Long-term clinical outcomes and cost-effectiveness of catheter vs thoracoscopic surgical ablation in long-standing persistent atrial fibrillation using continuous cardiac monitoring: CASA-AF randomized controlled trial.

BACKGROUND: Long-term clinical outcomes of catheter ablation (CA) compared to thoracoscopic surgical ablation (SA) to treat patients with long-standing persistent atrial fibrillation (LSPAF) are not known. OBJECTIVE: The purpose of this study was to compare the long-term (36-month) clinical efficacy, quality of life, and cost-effectiveness of SA and CA in LSPAF. METHODS: Participants were followed up for 3 years using implantable loop recorders and questionnaires to assess the change in quality of life. Intention-to-treat analyses were used to report the findings. RESULTS: Of the 115 patients with LSPAF treated, 104 (90.4%) completed 36-month follow-up [CA: n = 57 (95%); SA: n = 47 (85%)]. After a single procedure without antiarrhythmic drugs, 7 patients (12%) in the CA arm and 5 (11%) in the SA arm [hazard ratio 1.22; 95% confidence interval (CI) 0.81-1.83; P = .41] were free from atrial fibrillation/tachycardia (AF/AT) ≥30 seconds at 36 months. Thirty-three patients (58%) in the CA arm and 26 (55%) in the SA arm (hazard ratio 1.04; 95% CI 0.57-1.88; P = .91) had their AF/AT burden reduced by ≥75%. The overall impact on health-related quality of life was similar, with mean quality-adjusted life year estimates of 2.45 (95% CI 2.31-2.59) for CA and 2.32 (95% CI 2.13-2.52) for SA. Estimated costs were higher for SA (mean £24,682; 95% CI £21,746-£27,618) than for CA (mean £18,002; 95% CI £15,422-£20,581). CONCLUSION: In symptomatic LSPAF, CA and SA were equally effective at achieving arrhythmia outcomes (freedom from AF/AT ≥30 seconds and ≥75% burden reduction) after a single procedure without antiarrhythmic drugs. However, SA is significantly more costly than CA.

Assessment of left ventricular tissue mitochondrial bioenergetics in patients with stable coronary artery disease.

Recurrent myocardial ischemia can lead to left ventricular (LV) dysfunction in patients with coronary artery disease (CAD). In this observational cohort study, we assessed for chronic metabolomic and transcriptomic adaptations within LV myocardium of patients undergoing coronary artery bypass grafting. During surgery, paired transmural LV biopsies were acquired on the beating heart from regions with and without evidence of inducible ischemia on preoperative stress perfusion cardiovascular magnetic resonance. From 33 patients, 63 biopsies were acquired, compared to analysis of LV samples from 11 donor hearts. The global myocardial adenosine triphosphate (ATP):adenosine diphosphate (ADP) ratio was reduced in patients with CAD as compared to donor LV tissue, with increased expression of oxidative phosphorylation (OXPHOS) genes encoding the electron transport chain complexes across multiple cell types. Paired analyses of biopsies obtained from LV segments with or without inducible ischemia revealed no significant difference in the ATP:ADP ratio, broader metabolic profile or expression of ventricular cardiomyocyte genes implicated in OXPHOS. Differential metabolite analysis suggested dysregulation of several intermediates in patients with reduced LV ejection fraction, including succinate. Overall, our results suggest that viable myocardium in patients with stable CAD has global alterations in bioenergetic and transcriptional profile without large regional differences between areas with or without inducible ischemia.

The impact of COVID-19 pandemic on aortic valve surgical service: a single centre experience.

BACKGROUND: The coronavirus-disease 2019 (COVID-19) pandemic imposed an unprecedented burden on the provision of cardiac surgical services. The reallocation of workforce and resources necessitated the postponement of elective operations in this cohort of high-risk patients. We investigated the impact of this outbreak on the aortic valve surgery activity at a single two-site centre in the United Kingdom. METHODS: Data were extracted from the local surgical database, including the demographics, clinical characteristics, and outcomes of patients operated on from March 2020 to May 2020 with only one of the two sites resuming operative activity and compared with the respective 2019 period. A similar comparison was conducted with the period between June 2020 and August 2020, when operative activity was restored at both institutional sites. The experience of centres world-wide was invoked to assess the efficiency of our services. RESULTS: There was an initial 38.2% reduction in the total number of operations with a 70% reduction in elective cases, compared with a 159% increase in urgent and emergency operations. The attendant surgical risk was significantly higher [median Euroscore II was 2.7 [1.9-5.2] in 2020 versus 2.1 [0.9-3.7] in 2019 (p = 0.005)] but neither 30-day survival nor freedom from major post-operative complications (re-sternotomy for bleeding/tamponade, transient ischemic attack/stroke, renal replacement therapy) was compromised (p > 0.05 for all comparisons). Recommencement of activity at both institutional sites conferred a surgical volume within 17% of the pre-COVID-19 era. CONCLUSIONS: Our institution managed to offer a considerable volume of aortic valve surgical activity over the first COVID-19 outbreak to a cohort of higher-risk patients, without compromising post-operative outcomes. A backlog of elective cases is expected to develop, the accommodation of which after surgical activity normalisation will be crucial to monitor.

Hepatocellular carcinoma in an adult with Alagille syndrome: case report and literature review.

Alagille syndrome (AS) is an autosomal dominant multisystem disorder which can lead to hepatopathy and the development of focal hepatic lesions. The majority of the hepatic lesions are benign, including regenerative nodules, focal hyperplasia, and adenoma. Hepatocellular carcinoma (HCC) is extremely rare in AS, with very few cases reported in the literature. A 38-year-old man complaining of acute right upper quadrant pain with long-standing diagnosis of Alagille syndrome. On imaging, the patient had a large hepatic mass in the right lobe, with arterial hyperenhancement, washout appearance, and areas of internal hemorrhage. The patient underwent a right hepatectomy and histopathology demonstrated HCC. The patient passed away 3 months after the surgery due to infectious complications. HCC is a rare complication of AS, although rare, it should be considered. This case also emphasizes the need of HCC screening in patients with AS in order to allow an early diagnosis and treatment, which can improve patients' outcome.

Catheter Ablation versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation (CASA-AF): study protocol for a randomised controlled trial.

BACKGROUND: Atrial fibrillation is the commonest arrhythmia which raises the risk of heart failure, thromboembolic stroke, morbidity and death. Pharmacological treatments of this condition are focused on heart rate control, rhythm control and reduction in risk of stroke. Selective ablation of cardiac tissues resulting in isolation of areas causing atrial fibrillation is another treatment strategy which can be delivered by two minimally invasive interventions: percutaneous catheter ablation and thoracoscopic surgical ablation. The main purpose of this trial is to compare the effectiveness and safety of these two interventions. METHODS/DESIGN: Catheter Ablation versus Thoracoscopic Surgical Ablation in Long Standing Persistent Atrial Fibrillation (CASA-AF) is a prospective, multi-centre, randomised controlled trial within three NHS tertiary cardiovascular centres specialising in treatment of atrial fibrillation. Eligible adults (n = 120) with symptomatic, long-standing, persistent atrial fibrillation will be randomly allocated to either catheter ablation or thoracoscopic ablation in a 1:1 ratio. Pre-determined lesion sets will be delivered in each treatment arm with confirmation of appropriate conduction block. All patients will have an implantable loop recorder (ILR) inserted subcutaneously immediately following ablation to enable continuous heart rhythm monitoring for at least 12 months. The devices will be programmed to detect episodes of atrial fibrillation and atrial tachycardia ≥ 30 s in duration. The patients will be followed for 12 months, completing appropriate clinical assessments and questionnaires every 3 months. The ILR data will be wirelessly transmitted daily and evaluated every month for the duration of the follow-up. The primary endpoint in the study is freedom from atrial fibrillation and atrial tachycardia at the end of the follow-up period. DISCUSSION: The CASA-AF Trial is a National Institute for Health Research-funded study that will provide first-class evidence on the comparative efficacy, safety and cost-effectiveness of thoracoscopic surgical ablation and conventional percutaneous catheter ablation for long-standing persistent atrial fibrillation. In addition, the results of the trial will provide information on the effects on patients' quality of life. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN18250790 . Registered on 24 April 2015.

Impact of choice of skin preparation solution in cardiac surgery on rate of surgical site infection: a propensity score matched analysis.

BACKGROUND: Antiseptic skin preparations containing chlorhexidine gluconate and povidone iodine are routinely used to reduce the risk of surgical site infection (SSI). This study assesses the efficacy of two alcohol-based solutions, 2% chlorhexidine-alcohol and 10% povidone iodine-alcohol, on the incidence of cardiac SSI. METHODS: A total of 738 consecutive patients undergoing cardiac surgery had skin preparation with 2% chlorhexidine gluconate in 70% isopropanol (ChloraPrep, BD Ltd, UK) were propensity matched to 738 patients with skin prepared with 10% povidone-iodine in 30% industrial methylated spirit (Videne Alcoholic Tincture, Ecolab Ltd, UK). Continuous, prospective SSI surveillance data were collected for all these patients. A retrospective analysis of prospectively collected perioperative data was performed. RESULTS: The overall rate of SSI was similar in the chlorhexidine-alcohol and povidone-iodine-alcohol groups (3.3% versus 3.8%; P = 0.14; relative risk [RR] = 0.98; 95% confidence interval [CI] = 0.52-1.78). Superficial (1.2% versus 1.8%; P = 0.18; RR = 0.97; 95% CI = 0.48-1.80) and deep incisional (1.2% versus 1.6%; P = 0.24) SSI rates were also similar with 10% povidone-iodine-alcohol being marginally more effective against organ-space infections (0.8% versus 0.4%; P = 0.05; RR = 0.38; 95% CI = 0.20-1.01). CONCLUSION: Our analysis confirms that alcohol-based skin preparation in cardiac surgery with povidone-iodine reduces the incidence of organ-space infections with no significant superiority in preventing incisional SSI compared with chlorhexidine-alcohol.

Identification of myocardial diffuse fibrosis by 11 heartbeat MOLLI T 1 mapping: averaging to improve precision and correlation with collagen volume fraction.

OBJECTIVES: Our objectives involved identifying whether repeated averaging in basal and mid left ventricular myocardial levels improves precision and correlation with collagen volume fraction for 11 heartbeat MOLLI T 1 mapping versus assessment at a single ventricular level. MATERIALS AND METHODS: For assessment of T 1 mapping precision, a cohort of 15 healthy volunteers underwent two CMR scans on separate days using an 11 heartbeat MOLLI with a 5(3)3 beat scheme to measure native T 1 and a 4(1)3(1)2 beat post-contrast scheme to measure post-contrast T 1, allowing calculation of partition coefficient and ECV. To assess correlation of T 1 mapping with collagen volume fraction, a separate cohort of ten aortic stenosis patients scheduled to undergo surgery underwent one CMR scan with this 11 heartbeat MOLLI scheme, followed by intraoperative tru-cut myocardial biopsy. Six models of myocardial diffuse fibrosis assessment were established with incremental inclusion of imaging by averaging of the basal and mid-myocardial left ventricular levels, and each model was assessed for precision and correlation with collagen volume fraction. RESULTS: A model using 11 heart beat MOLLI imaging of two basal and two mid ventricular level averaged T 1 maps provided improved precision (Intraclass correlation 0.93 vs 0.84) and correlation with histology (R 2 = 0.83 vs 0.36) for diffuse fibrosis compared to a single mid-ventricular level alone. ECV was more precise and correlated better than native T 1 mapping. CONCLUSION: T 1 mapping sequences with repeated averaging could be considered for applications of 11 heartbeat MOLLI, especially when small changes in native T 1/ECV might affect clinical management.

Catheter ablation vs electrophysiologically guided thoracoscopic surgical ablation in long-standing persistent atrial fibrillation: The CASA-AF Study.

BACKGROUND: Catheter ablation (CA) outcomes for long-standing persistent atrial fibrillation (LSPAF) remain suboptimal. Thoracoscopic surgical ablation (SA) provides an alternative approach in this difficult to treat cohort. OBJECTIVE: To compare electrophysiological (EP) guided thoracoscopic SA with percutaneous CA as the first-line strategy in the treatment of LSPAF. METHODS: Fifty-one patients with de novo symptomatic LSPAF were recruited. Twenty-six patients underwent electrophysiologically guided thoracoscopic SA. Conduction block was tested for all lesions intraoperatively by an independent electrophysiologist. In the CA group, 25 consecutive patients underwent stepwise left atrial (LA) ablation. The primary end point was single-procedure freedom from atrial fibrillation (AF) and atrial tachycardia (AT) lasting >30 seconds without antiarrhythmic drugs at 12 months. RESULTS: Single- and multiprocedure freedom from AF/AT was higher in the SA group than in the CA group: 19 of 26 patients (73%) vs 8 of 25 patients (32%) (P = .003) and 20 of 26 patients (77%) vs 15 of 25 patients (60%) (P = .19), respectively. Testing of the SA lesion set by an electrophysiologist increased the success rate in achieving acute conduction block by 19%. In the SA group, complications were experienced by 7 of 26 patients (27%) vs 2 of 25 patients (8%) in the CA group (P = .07). CONCLUSION: In LSPAF, meticulous electrophysiologically guided thoracoscopic SA as a first-line strategy may provide excellent single-procedure success rates as compared with those of CA, but there is an increased up-front risk of nonfatal complications.

Right Coronary Artery and Left Anterior Descending Artery Occlusion after Aortic Valve Replacement.

Coronary artery stenosis is a potentially life-threatening complication after heart valve surgery. The details are presented of a patient with unobstructed coronary arteries, who underwent routine aortic valve replacement and developed dissection of the right coronary artery (RCA) on the third postoperative day, and occlusion of the left anterior descending (LAD) artery one month after surgery. This complication required prompt clinical recognition and diagnosis by repeat coronary angiography, and a rapid intervention with coronary artery bypass grafting or with angioplasty and stenting.

Management of a left atrial intramural hematoma after percutaneous intervention.

Left atrial intramural hematoma is a rare complication of percutaneous intervention. We report the case of a 69-year-old man with recurrent angina after CABG 19 years ago who was admitted for percutaneous intervention. After an attempt to recanalize the native circumflex artery and the vein graft, he had a cardiac arrest and was resuscitated successfully. Transesophageal echocardiography showed a large expanding hematoma within the left atrial wall causing obstruction of the mitral valve and compressing the right atrium from across the septum. An emergency thoracotomy was performed and with transesophageal echocardiography guidance and left atrial intramural hematoma was drained successfully.

Fungal endocarditis of the eustachian valve in carcinoid heart disease: a case report.

The case is presented of a fungal-origin endocarditis affecting the eustachian valve. During surgery for pulmonary and tricuspid valve replacement, a 54-year-old male with carcinoid disease was found to have a 3-cm vegetation attached to the eustachian valve. Histopathological assessment of the vegetation revealed the presence of Candida species. The patient made a good postoperative recovery and was continued on a three-month course of antifungal therapy.

Successful double bioprosthetic valve replacement in a 64-year-old man with carcinoid syndrome and bipolar disorder: case report.

The case is described of a 64-year-old man with bipolar disorder and severe carcinoid heart disease who required a double valve replacement. Multidisciplinary team involvement and extensive preoperative investigations resulted in a successful regimen which prevented reactivation of carcinoid syndrome and avoided the serious side effects of lantreotide and lithium therapy. In addition, two bioprosthetic valves were used, thereby avoiding the potential complications of anticoagulation in a patient with known hepatic metastases.

Comparison of flow characteristics and vascular reactivity of radial artery and long saphenous vein grafts [NCT00139399].

BACKGROUND: The morphological and functional differences between arteries and veins may have implications on coronary artery bypass graft (CABG) survival. Although subjective differences have been observed between radial artery (RA) and long saphenous venous (LSV) grafts, these have not been quantified. This study assessed and compared the flow characteristics and in-vivo graft flow responses of RA and LSV aorto-coronary grafts. METHODS: Angiograms from 52 males taken 3.7 +/- 1.0 months after CABG surgery were analyzed using adjusted Thrombolysis in Myocardial Infarction (TIMI) frame count. Graft and target coronary artery dimensions were measured using quantitative coronary angiography. Estimated TIMI velocity (V(E)) and volume flow (F(E)) were then calculated. A further 7 patients underwent in-vivo graft flow responses assessments to adenosine, acetylcholine and isosorbide dinitrate (ISDN) using intravascular Doppler. RESULTS: The V(E) for RA grafts was significantly greater than LSV grafts (P = 0.002), however there was no difference in volume F(E) (P = 0.20). RA grafts showed positive endothelium-dependent and -independent vasodilatation, and LSV grafts showed no statistically significant response to adenosine and acetylcholine. There was no difference in flow velocity or volume responses. Seven RA grafts (11%) had compromised patency (4 (6%) > or = 50% stenosis in the proximal/distal anastomoses, and 3 (5%) diffuse narrowing). Thirty-seven (95%) LSV grafts achieved perfect patency and 2 (5%) were occluded. CONCLUSION: The flow characteristics and flow responses of the RA graft suggest that it is a more physiological conduit than the LSV graft. The clinical relevance of the balance between imperfect patency versus the more physiological vascular function in the RA graft may be revealed by the 5-year angiographic follow-up of this trial.

Determinants of successful endoscopic internal thoracic artery harvesting: a prospective analysis.

OBJECTIVE: Endoscopic internal thoracic artery (ITA) harvesting is employed during minimal-access coronary artery bypass grafting. To improve case selection, we prospectively analyzed our entire experience to identify variables that predict intraoperative conversion to sternotomy. METHODS: We performed a prospective study from September 1999 to November 2003 of 100 consecutive patients with an endoscopically harvested left ITA (LITA). Success was defined as an endoscopic dissection of the LITA sufficient to reach the anastomosis. Multivariate logistic regression analysis was performed to identify independent preoperative and procedural predictors of success. RESULTS: The measured parameters (mean +/- SD) were age (62 +/- 9 years), height (174 +/- 9 cm), weight (81 +/- 14 kg), and logistic Euroscore (2.0 +/- 1.7). Patients comprised 8 (8%) women, 17 (17%) with urgent operations, 42 (42%) with multiple vessel disease, 17 (17%) with a left ventricular ejection fraction <50%, 2 (2%) redo procedures, and 3 (3%) with pleural disease. The Zeus robot was used in 17 patients (17%). Eight-eight (88%) of the LITA were successfully harvested endoscopically. Among the 12 patients who underwent conversions, pleural adhesions were the most common finding (n = 4, 33%). One LITA was unusable. In the final multivariate model, lung disease was a negative predictor of successful endoscopic harvest (odds ratio, 0.13; 95% confidence interval, 0.02-0.63; P =.012). The variables of age, sex, left ventricular function, logistic Euroscore, operative priority, and use of the Zeus robot did not achieve statistical significance. CONCLUSIONS: Acceptable conversion rates and low conduit wastage are achievable during a unit's initial experience. Lung disease is associated with increased conversion frequency, and surgeons embarking on endoscopic harvesting should consider excluding these patients to improve their chances of success. Pleural adhesions increase the technical difficulty of surgery.

A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery.

BACKGROUND: The effect of the use of coronary-artery bypass surgery without cardiopulmonary bypass and cardiac arrest ("off pump") on graft patency remains uncertain. We undertook a prospective, randomized, controlled study to compare graft-patency rates and clinical outcomes in off-pump surgery with conventional, "on-pump" surgery. METHODS: We randomly assigned 50 patients to undergo on-pump coronary-artery bypass grafting and 54 to undergo off-pump surgery. Surgical and anesthetic techniques were standardized for both groups. Clinical outcomes and troponin T levels were measured. Three months later, the patients underwent coronary angiography, including quantitative analysis. RESULTS: The mean age of the patients was 63 years, and 87 percent were men. The on-pump group received a mean of 3.4 grafts, and the off-pump group 3.1 (P=0.41). There were no deaths. There was no significant difference in the median postoperative length of stay between the two groups (seven days in each group). The area under the curve of troponin T levels was higher during the first 72 hours in the on-pump group than in the off-pump group (30.96 hr x microg per liter vs. 19.33 hr x microg per liter, P=0.02). At three months, 127 of 130 grafts were patent in the on-pump group (98 percent), as compared with 114 of 130 in the off-pump group (88 percent, P=0.002). The patency rate was higher for all graft territories in the on-pump group than in the off-pump group. CONCLUSIONS: In this randomized study, off-pump coronary surgery was as safe as on-pump surgery and caused less myocardial damage. However, the graft-patency rate was lower at three months in the off-pump group than in the on-pump group, and this difference has implications with respect to the long-term outcome.

Improved recovery after the endoscopic atraumatic coronary artery bypass procedure compared with sternotomy for off-pump bypass of the left internal thoracic artery to the left anterior descending coronary artery: a case-matched study.

OBJECTIVE: The endoscopic atraumatic coronary artery bypass (endo-ACAB) procedure allows single-vessel coronary artery bypass grafting (CABG), avoiding sternotomy or thoracotomy. We set out to define the effect of this surgical approach on postoperative recovery, blood loss, and return to work. METHODS: We performed a case-control comparison of our first 29 endo-ACAB procedures for left anterior descending coronary artery (LAD) disease against 29 control patients, who underwent off-pump beating heart CABG via sternotomy for isolated LAD disease in the same institution. Control pairs were matched for age, sex, and ventricular function. RESULTS: In a matched population, endo-ACAB is associated with shorter postoperative ventilation times (6.2 hours versus 9.0 hours, P = .034) and hospital stays (5.3 nights versus 6.4 nights, P = .04), less blood loss (363.9 mL versus 570.3 mL, P = .017), and lower transfusion requirements. Endo-ACAB patients were more likely to return to employment and did so at a mean of 6.6 weeks earlier than sternotomy patients (P = .019). CONCLUSIONS: Endo-ACAB for grafting of the left internal mammary artery to the LAD is associated with reduced blood loss and faster postoperative recovery. Avoiding sternotomy appears to be a significant factor in recovery after beating heart single-vessel CABG surgery.

Correlation between thrombin potential and bleeding after cardiac surgery in adults.

We used a sensitive assay to measure thrombin potential in 20 patients who underwent cardiopulmonary bypass surgery for coronary artery bypass grafts. We measured coagulation factors II, V, VII, VIII and X. Blood loss was measured as the total amount in the mediastinal drains in the first 24 h postoperatively. Thrombin potential was median 107 nmol/l.min (range 62-181) preoperatively and median 46 nmol/l.min (range 19-120) postoperatively. Coagulation factors II, V, VII,VIII and X were within normal limits preoperatively. Factor II fell from 77 IU/dl preoperatively to 37 IU/dl at 120 min postoperatively. Factor V fell from 85 IU/dl preoperatively to 61 IU/dl postoperatively. Factor VII fell from 91 IU/dl to 66 IU/dl postoperatively. Factor VIII was 128 IU/dl preoperatively and 127 IU/dl postoperatively. Factor X fell from 90 IU/dl preoperatively to 50 IU/dl postoperatively. Total blood loss in 24 h in the mediastinal drains postoperatively was mean 673 ml, median 650 ml (range 250-2000). Reduction in thrombin potential correlated inversely with postoperative blood loss, r= -0.75 (Spearman correlation). The fall in the thrombin potential correlated with the prothrombin level (r = 0.75) and factor X (r = 0.47).