Mid-term outcomes of concomitant Cox-Maze IV: Results from a multicenter prospective registry.

BACKGROUND: Benefits of concomitant atrial fibrillation (AF) surgical treatment are well established. Cardiac societies support treating AF during cardiac surgery with a class I recommendation. Despite these guidelines, adoption has been inconsistent. We report results of routine performance of concomitant Cox-Maze IV (CMIV) from participating centers using a standardized, prospective registry. METHODS: Nine surgeons at four cardiac surgery programs enrolled 807 patients undergoing concomitant CMIV surgery over 12 years. Lesions were created using bipolar radiofrequency clamps and cryoablation probes. Follow-up occurred at 3- and 6-months, then annually for 3 years. Freedom from AF was defined as no episode >30 s of atrial arrhythmia. RESULTS: Sixty-four percent of patients were male, mean age 69 years, mean left atrial size 4.6 cm, mean preoperative AF duration 4.0 years, mean EuroSCORE 6.4, and mean CHADS2 score 3.1. Thirty-day postoperative mortality and neurologic event rates were 3.3% and 1.3%, respectively. New pacemaker implant rate was 6.3%. Freedom from AF rates at 1- and 3-years stratified by preoperative AF type were: paroxysmal 94.6% and 87.5%, persistent 82.1% and 81.9%, and longstanding persistent 84.1% and 78.1%. At 3-year follow up, 84% of patients were off antiarrhythmic drugs and 74% of sinus rhythm patients were off oral anticoagulants. CONCLUSIONS: Routine CMIV is safe and effective. Acceptable outcomes can be achieved across multiple centers and multiple operators even in a moderate risk patient population undergoing more complex procedures. Surgeons and institutions should be encouraged by all cardiac societies to adopt the CMIV procedure to maximize patient benefit.

Prophylactic Left Atrial Appendage Exclusion in Cardiac Surgery Patients With Elevated CHA2DS2-VASc Score: Results of the Randomized ATLAS Trial.

OBJECTIVE: Patients with elevated CHA2DS2-VASc scores are at high risk for atrial fibrillation (AF) and thromboembolic events (TE) after cardiac surgery. Left atrial appendage exclusion (LAAE) is a permanent, continuous approach to stroke prevention in AF, overcoming limitations of oral anticoagulation (OAC). We report ATLAS trial results focused on LAAE technical success and perioperative safety and TE rates with and without LAAE in cardiac surgery patients who developed postoperative AF (POAF). METHODS: ATLAS (NCT02701062) was a prospective, multicenter, feasibility trial. Patients age ≥18 years, undergoing structural heart procedure, with no preoperative AF, CHA2DS2-VASc ≥2, and HAS-BLED ≥2 were randomized 2:1 to LAAE or no LAAE. Patients who developed POAF and/or received LAAE were followed for 1 year. LAAE was evaluated with intraoperative transesophageal echocardiography. RESULTS: A total of 562 patients were randomized to LAAE (n = 376) or no LAAE (n = 186). Mean CHA2DS2-VASc (3.4 vs 3.4) and HAS-BLED (2.8 vs 2.9) scores were similar for LAAE and no LAAE groups. LAAE success (no flow nor residual stump >10 mm) was 99%. One LAAE-related serious adverse event (0.27%) occurred and was resolved without sequelae. There were 44.3% of patients who developed POAF. Through 1 year, 3.4% of LAAE patients and 5.6% of no LAAE patients had TE. OAC was used by 32.5% of POAF patients. Bleeding was higher with OAC than without (16.1% vs 5.4%, P = 0.008). CONCLUSIONS: ATLAS demonstrated a high rate of successful LAAE with low LAAE-related serious adverse events in cardiac surgery patients. Study results should be considered in future trial design to further evaluate prophylactic LAAE for stroke prevention in cardiac surgery patients with elevated stroke risk.

Diffuse alveolar haemorrhage secondary to haemophilus influenzae in a vaping patient.

Diffuse alveolar haemorrhage (DAH) is known to occur from several infectious and non-infectious aetiologies. Among the infectious aetiologies, Haemophilus influenzae, an organism known to cause community-acquired pneumonia, has not been reported in association with DAH prior to this case. On the other hand, vaping, an evolving epidemic concern, has been linked to various types of lung injury, including DAH. However, DAH related to vaping is only limited to several case reports. Our case describes H. influenzae pneumonia with DAH in a patient known to have vaped until the night prior to elective lobectomy for lung cancer and developed DAH within 24 hours of hospitalisation. He subsequently recovered with treatment. DAH requires immediate recognition, and healthcare providers need to be aware that neither haemoptysis nor decrease in haemoglobin level is necessarily associated. Prior to diagnosis, empirical treatment with intravenous steroids and antibiotics can be life-saving.

Safety and long-term efficacy of thoracoscopic Epicardial ablation in patients with paroxysmal atrial fibrillation: a retrospective study.

BACKGROUND: The aim of this study is to report the long-term efficacy and safety of thoracoscopic epicardial left atrial ablation (TELA) in patients with paroxysmal atrial fibrillation (AF). METHODS: This was a retrospective review of medical records. We included all patients diagnosed with paroxysmal AF who underwent TELA at our institution between 04/2011 and 06/2017. TELA included pulmonary vein isolation, LA dome lesions and LA appendage exclusion. All (n = 55) patients received an implantable loop recorder (ILR), 30 days post-operatively. Antiarrhythmic and anticoagulation therapy were discontinued at 90 and 180 days postoperatively, respectively, if patients were free of AF recurrence. Failure was defined as ≥two minutes of continuous AF, or atrial tachycardia. RESULTS: Fifty-five patients (78% males, mean age = 61.6 years) qualified for the study. The average duration in AF was 3.64 +/- 3.4 years, mean CHA2DS2-VASc Score was 2.0 +/- 1.6. The procedure was attempted in 57 patients and completed successfully in 55 (96.5%). Two patients experienced a minor pulmonary vein bleed that was managed conservatively. Post procedure, one patient experienced pulmonary edema, another experienced a pneumothorax requiring a chest tube and another experienced acute respiratory distress syndrome resulting in longer hospitalization. Otherwise, there were no major procedural complications. Success rates were 89.1% (n = 49/55), 85.5% (n = 47/55) and 76.9% (n = 40/52) at 6, 12 and 24 months, respectively. In the multivariate cox-proportional hazard model, survival at the mean of covariates was 86 and 74% at 12 and 24 months, respectively. CONCLUSION: In this single center experience, TELA was a safe and efficacious procedure for patients with paroxysmal AF.

Stroke and atrial fibrillation following cardiac surgery.

OBJECTIVE: Stroke is an occasional devastating complication of cardiac surgery. Transient atrial fibrillation (AF) is a frequent complication of cardiac surgery. Emboli originating from the fibrillating left atrium are a known cause of stroke in the non-surgical setting. The purpose of this quality improvement initiative, conducted by the Wausau Heart Institute, was to characterize strokes after cardiac surgery and to investigate the relationship between AF and the occurrence of postoperative strokes. METHODS: We conducted a retrospective record review of all patients undergoing cardiac surgery utilizing cardiopulmonary bypass without associated carotid surgery at our institution between January 1, 1993 and June 30, 1999. The occurrence of strokes and AF was noted. The timing of the AF (duration and relationship to surgery) was recorded. RESULTS: Of the 2104 eligible patients, strokes occurred in 68 (3.2%). In 18 patients (27%), stroke was immediately apparent as the patient recovered from anesthesia (intra-operative stroke). Fifty of the 68 strokes (74%) were acquired following the immediate operative period after the patient awoke from anesthesia neurologically intact (postoperative stroke). Postoperative stroke occurred in 2.1% of patients undergoing coronary bypass surgery only, in 2.2% if valve surgery only was performed, and 4.6% if both valve and bypass surgery were performed. AF occurred in 700 patients (33%). The incidence of postoperative stroke was 5.4% in patients with AF and 0.89% in those without AF (P < 0.001). Of those patients suffering a postoperative stroke, 76% had AF following cardiac surgery, compared to 32% if a postoperative stroke did not occur (P < 0.001). Carotid bruits were present in 7 (14%) of the patients with postoperative stroke. Carotid ultrasound studies were performed in 32 patients (63%) and a lesion of > 70% was found in 8 patients (25%). Cerebral lesions contralateral to the stenotic carotid artery occurred in 3 of these 8 patients. CONCLUSION: Most strokes complicating cardiac surgery occur in patients without significant carotid disease, and are acquired after the patient awakens neurologically intact. The high incidence of postoperative AF in these patients suggests a possible embolic cause for some of the strokes. As such, some postoperative strokes may be preventable.

The pneumatic tourniquet technique for endoscopic radial artery harvest.

BACKGROUND: Endoscopic vessel harvest is viewed as a safe, reliable, and cost-effective method for greater saphenous vein removal. As the radial artery has more recently become a popular conduit choice in coronary artery revascularization, we describe herein an endoscopic technique for radial artery harvest in our first 50 patients as an alternative to the more traditional open technique. METHODS: From November 2001 to July 2002, 54 radial arteries were harvested endoscopically in 50 patients utilizing the VasoView Endoscopic Vessel Harvesting System, an Esmark bandage, and a pneumatic cuff tourniquet. RESULTS: No patients experienced symptoms of vascular compromise, or signs of infection in the donor arm. No adjunctive procedures were required during the vessel harvest, i.e., conversion to open technique. All radial arteries were successfully removed with endoscopic technique and 53 of the 54 radial arteries were successfully used as bypass conduits. Although the quality of the radial artery harvested remains subjective, we found less vasospasm than in our experience with the open technique. Thirty-day follow-up revealed no readmissions, no cardiac ischemic complications, no significant complications with the donor arm, and an excellent cosmetic result. CONCLUSIONS: Endoscopic harvest of the radial artery with the tourniquet technique may offer advantages over the more traditional open technique.