitant LAA-A/L with OPCAB can safely prevent postoperative stroke occurrence in case patients develop AF, the most common arrhythmia associated with stroke.

Left Atrial Appendage Closure Reduces the Incidence of Postoperative Cerebrovascular Accident in Patients Undergoing Cardiac Surgery.

BACKGROUND: Cerebrovascular accidents (CVA) are a major adverse event following cardiac surgery, for which atrial fibrillation (AF) is considered as a risk factor. We have recently performed left atrial appendage (LAA) surgical closure or amputation (LAAC/A), which is the main source of emboli, during open-heart surgery. METHODS AND RESULTS: A prospective observational study of 1,831 consecutive patients (69.2% male, aged 66.8±12.2 years) undergoing cardiac surgery between 2009 and 2013 was performed. The incidence of postoperative CVA within 6 months in patients with and without LAAC/A was compared. We further stratified patients according to their risk of CVA using CHA2DS2-VASc score; dichotomizing low-risk (score <2) and high-risk groups (≥2). A total of 369 patients (20.2%) underwent LAAC/A. Although these patients had larger left atrial diameter preoperatively and developed postoperative AF more frequently than those without LAAC/A (45.4 vs. 41.1 mm, 49.3 vs. 39.1%, respectively, both P<0.001), the CVA incidence was not different between the groups (3.5 vs. 3.0%, P=0.612). Multivariate analysis revealed no association between LAAC/A and CVA in patients with CHA2DS2-VASc score ≥2, whereas in patients with CHA2DS2-VASc score <2, LAAC/A was the only and independent factor negatively associated with CVA development (odds ratio <10(-6); P=0.021). CONCLUSIONS: Additional LAA procedure at the time of cardiac surgery reduces the incidence of early postoperative CVA in patients with low CHA2DS2-VASc score.

Mid-term results for the Maze procedure in patients with non-mitral valvular atrial fibrillation.

BACKGROUND: The Maze procedure in patients without mitral valve disease remains controversial, because of the increased invasiveness and operation time required to create additional incisions in the atria. The aim of this study was to assess prognosis following the Maze procedure in patients without mitral valve disease. METHODS AND RESULTS: One hundred and seven consecutive patients who underwent the Maze procedure between 2002 and 2008 was enrolled in this study. Patients were divided into two groups based on the presence or absence of mitral valve disease. Freedom from atrial fibrillation was compared by multivariate logistic regression analysis at discharge. The Kaplan-Meier method and Cox-proportional hazard analysis adjusted for other predictors were estimated to compare freedom from atrial fibrillation at follow-up. Follow-up was 98% complete and mean duration of follow-up was 457 days. Operation and aorta cross-clamp times were similar between groups. No differences were identified in freedom from atrial fibrillation at discharge (non-mitral valve surgery, 55% vs. mitral valve surgery, 66%) or follow-up (57% vs. 61%, respectively). In multivariate Cox proportional hazard modelling, the presence of mitral valve disease was not associated with a poor success rate of conversion. CONCLUSIONS: Results of the Maze procedure for atrial fibrillation without mitral valve disease were acceptable. The Maze procedure could be a beneficial option for these patients to avoid adverse events of atrial fibrillation.

Anomalous right subclavian artery with ascending aortic aneurysm: a case report.

We report a rare case of the ascending aortic aneurysm with an anomalous origin of the right subclavian artery. The right subclavian artery branched from the aorta as the fourth major vessel and ran behind the esophagus. Moreover, the left and right coronary arteries arose ectopically from the posterior and the left aortic sinus, respectively.