European registry of type A aortic dissection (ERTAAD) - rationale, design and definition criteria.

BACKGROUND: Acute Stanford type A aortic dissection (TAAD) is a life-threatening condition. Surgery is usually performed as a salvage procedure and is associated with significant postoperative early mortality and morbidity. Understanding the patient's conditions and treatment strategies which are associated with these adverse events is essential for an appropriate management of acute TAAD. METHODS: Nineteen centers of cardiac surgery from seven European countries have collaborated to create a multicentre observational registry (ERTAAD), which will enroll consecutive patients who underwent surgery for acute TAAD from January 2005 to March 2021. Analysis of the impact of patient's comorbidities, conditions at referral, surgical strategies and perioperative treatment on the early and late adverse events will be performed. The investigators have developed a classification of the urgency of the procedure based on the severity of preoperative hemodynamic conditions and malperfusion secondary to acute TAAD. The primary clinical outcomes will be in-hospital mortality, late mortality and reoperations on the aorta. Secondary outcomes will be stroke, acute kidney injury, surgical site infection, reoperation for bleeding, blood transfusion and length of stay in the intensive care unit. DISCUSSION: The analysis of this multicentre registry will allow conclusive results on the prognostic importance of critical preoperative conditions and the value of different treatment strategies to reduce the risk of early adverse events after surgery for acute TAAD. This registry is expected to provide insights into the long-term durability of different strategies of surgical repair for TAAD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04831073 .

Combination of sotalol and magnesium prevents atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Atrial fibrillation (AF) is a common complication reported in 20% to 40% of patients after coronary operations. Sotalol alone and magnesium alone have been shown to partially decrease the incidence of AF. The goal of this study was to evaluate the efficacy of these two pharmacological agents, used alone or in combination, to reduce postoperative AF. METHODS: Two hundred seven consecutive coronary artery bypass patients (mean age 62 +/- 11 years) were randomized to receive sotalol alone (80 mg twice daily for 5 days starting from the morning of the first postoperative day) (group S), magnesium alone (1.5 g daily for 6 days starting in the operating room just before cardiopulmonary bypass) (group M), both pharmacologic agents at the same dosages (group S+M), or no antiarrhythmic agents (group CTR). All patients with an ejection fraction less than 0.40 were excluded. RESULTS: The incidence of postoperative AF was 11.8% (6/51) in the S group, 14.8% (8/54) in the M group, 1.9% (1/52) in the S+M group, and 38% (19/50) in the CTR group. The following differences were significant: group CTR versus groups S, M, and S+M with values of p = 0.002, p = 0.007 and p < 0.0001, respectively; and group S+M versus groups S and M with p = 0.04 and p = 0.01, respectively. CONCLUSIONS: Incidence of AF after coronary operation was significantly reduced by the administration of sotalol alone and magnesium alone; more importantly, the incidence was further reduced by combining these agents.

Cardiac surgery in moderate to end-stage renal failure: analysis of risk factors.

BACKGROUND: The incremental surgical risk caused by different categories of renal failure is not well defined. METHODS: Data from 159 patients with moderate to end-stage renal dysfunction, who had consecutive operations using cardiopulmonary bypass, were included in a multivariate analysis of morbidity and survival. Ninety-nine patients had preoperative serum creatinine levels (PSCL) of 1.9 to 2.5 mg/dL (moderate), 36 had PSCL higher than 2.5 mg/dL and were not dialysis dependent (severe), and 24 required chronic dialysis (end-stage dysfunction). RESULTS: Operative mortality was 4% with moderate dysfunction and compared favorably with 16.7% in severe and 8% in end-stage dysfunction (p < 0.05). Independent predictors of death were severe non-dialysis-dependent renal dysfunction (p < 0.05), diabetes (p < 0.05), and cardiopulmonary bypass time (p < 0.01). Severe renal dysfunction (p < 0.01) and diabetes (p < 0.01) also predicted pulmonary and neurologic morbidity. Freedom from late death at 4 years was 82% +/- 5% with moderate, 49% +/- 10% with severe, and 60% +/- 10% with end-stage dysfunction (p < 0.01). Time to late death was adversely affected by severe (p < 0.05) and end-stage dysfunction (p < 0.01). Persistent improvement of symptoms was observed in all subgroups. CONCLUSIONS: Satisfactory early and late surgical outcomes may be expected in patients with moderate renal failure, but outcomes are often poor with severe non-dialysis-dependent and end-stage renal dysfunction.

Conversion to sinus rhythm by ablation improves quality of life in patients submitted to mitral valve surgery.

BACKGROUND: Atrial fibrillation can be successfully treated with surgical ablation, but the effect of restoring sinus rhythm on the quality of life has yet to be established. We evaluate the effects of left atrial ablation combined with mitral valve surgery on health-related quality of life in patients with permanent atrial fibrillation. METHODS: Ninety-one consecutive patients with permanent atrial fibrillation underwent mitral valve surgery at our division. The last 53 also received left atrial ablation by means of monopolar radiofrequency and excision of the left appendage. The patients were divided into two groups according to the median total score obtained at the Short Form 36 Health Survey used to evaluate their quality of life (ie, the good quality of life group [n = 54] and the poor quality of life group [n = 37]). RESULTS: Preoperative and intraoperative data of the two groups were similar. In-hospital mortality and morbidity were similar in both groups. Sinus rhythm was obtained in 68% of patients (36 of 53) treated with left atrial ablation and it occurred spontaneously in 10% of patients (4 of 38) treated for the mitral pathology only. At follow-up, there was no difference between the groups in ejection fraction, left atrial diameter, mitral dysfunction, tricuspidal regurgitation, and New York Heart Association functional class. Using stepwise logistic regression, only the presence of sinus rhythm was associated with better quality of life. CONCLUSIONS: In patients submitted to mitral surgery, conversion to sinus rhythm by left atrial ablation can significantly improve the health-related quality of life.

The Valsalva graft in aortic valve repair and replacement.

Presentation of the use of the new Valsalva graft that incorporates sinuses of Valsalva: its use is mostly recommended for the reimplantation type of valve sparing procedure where it combines the advantages of proper anatomical reconstruction with those of annular stabilization. Its advantages when used in the remodeling technique or in a classical Bentall procedure are also shown. The problem of graft sizing and of proper geometrical reconstruction of the aortic root are addressed.

Combination therapy for prevention of atrial fibrillation after coronary artery bypass surgery: a randomized trial of sotalol and magnesium.

OBJECTIVE: Atrial Fibrillation (AF) is a common complication of coronary artery bypass surgery reported to occur in 20-40% of patients. Sotalol alone and magnesium alone have been shown to decrease the incidence of AF. The aim of this study was to evaluate the efficacy of these two agents, alone or in combination, to reduce postoperative AF. METHODS: Two hundreds and seven consecutive coronary artery bypass patients were randomized to receive sotalol alone (80 mg two times daily for five days starting from the morning of the first postoperative day), magnesium alone (1.5 g daily for six days starting in the operating room just before cardiopulmonary bypass), both pharmacological agents at the same dosages or no antiarrhythmic agents (Control group). Patients with an ejection fraction <40% were excluded. RESULTS: The incidence of postoperative AF was 11.8% (6/51) in the sotalol group, 14.8% (8/54) in the magnesium group, 1.9% (1/52) in sotalol+magnesium group and 38% (19/50) in the control group. The differences were significant between the control group and the other three groups (sotalol, magnesium and sotalol + magnesium groups: p = 0.002, p = 0.007 and p < 0.0001 respectively), and between the sotalol + magnesium group and single drug groups (sotalol and magnesium groups: p = 0.04 and p = 0.01, respectively. CONCLUSION: The incidence of AF after coronary surgery was significantly reduced by the administration of sotalol alone and magnesium alone. The incidence of postoperative AF was further reduced by combining the two pharmacological agents.