Rapid cardiac ischemia detection with an epicardial graphene probe.

Introduction: In this study, a new probe was designed to enable electrocardiography of a rotated heart during cardiac surgery when skin electrodes became non-functional. This probe adhered non-invasively to the epicardium and collected the ECG signal independently from the position of the heart. The study compared the accuracy of cardiac ischemia detection between classic skin and epicardial electrodes in an animal model. Methods: Using six pigs, an open chest model was devised with cardiac ischemia induction by coronary artery ligation in two non-physiologic heart positions. Both the accuracy and the time of detection of electrocardiographic symptoms of acute cardiac ischemia were compared between skin and epicardial methods of signal collection. Results: Heart rotation to expose either the anterior or the posterior wall resulted in a distortion or loss of the ECG signal collected by skin electrodes after coronary artery ligation, standard skin ECG monitoring did not reveal any ischemia symptoms. Attachment of an epicardial probe on the anterior and posterior walls helped in the recovery of the normal ECG wave. After ligation of the coronary artery, the epicardial probes recorded cardiac ischemia within 40 s. Discussion: This study highlighted the effectiveness of ECG monitoring with epicardial probes in a rotated heart. It can be concluded that epicardial probes can detect the presence of acute ischemia of a rotated heart when skin ECG monitoring becomes ineffective.

Standalone epicardial left atrial appendage exclusion for thromboembolism prevention in atrial fibrillation.

OBJECTIVES: Most strokes associated with atrial fibrillation (AF) result from left atrial appendage thrombi. Oral anticoagulation can reduce stroke risk but is limited by complication risk and non-compliance. Left atrial appendage exclusion (LAAE) is a new surgical option to reduce stroke risk in AF. The study objective was to evaluate the safety and feasibility of standalone thoracoscopic LAAE in high stroke risk AF patients. METHODS: This was a retrospective, multicentre study of high stroke risk AF patients who had oral anticoagulation contraindications and were not candidates for ablation nor other cardiac surgery. Standalone thoracoscopic LAAE was performed using 3 unilateral ports access and epicardial clip. Periprocedural adverse events, long-term observational clinical outcomes and stroke rate were evaluated. RESULTS: Procedural success was 99.4% (174/175 patients). Pleural effusion occurred in 4 (2.3%) patients; other periprocedural complications were <1% each. One perioperative haemorrhagic stroke occurred (0.6%). No phrenic nerve palsy or cardiac tamponade occurred. Predicted annual ischaemic stroke rate of 4.8/100 patient-years (based on median CHA2DS2-VASc score of 4.0) was significantly higher than stroke risk observed in follow-up after LAAE. No ischaemic strokes occurred (median follow-up: 12.5 months), resulting in observed rate of 0 (95% CI 0-2.0)/100 patient-years (P < 0.001 versus predicted). Six all-cause (non-device-related) deaths occurred during follow-up. CONCLUSIONS: Study proved that a new surgical option, standalone thoracoscopic LAAE, is feasible and safe. With this method, long-term stroke rate may be reduced compared to predicted for high-risk AF population.

Successful surgical ablation of atrial fibrillation does not disturb long-term sinus rhythm variability.

OBJECTIVES: Surgical ablation of atrial fibrillation (AF) aims to restore normal sinus rhythm while protecting the sinus node from surgical damage. Surgical lesions may affect autonomic neural structures and influence physiological heart rate variability (HRV). The primary aim of this study was to describe long-term dynamics of HRV after successful surgical ablation of AF. The secondary aim was to compare sinus node function after successful ablation of AF with either left atrial modified Maze procedure or epicardial pulmonary vein isolation after long-term follow-up. METHODS: This retrospective study included 75 patients who underwent successful ablation of paroxysmal or persistent AF (53 patients, 71%) and long-standing persistent AF (22 patients, 29%). Standard variables were selected to describe HRV and the minimal and mean heart rates. In all patients, a 24-h Holter ECG study was performed preoperatively, at hospital discharge and after 3, 6, 12 and 24 months. RESULTS: A significant reduction in the main HRV parameters and an increase in heart rate were observed at discharge when compared with the preoperative period. During follow-up, all HRV parameters returned to preoperative levels. No significant differences were observed in HRV parameters and HR between the modified Maze and pulmonary vein isolation procedure groups at any time. CONCLUSIONS: Successful surgical ablation of paroxysmal, persistent and long-standing persistent AF using either pulmonary vein isolation or modified left atrial Maze procedure does not disrupt long-term HRV. A significant early postoperative reduction in HRV with a gradual increase in the following months is typical in patients after surgical restoration of sinus rhythm.

Freedom from pulmonary vein stenosis after multiple applications of epicardial ablation energy.

OBJECTIVES: In patients undergoing cardiac surgical procedures, pulmonary vein isolation may be easily accomplished, and it is important to achieve bidirectional conduction block across created lesions. The primary aim of this study was to assess the risk of pulmonary vein stenosis (PVS) after multiple applications of epicardial bipolar radiofrequency energy. METHODS: Thirty-five consecutive patients who were referred for off-pump coronary revascularization with concomitant pulmonary vein isolation and left atrial appendage occlusion were prospectively included in the study. The ablation protocol provided 8 standard epicardial applications of bipolar energy with additional applications until the acute bidirectional conduction block was achieved. Three to 6 months after surgery, patients underwent computed tomography to assess PVS. RESULTS: In all patients, bidirectional conduction block was achieved across the created lesions. In 31 (89%) patients, conduction block was accomplished after the standard 8 energy applications on each side. In 4 (11%) patients, additional applications of energy were needed. All patients had computed tomography (128 total pulmonary veins) scans, which showed no evidence of PVS. CONCLUSIONS: Multiple applications of bipolar radiofrequency energy during off-pump epicardial pulmonary vein isolation did not lead to PVS. Creating bidirectional conduction block using multiple energy applications through created lesions is feasible in all patients using the ablation protocol described.

Dalbavancin treatment in a deep sternal wound MRSA infection after coronary artery bypass surgery: a case report.

BACKGROUND: A deep sternal wound infection (DSWI) can become a severe complication after cardiac surgery, with in-hospital mortality rates reaching up to 35%. Staphylococci, particularly methicillin resistant Staphylococcus aureus (MRSA), play important roles in its etiology. CASE PRESENTATION: This case report presents a patient who underwent coronary artery bypass surgery, and suffered postoperatively from a DSWI caused by MRSA. The pathogen was susceptible to vancomycin and rifampicin in vitro; however, this therapy was clinically ineffective. Both clinical improvement and MRSA eradication were achieved after surgical debridement of the wound and the intravenous administration of dalbavancin. CONCLUSIONS: We decided to administer dalbavancin because of its convenient pharmacological profile. The patient's tolerance of the antimicrobial was good, the biochemical markers of inflammation returned to the normal ranges, and the microbiological results one week after the dalbavancin administration were negative. A good clinical outcome was achieved with both the surgery and antimicrobial administration. In this case, dalbavancin was more effective in the treatment of the sternal and surrounding tissue infections caused by MRSA, when compared to vancomycin.

Intraoperative epicardial focal pulmonary venous electrocardiography in patients with atrial fibrillation.

OBJECTIVES: In patients referred to off-pump coronary artery bypass grafting, pulmonary vein isolation (PVI) may be used for those with persistent atrial fibrillation (AF), an alternative to the Maze procedure. However, the success rate of PVI in persistent AF is limited. The study assesses the prognostic value of focal epicardial electrocardiography of the pulmonary veins (PVs) for surgical ablation results. METHODS: We mapped 140 PV in 35 cases undergoing off-pump coronary artery bypass grafting. Data obtained using a sensing-pacing probe before ablation were analysed. The composite study end-point consisted of the need for electrical cardioversion for in-hospital recurrence of AF and the presence of AF at hospital discharge and after 6 months follow-up confirmed by 24-h Holter electrocardiographic monitoring. RESULTS: In patients with epicardial far-field (FF) signals recorded over at least 1 PV, the composite end-point occurred in 61% (14) vs 25% (3) of patients with no FF signal recorded over any PV (P = 0.04). The presence of FF signals in at least 1 PV significantly increased the risk of composite end-point occurrence (odds ratio 3; P = 0.04). The composite end-point occurred in 86% (6) of patients with FF signals recorded over all PVs and in 39% (11) in the remainder of the study population (P = 0.03). CONCLUSIONS: Intraoperative epicardial focal electrocardiography of PVs revealed more than 40% of PVs had only FF atrial signals. The presence of FF signals in PVs is related to a lower early effectiveness of PVI on ablating AF. Epicardial focal electrocardiography of PVs may be a clinically effective intraoperative tool in the decision-making process between less invasive PVI and the standard Maze procedure.

Left Atrial Ganglionated Plexi Detection is Related to Heart Rate and Early Recurrence of Atrial Fibrillation after Surgical Ablation.

INTRODUCTION:: Left atrial ganglionated plexi ablation is an adjuvant technique used to increase the success rate of surgical ablation of atrial fibrillation. Ganglionated plexi ablation requires previous detection. We aimed to assess determinants of successful ganglionated plexi detection and to correlate range of ganglionated plexi ablation with risk of early atrial fibrillation recurrence. METHODS:: The study involved 34 consecutive patients referred for surgical coronary revascularization with concomitant atrial fibrillation ablation. Ganglionated plexi detection was done by inducing vagal reflexes in the area of the pulmonary veins and left atrial fat pads. RESULTS:: Detection of GP was successful in 85% of the patients. There was no difference in preoperative characteristics nor in atrial fibrillation type between patients in whom ganglionated plexi detection was successful and others. The number of detected ganglionated plexi correlated significantly only with preoperative resting heart rate. Significant negative correlation was found in patients with preoperative heart rate>75 beat/min in terms of total number of detected ganglionated plexi (P=0.04). Average number of detected ganglionated plexi was significantly higher in patients with in-hospital atrial fibrillation recurrence requiring electrical cardioversion (3.8±3) in comparison to rest of the study population (2±1.3; P=0.02). In patients in whom 4 or more ganglionated plexi were detected, significantly increased risk of in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI 1.5-164; P=0.003). CONCLUSION:: Left atrial ganglionated plexi detection was unsuccessful in a considerable percentage of patients. Preoperative heart rate significantly influenced positive ganglionated plexi detection and number of ablated ganglia. Higher number of detected ganglionated plexi was related with early recurrence of atrial fibrillation.

Left atrial ganglionated plexi detection is related to heart rate and early recurrence of atrial fibrillation after surgical ablation

Abstract INTRODUCTION: Left atrial ganglionated plexi ablation is an adjuvant technique used to increase the success rate of surgical ablation of atrial fibrillation. Ganglionated plexi ablation requires previous detection. We aimed to assess determinants of successful ganglionated plexi detection and to correlate range of ganglionated plexi ablation with risk of early atrial fibrillation recurrence. METHODS: The study involved 34 consecutive patients referred for surgical coronary revascularization with concomitant atrial fibrillation ablation. Ganglionated plexi detection was done by inducing vagal reflexes in the area of the pulmonary veins and left atrial fat pads. RESULTS: Detection of GP was successful in 85% of the patients. There was no difference in preoperative characteristics nor in atrial fibrillation type between patients in whom ganglionated plexi detection was successful and others. The number of detected ganglionated plexi correlated significantly only with preoperative resting heart rate. Significant negative correlation was found in patients with preoperative heart rate>75 beat/min in terms of total number of detected ganglionated plexi (P=0.04). Average number of detected ganglionated plexi was significantly higher in patients with in-hospital atrial fibrillation recurrence requiring electrical cardioversion (3.8±3) in comparison to rest of the study population (2±1.3; P=0.02). In patients in whom 4 or more ganglionated plexi were detected, significantly increased risk of in-hospital atrial fibrillation recurrence was observed (OR 15; 95% CI 1.5-164; P=0.003). CONCLUSION: Left atrial ganglionated plexi detection was unsuccessful in a considerable percentage of patients. Preoperative heart rate significantly influenced positive ganglionated plexi detection and number of ablated ganglia. Higher number of detected ganglionated plexi was related with early recurrence of atrial fibrillation.

Right atrium positioning for exposure of right pulmonary veins during off-pump atrial fibrillation ablation.

OBJECTIVES: Concomitant surgical ablation of atrial fibrillation (AF) is recommended for patients undergoing off-pump coronary revascularization in the presence of this arrhythmia. Achievement of optimal visualization of pulmonary veins while maintaining stable haemodynamic conditions is crucial for proper completion of the ablation procedure. This study evaluates the safety and feasibility of right atrial positioning using a suction-based cardiac positioner as opposed to compressive manoeuvres for exposure during off-pump surgical ablation for AF. METHODS: Thirty-four consecutive patients underwent pulmonary vein isolation, ganglionated plexi ablation and left atrial appendage occlusion during off-pump coronary artery bypass grafting. Right atrial suction positioning was used to visualize right pulmonary veins. Safety and feasibility end points were analysed intraoperatively and in the early postoperative course. RESULTS: In all patients, right atrial positioning created optimal conditions to complete transverse and oblique sinus blunt dissection, correct placement of a bipolar ablation probe, detection and ablation of ganglionated plexi and conduction block assessment. In all patients, this entire right-sided ablation procedure was completed with a single exposure manoeuvre. Feasibility end points were achieved in all study patients. CONCLUSIONS: This report documents the safety and feasibility of right atrial exposure using a suction-based cardiac positioner to complete ablation for AF concomitant with off-pump coronary revascularization. This technique may be widely adopted to create stable haemodynamic conditions and optimal visualization of the right pulmonary veins.

Early operative comparison of two epicardial left atrial appendage occluding systems applied during off-pump coronary revascularisation in patients with persistent atrial fibrillation.

INTRODUCTION: Atrial fibrillation (AF) increases long-term mortality and stroke rate in patients having coronary artery bypass grafting (CABG). Because oral anticoagulation (OAC) is associated with both a significant incidence of discontinuation and well known complication rates, left atrial appendage occlusion might be beneficial for stroke prevention. This study presents the first clinical and practical comparison of two epicardial left appendage occluders (LAAO) accruing experience in application during off-pump coronary revascularisation in patients with persistent AF. MATERIAL AND METHODS: Fifteen consecutive patients with persistent AF were assigned to intraoperative LAA occlusion with either TigerPaw System II (n = 8) or AtriClip (n = 7) device during off-pump CABG and concomitant left atrial epicardial ablation. Both systems were analysed in terms of ease and safety of application along with intraoperative LAA occlusion success. RESULTS: Surgical risk was increased in the study population (mean EuroScore II: 3.2 ± 0.3%). In all patients in the AtriClip group successful off-pump LAA occlusion confirmed by intraoperative transoesophageal echocardiography was achieved. The TigerPaw application was quicker and easier, but in 2 patients it was unsuccessful. During the hospital stay there were no bleeding or thromboembolic events recorded. CONCLUSIONS: In a pilot cohort epicardial LAAO during off-pump CABG in patients with persistent AF was performed safely and successfully with an AtriClip device. The TigerPaw System requires technological improvement. It might be useful to adapt the use of the type of occluding device to the LAA morphologic type and target revascularisation vessels to avoid the additional use of a heart positioner or obviate coronary compression.

Intraoperative Assessment of Left Atrial Diverticulum and Remnant Stump after Left Atrial Appendage Epicardial Occlusion.

OBJECTIVES: Epicardial left atrial appendage (LAA) closure with use of occluder is an emerging technique. Absence of remnant LAA stump is major criterion of successful obliteration. The aim of study was to assess early success rate of epicardial LAA closure. METHODS: Fifteen patients with persistent AF and coronary artery disease underwent off-pump coronary revascularization with concomitant ablation and LAA epicardial occlusion with use of two types of occluders. Before incision and after appendage closure, TEE was performed to assess the LAA anatomy, diameter of left atrial ridge, and remnant LAA stump after occlusion. RESULTS: In 80% (12) of patients, formation of a left atrial diverticulum was observed with the left atrial ridge forming the superior boundary. In 5 patients (33%), a minimal remnant LAA stump was found, none exceeding 1 cm (average length: 1.5 ± 2.3 mm). In all patients, blood flow in LAA cavity distal to the occluder was absent. There was no significant difference in LAA type, average left atrial diameter, LAA orifice, LAA length, left atrial ridge, or size of occluder used between patients with and without a remnant LAA stump. Occurrence of a remnant LAA stump correlated significantly with unfavorable anatomy (LAA orifice < 20 mm and LA ridge > 5 mm; r = 0.5774, P = 0.02). CONCLUSION: The early success of epicardial LAA occlusion is not dependent on LAA morphologic type or occluder used. A minimal remnant LAA stump not exceeding 1 cm in length without distal blood flow was observed in one-third of the cases.

Delayed Pulmonary Artery Perforation With Left Atrial Appendage Occluder Hooks.

We describe a case of delayed pulmonary artery perforation with the anchoring hooks of the Amplazer Cardiac Plug (ACP) (St Jude Medical, MN), which occurred 17 days after its proper and uncomplicated implantation. The patient was successfully treated with a surgical procedure. Technologic improvement of the ACP anchoring system seems to be most rational solution necessary to eliminate the risk of the adverse event described here.

Validation of an External Support for Coronary Artery Saphenous Vein Grafts without Fibrin Sealant.

BACKGROUND: The aim of the study is to report on a new technique for applying the eSVS Mesh (Kips Bay Medical, Minneapolis, Minnesota, United States), an external saphenous vein support system, without the use of fibrin sealant. METHODS: The mesh covers the entire body of the graft with the exception of both anastomoses. Fibrin sealant was not used to fix the mesh. Two patients underwent surgery using this preparation. EVALUATION: At 4 weeks, computed tomographic angiography revealed no signs of mesh compression at either anastomotic area. The proximal anastomosis inflow diameter was greater than the diameter of the mesh-supported body of the graft. CONCLUSION: This technique successfully eliminates the need for the use of sealant and supports favorable anastomotic geometry.

Pulmonary artery aneurysm in an adult patient with idiopathic dilatation of the pulmonary artery.

Idiopathic dilatation of the pulmonary artery (IDPA) is a rare congenital heart disease. It has been described for almost one hundred years, and numerous definitions have been proposed. The IDPA diagnostic criteria have not been updated for years. Secondary to primary disease, pulmonary artery aneurism was recognised as a lethal defect; however, long-term follow-up of patients with IDPA has not been well researched. Thus, indications to medical or surgical treatment are not evidence based. Here, we present a rare case of a 54-year-old patient with IDPA, who remained under observation for 36 years without surgical intervention.

[Angiographic and stress echocardiographic evaluation after surgical treatment of Bland-White-Garland syndrome and mitral valve insufficiency]. / Ocena angiograficzna i obciazeniowa echokardiograficzna po chirurgicznym leczeniu zespolu Bland−White−Garlanda oraz wady zastawki mitralnej.

We report case of 58-year-old male patient with severe mitral insufficiency in whom in preoperative angiography anomalous left anterior descending coronary artery arising from pulmonary artery was revealed. Patient successfully underwent mitral valve replacement, ligation and bypass of left anterior descending artery. Eighteen months after surgery control exercise echocardiography and angiography were performed to evaluate coronary flow, valve prosthesis and left ventricle function.