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.

Heart Transplantation Following Fontan Failure: Long-Term Survival Analysis.

Objectives: Fontan circulation presents significant challenges for patients with congenital heart disease, often necessitating heart transplantation (HTX) due to deteriorating functionality across multiple organ systems. However, the impact of prior Fontan palliation on HTX outcomes remains poorly understood, with early mortality rates suggesting a heightened risk. The aim of our study is to evaluate the long-term results after heart transplantation in patients with univentricular congenital heart disease previously palliated with Fontan circulation. Methods: A retrospective analysis was conducted on patients who underwent HTX for congenital heart disease. Patients were categorized into two groups based on the pre-HTX circulation pathway: the Failing Fontan Group (FFG) and the Biventricular Congenital Group (BCG). Data were collected from patients between 1987 and 2018. Early and late outcomes, including survival rates, were assessed and critically analyzed. Results: Of the 66 patients, 29 (43%) had a failing Fontan palliation (FFG), and 37 had biventricular congenital diseases (BCG) before heart transplantation. Early mortality (30-day) was not statistically different between the two group. The overall survival rate was 82.6 ± 13.9% at 1 year, 79.0 ± 14.9% at 5 years, 67.2 ± 17.6% at 10 years and 63.2 ± 18.2 ± at 15 years for the FFG, and 86.1 ±11.4% at 1 year, 79.5 ± 13.7% at 5 years, 75.7 ± 14.9% at 10 years, 75.7 ± 14.9% at 15 years for the BCG, with no statistically significant difference (Mantel Cox p value: 0.69, 0.89, 0.52 and 0.39, respectively). Regarding Cox-regression analysis, the long-term survival rate was not affected either by previous Fontan surgery or by the era of heart transplantation (before vs. after the year 2000). Conclusions: Although heart transplantation after Fontan palliation showed a higher risk in the early post-operative period, the medium- and long-term survival rates are comparable with biventricular circulation patients. Despite the failing Fontan patients being a challenging set of candidates for transplantation, it is a reasonable option in their treatment.

Sutureless Aortic Valve Replacement vs. Transcatheter Aortic Valve Implantation in Patients with Small Aortic Annulus: Clinical and Hemodynamic Outcomes from a Multi-Institutional Study.

OBJECTIVE: This study aimed to compare hemodynamic performances and clinical outcomes of patients with small aortic annulus (SAA) who underwent aortic valve replacement by means of sutureless aortic valve replacement (SUAVR) or transcatheter aortic valve implantation (TAVI). METHODS: From 2015 to 2020, 622 consecutive patients with SAA underwent either SUAVR or TAVI. Through a 1:1 propensity score matching analysis, two homogeneous groups of 146 patients were formed. Primary endpoint: all cause-death at 36 months. Secondary endpoints: incidence of moderate to severe patient-prosthesis mismatch (PPM) and incidence of major adverse cardiovascular and cerebrovascular events (MACCEs). RESULTS: All-cause death at three years was higher in the TAVI group (SUAVR 12.2% vs. TAVI 21.0%, P=0.058). Perioperatively, comparable hemodynamic performances were recorded in terms of indexed effective orifice area (SUAVR 1.12 ± 0.23 cm2/m2 vs. TAVI 1.17 ± 0.28 cm2/m2, P=0.265), mean transvalvular gradients (SUAVR 12.9 ± 5.3 mmHg vs. TAVI 12.2 ± 6.2 mmHg, P=0.332), and moderate-to-severe PPM (SUAVR 4.1% vs. TAVI 8.9%, P=0.096). TAVI group showed a higher cumulative incidence of MACCEs at 36 months (SUAVR 18.1% vs. TAVI 32.6%, P<0.001). Pacemaker implantation (PMI) and perivalvular leak ≥ 2 were significantly higher in TAVI group and identified as independent predictors of mortality (PMI: hazard ratio [HR] 3.05, 95% confidence interval [CI] 1.34-6.94, P=0.008; PPM: HR 2.72, 95% CI 1.25-5.94, P=0.012). CONCLUSION: In patients with SAA, SUAVR and TAVI showed comparable hemodynamic performances. Moreover, all-cause death and incidence of MACCEs at follow-up were significantly higher in TAVI group.

Reliability of EuroSCORE II on Prediction of Thirty-Day Mortality and Long-Term Results in Patients Treated with Sutureless Valves.

Background: EuroSCORE II (ES2) is a reliable tool for preoperative cardiac surgery mortality risk prediction; however, a patient's age, a surgical procedure's weight and the new devices available may cause its accuracy to drift. We sought to investigate ES2 performance related to the surgical risk and late mortality estimation in patients who underwent aortic valve replacement (AVR) with sutureless valves. Methods: Between 2012 and 2021, a total of 1126 patients with isolated aortic stenosis who underwent surgical AVR by means of sutureless valves were retrospectively collected from six European centers. Patients were stratified into three groups according to the EuroSCORE II risk classes (ES2 < 4%, ES2 4-8% and ES2 > 8%). The accuracy of ES2 in estimating mortality risk was assessed using the standardized mortality ratio (O/E ratio), ROC curves (AUC) and Hosmer-Lemeshow (HL) test for goodness-of-fit. Results: The overall observed mortality was 3.0% (predicted mortality ES2: 5.39%) with an observed/expected (O/E) ratio of 0.64 (confidential interval (CI): 0.49-0.89). In our population, ES2 showed a moderate discriminating power (AUC 0.65, 95%CI 0.56-0.72, p < 0.001; HL p = 0.798). Good accuracy was found in patients with ES2 < 4% (O/E ratio 0.54, 95%CI 0.23-1.20, AUC 0.75, p < 0.001, HL p = 0.999) and for patients with an age < 75 years (O/E ratio 0.98, 95%CI 0.45-1.96, AUC 0.76, p = 0.004, HL p = 0.762). Moderate discrimination was observed for ES2 in the estimation of long-term risk of mortality (AUC 0.64, 95%CI: 0.60-0.68, p < 0.001). Conclusions: EuroSCORE II showed good accuracy in patients with an age < 75 years and patients with ES2 < 4%, while overestimating risk in the other subgroups. A recalibration of the model should be taken into account based on the complexity of actual patients and impact of new technologies.

Hybrid coronary revascularization: position paper of the European Society of Cardiology Working Group on Cardiovascular Surgery and European Association of Percutaneous Cardiovascular Interventions.

Myocardial revascularization in coronary artery disease via percutaneous coronary intervention or coronary artery bypass graft (CABG) surgery effectively relieves symptoms, significantly improves prognosis and quality of life when combined with guideline-directed medical therapy. Hybrid coronary revascularization is a promising alternative to percutaneous coronary intervention or CABG in selected patients and is defined as a planned and/or intended combination of consecutive CABG surgery using at least 1 internal mammary artery to the left anterior descending (LAD), and catheter-based coronary intervention to the non-LAD vessels for the treatment of multivessel disease. The main indications for hybrid coronary revascularization are (i) to achieve complete revascularization in patients who cannot undergo conventional CABG, (ii) to treat patients with acute coronary syndromes and multivessel disease with a non-LAD vessel as the culprit lesion that needs revascularization and (iii) in highly select patients with multivessel disease with complex LAD lesions and simple percutaneous coronary intervention targets for all other vessels. Hybrid coronary revascularization patients receive a left internal mammary artery graft to the LAD artery through a minimal incision along with percutaneous coronary intervention to the remaining diseased coronary vessels using latest generation drug-eluting stents. A collaborative environment with a dedicated heart team is the optimal platform to perform such interventions, which aim to improve the quality and outcome of myocardial revascularization. This position paper analyses the rationale of hybrid coronary revascularization and the currently available evidence on the various techniques and delves into the sequence of the interventions and pharmacological management during and after the procedure.

Risk Score for Long-Term Survival and Major Adverse Cardiovascular and Cerebrovascular Events After Coronary Artery Bypass Grafting Surgery.

To develop risk scoring models predicting long-term survival and major adverse cardiovascular and cerebrovascular events (MACCEs), including myocardial infarction and stroke after coronary artery bypass grafting (CABG). All 4,821 consecutive patients who underwent isolated CABG at Lankenau between January 2005 and July 2021 were included. MACCE was defined as all-cause mortality + myocardial infarction + stroke. Variable selection for both outcomes was obtained using a double-selection logit least absolute shrinkage and selection operator with adaptive selection. Model performance was internally evaluated by calibration and accuracy using bootstrap cross-validation. Mortality and MACCEs were compared in patients split into 3 groups based on the predicted risk scores for all-cause mortality and MACCEs. An external validation of our database was performed with 665 patients from the University of Brescia, Italy. Preoperative risk predictors were found to be predictors for all-cause mortality and MACCEs. In addition, being of African-American ethnicity is a significant predictor for MACCEs after isolated CABG. The areas under the curve (AUCs), which measures the discrimination of the models, were 80.4%, 79.1%, 81.3%, and 79.2% for mortality at 1, 2, 3, and 5 years follow-up. The AUCs for MACCEs were 75%, 72.5%, 73.8%, and 72.7% at 1, 2, 3, and 5 years follow-up. For external validation, the AUCs for all-cause mortality and MACCEs at 1, 2, 3, and 5 years were 73.7%, 70.8%, 68.7%, and 72.2% and 72.3%, 68.2%, 65.6%, and 69.6%, respectively. The Advanced (AD) Coronary Risk Score for All-Cause Mortality and MACCE provide good discrimination of long-term mortality and MACCEs after isolated CABG. External validation observed a more AUCs greater than 70%.

2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC.

Document Reviewers: Rudolf A. de Boer (CPG Review Co-ordinator) (Netherlands), P. Christian Schulze (CPG Review Co-ordinator) (Germany), Elena Arbelo (Spain), Jozef Bartunek (Belgium), Johann Bauersachs (Germany), Michael A. Borger (Germany), Sergio Buccheri (Sweden), Elisabetta Cerbai (Italy), Erwan Donal (France), Frank Edelmann (Germany), Gloria Färber (Germany), Bettina Heidecker (Germany), Borja Ibanez (Spain), Stefan James (Sweden), Lars Køber (Denmark), Konstantinos C. Koskinas (Switzerland), Josep Masip (Spain), John William McEvoy (Ireland), Robert Mentz (United States of America), Borislava Mihaylova (United Kingdom), Jacob Eifer Møller (Denmark), Wilfried Mullens (Belgium), Lis Neubeck (United Kingdom), Jens Cosedis Nielsen (Denmark), Agnes A. Pasquet (Belgium), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Bianca Rocca (Italy), Xavier Rossello (Spain), Leyla Elif Sade (United States of America/Türkiye), Hannah Schaubroeck (Belgium), Elena Tessitore (Switzerland), Mariya Tokmakova (Bulgaria), Peter van der Meer (Netherlands), Isabelle C. Van Gelder (Netherlands), Mattias Van Heetvelde (Belgium), Christiaan Vrints (Belgium), Matthias Wilhelm (Switzerland), Adam Witkowski (Poland), and Katja Zeppenfeld (Netherlands) All experts involved in the development of this Focused Update have submitted declarations of interest. These have been compiled in a report and simultaneously published in a supplementary document to the Focused Update. The report is also available on the ESC website www.escardio.org/guidelines See the European Heart Journal online for supplementary documents that include evidence tables.