Crioablación biauricular frente a la ablación aislada de la aurícula izquierda en fibrilación auricular persistente. Recurrencia a medio-largo plazo / Biatrial vs. isolated left atrial cryoablation for the treatment of long-lasting permanent atrial fibrillation. Midterm recurrence rate

Resumen Los resultados a largo plazo del procedimiento de maze con criotermia en pacientes con fibrilación auricular durante procedimientos quirúrgicos concomitantes son todavía inciertos. Método Entre 2006 y 2011, 150 pacientes consecutivos con fibrilación auricular persistente y cardiopatía asociada fueron sometidos a cirugía de ablación mediante criotermia asociada a cirugía concomitante. El procedimiento de Cox-Maze biauricular fue realizado en 67 pacientes y ablación aislada de la aurícula izquierda en 83 pacientes. Los resultados a tres años en estos grupos fueron comparados mediante seguimiento clínico, electrocardiográfico y mediante Holter 24 horas y ecocardiografía con medición de la onda A transmitral al mes, a los 6 y 12 meses y después anualmente. Resultados Los pacientes sometidos a ablación Cox-Maze presentaron una libertad de fibrilación auricular del 97, 94, 89, 80 y 54% a 1, 6, 12, 24 y 36 meses respectivamente. En el seguimiento de los 12 meses estas diferencias resultaron significativas (p < 0.05). Como factor de riesgo de recurrencia de fibrilación auricular se identificó la ablación aislada de la aurícula izquierda. Conclusiones La ablación mediante criotermia tiene un elevado porcentaje de éxitos a dos años; la recurrencia se incrementa a partir de entonces independientemente de la técnica realizada. Para el tratamiento de la fibrilación auricular persistente asociada a otra patología quirúrgica cardiaca se debe realizar un tratamiento intensivo mediante ablación biauricular.

Abstract The long-term results of cryomaze in patients with longstanding persistent atrial fibrillation during concomitant surgical procedures are still uncertain. Methods Between 2006 and 2011, 150 consecutive patients with associated long-lasting permanent atrial fibrillation and associated heart disease underwent heart surgery were treated by biatrial Cox-Maze (63 patients) or by isolated endocardial or epicardial left atrial cryoablation (83 patients) concomitantly. The results at 3 years in these groups were compared with clinical monitoring, electrocardiography, 24-hour Holter, and echocardiography with measurement of the transmitral A wave at 1, 6 and 12 months and annually thereafter in all patients. Results Patients undergoing Cox-Maze IV ablation presented rates of freedom from atrial fibrillation of 97, 94, 89, 80 and 54% at 1, 6, 12, 24 and 36 months, respectively. In the 12-month follow-up, these differences were significant (p < .05). The independent risk factors of atrial fibrillation recurrence was isolated ablation of left atrium. Conclusions Atrial fibrillation by cryothermia ablation had a high success rate before 2 years postoperatively. Recurrence of atrial fibrillation increased thereafter regardless of the technique used, although it was more intense and developed earlier in cases of monoatrial ablation. For the treatment of other long-lasting permanent atrial fibrillation cardiac surgery-associated pathology, an aggressive biatrial treatment with Cox maze ablation should be performed.

[Biatrial vs. isolated left atrial cryoablation for the treatment of long-lasting permanent atrial fibrillation. Midterm recurrence rate]. / Crioablación biauricular frente a la ablación aislada de la aurícula izquierda en fibrilación auricular persistente. Recurrencia a medio-largo plazo.

UNLABELLED: The long-term results of cryomaze in patients with longstanding persistent atrial fibrillation during concomitant surgical procedures are still uncertain. METHODS: Between 2006 and 2011, 150 consecutive patients with associated long-lasting permanent atrial fibrillation and associated heart disease underwent heart surgery were treated by biatrial Cox-Maze (63 patients) or by isolated endocardial or epicardial left atrial cryoablation (83 patients) concomitantly. The results at 3 years in these groups were compared with clinical monitoring, electrocardiography, 24-hour Holter, and echocardiography with measurement of the transmitral A wave at 1, 6 and 12 months and annually thereafter in all patients. RESULTS: Patients undergoing Cox-Maze IV ablation presented rates of freedom from atrial fibrillation of 97, 94, 89, 80 and 54% at 1, 6, 12, 24 and 36 months, respectively. In the 12-month follow-up, these differences were significant (p<.05). The independent risk factors of atrial fibrillation recurrence was isolated ablation of left atrium. CONCLUSIONS: Atrial fibrillation by cryothermia ablation had a high success rate before 2 years postoperatively. Recurrence of atrial fibrillation increased thereafter regardless of the technique used, although it was more intense and developed earlier in cases of monoatrial ablation. For the treatment of other long-lasting permanent atrial fibrillation cardiac surgery-associated pathology, an aggressive biatrial treatment with Cox maze ablation should be performed.

Efficacy of Oral Anticoagulation in Stroke Prevention among Sinus-Rhythm Patients Who Lack Left Atrial Mechanical Contraction after Cryoablation.

The customary recommendation is that oral anticoagulation be withdrawn a few months after cryoablation for atrial fibrillation, independently of left atrial mechanical contraction in patients in sinus rhythm. Recently, a 5-fold increase in stroke has been described in sinus-rhythm patients who lack atrial mechanical contraction. One aim of this study was to evaluate the efficacy of oral anticoagulation in preventing postoperative stroke in such patients. This prospective study divided 154 sinus-rhythm patients into 2 groups, depending on the presence (108 patients) or absence (46 patients) of left atrial mechanical contraction at 6 months after surgery, and monitored them annually for 5 years. Those without left atrial contraction were maintained on acenocumarol. The primary endpoint was the occurrence of ischemic stroke. The median follow-up period was 29 ± 16 months; 4 patients (2.5%), all belonging to the group with preserved atrial contraction, had ischemic stroke; the group of patients without left atrial contraction had no episodes of stroke during follow-up. Logistic binary regression analyses showed no evidence of factors independently predictive of stroke. Among anticoagulated patients in sinus rhythm without left atrial contraction, we found the incidence of stroke to be zero. In a small, nonrandomized group such as this, we cannot discount the element of chance, yet we suggest that maintaining anticoagulation might lower the incidence of stroke in this population.

Mitral stenosis after IMR ETlogix ring annuloplasty for ischemic regurgitation.

OBJECTIVES: Ring annuloplasty combined with coronary artery bypass grafting is the standard approach for treatment of patients with ischemic mitral regurgitation. We evaluated mitral valve hemodynamic performance and recurrence of mitral regurgitation after ring annuloplasty. PATIENTS AND METHODS: 40 consecutive patients (mean age, 70±8 years) with chronic ischemic mitral regurgitation grade ≥2+ received annuloplasty with an IMR ETlogix ring. During follow-up (25.9±15.5 months), 84% of surviving patients underwent exercise stress echocardiography to assess recurrence of mitral regurgitation and differences between rest and exercise mitral valve hemodynamic performance. RESULTS: Hospital mortality was 10%. During follow-up, we found no significant differences between left ventricular ejection fraction or end-diastolic and end-systolic diameters pre- and postoperatively (41% vs. 45%, 59 vs. 56 mm, and 49 vs. 46 mm, respectively), but there was a significant increase in mitral mean gradient with exercise (3.3±1.2 vs. 7.8±4 mmHg, p<0.001). Two patients had mitral regurgitation ≥grade III-IV. CONCLUSIONS: Mitral annuloplasty with the IMR ETlogix ring provides effective correction of chronic ischemic mitral regurgitation, but this technique may induce functional mitral stenosis.

Placement of a rigid tricuspid annuloplasty ring over a flexible ring for the treatment of recurrent tricuspid regurgitation.

We describe a technique that implants a rigid tricuspid annuloplasty ring over a previously inserted flexible ring for the treatment of recurrent tricuspid regurgitation. This technique avoids the trauma associated with the excision of a flexible ring in patients with friable annular tissue.

Early thrombosis of a tricuspid annuloplasty ring and mild hyperhomocysteinemia.

Tricuspid annuloplasty ring thrombosis is an extremely infrequent pathology, and no evidence-based antithrombotic management has been described. We present the case of a 40-year-old female with isolated mild hyperhomocysteinemia and early ring thrombus formation after surgical primary closure of an atrial septal defect and ring tricuspid annuloplasty. Clinical management, antithrombotic treatment, and hyperhomocysteinemia implications are discussed.

Mitral valve prosthesis implanted in atrial wall over huge calcified annulus.

We describe an alternative technique for mitral valve replacement in patients with severe mitral annular calcification, in whom conventional techniques are not feasible. A new annulus that allows supra-annular prosthetic implantation is created.

Surgical treatment of giant intramural left ventricular fibroma in an adult patient with refractory ventricular tachycardia.

Cardiac fibromas are rare benign tumors predominantly diagnosed in children and teenagers. We report a 57-year-old male patient with class II dyspnea and angina. During electrocardiographic assessment, recurrent ventricular tachycardia was present and magnetic resonance imaging revealed a giant (12.5 × 5 × 4 cm) intramural left ventricular tumor compatible with cardiac fibroma. After surgical biopsy and histological confirmation, open-heart surgical resection was successfully performed. After nine months of follow up, the patient remains asymptomatic without evidence of ventricular tachycardia.

Giant left main coronary artery to right atrium fistula.

Aneurysmal arterial origin of coronary fistulae is an extremely rare combination. We report a case of a giant left main coronary artery to right atrium fistula in a 48-year-old male. We describe the clinical course and management options.

Emergent surgery for ruptured aortic arch aneurysm in an octogenarian patient: quo vadis?

Aortic arch aneurysms induce great morbidity and mortality especially when clinical signs of rupture are present. Surgical indications for repair in the high-risk octogenarian population are controversial. We present the case of an 87-year-old man with a ruptured aortic arch aneurysm with a good surgical outcome. We discuss the clinical impact of the surgical treatment in this group of patients.

Mitroflow bioprosthesis stent deformation: a rare cause of early prosthetic stenosis.

We report the case of a severe prosthetic aortic stenosis in a 61-year-old male patient with an aortic Mitroflow LF bioprosthesis (Sorin Group) at early (6 months) postoperative echocardiographic follow-up. At reintervention, we found significant stent deformation, asymmetric orientation of the posts, and subsequent central kinking and prolapse of one leaflet. Maldistribution of pledgeted mattress sutures over the flexible stent was found to be the origin of its permanent deformation. Simple technical preventive strategies of this previously unreported complication are suggested.

Preoperative statin therapy and troponin T predict early complications of coronary artery surgery.

BACKGROUND: Pretreatment with statins reduces early ischemic events after percutaneous coronary interventions, primarily in patients with a high level of inflammation markers. We sought to examine the association between preoperative statin therapy, systemic inflammation, and myocardial ischemia with the occurrence of early cardiac complications after coronary artery bypass grafting surgery. METHODS: One hundred forty-one consecutive patients who underwent coronary artery bypass grafting surgery from two university tertiary hospitals were stratified according to their preoperative status of statin therapy (87 treated and 54 nontreated). Preoperative blood samples were collected for measurement of lipid parameters, C-reactive protein, interleukin-6, and troponin T. The evaluated primary endpoint was a composite of death and myocardial infarction at 30 days. RESULTS: Patients undergoing preoperative statin therapy showed a reduced incidence of death (2.3% versus 13.0%, p = 0.012), myocardial infarction (5.7% versus 18.5%, p = 0.017), and primary combined endpoint (8.0% versus 22.2%, p = 0.017). In the multivariate model, preoperative troponin T greater than 0.01 ng/mL (odds ratio 6.85, p = 0.001) and nonstatin therapy (odds ratio 4.2, p = 0.01) predicted a higher risk of primary endpoint. Statins showed a significant interaction with troponin T status and benefited primarily those patients with positive troponin T. Among 19 patients with troponin T greater than 0.01 ng/mL, the primary endpoint occurred in all 6 nonstatin-treated patients, but it occurred in only 1 of 13 statin-treated patients (p < 0.001). Neither C-reactive protein nor interleukin-6 predicted early complications, nor did they interact with statin therapy (p = not significant). CONCLUSIONS: Preoperative statin therapy reduces early complications and offers additional protection in patients with positive troponin T status, regardless of inflammatory markers.

Statins and postoperative risk of atrial fibrillation following coronary artery bypass grafting.

Atrial fibrillation (AF) is a common complication after coronary artery bypass grafting. Atrial remodeling has been observed in AF and has been associated with the development of this arrhythmia. Because 3-hydroxy-3-methylglutaryl coenzyme A inhibitors (statins) have been demonstrated to modify remodeling, we hypothesized a protective role of statins against postoperative AF. We also hypothesized that extracellular matrix turnover and brain natriuretic peptide (BNP) might be related to such atrial remodeling. We studied 234 consecutive patients who underwent coronary artery bypass grafting (173 men; 65 +/- 9 years of age) in whom the occurrence of postoperative AF was monitored. In a subgroup of 66 patients, we measured plasma levels of matrix metalloproteinase-1 (MMP-1), its inhibitor, tissue inhibitor matrix metalloproteinase-1 (TIMP-1; as indexes of extracellular matrix remodeling), and N-terminus pro-BNP (related to left ventricular function) at baseline and at 24 hours after surgery. Of 234 patients, 66 (28.2%) developed postoperative AF. In multivariate analysis, previous AF was related to an increase in the development of AF (odds ratio 11.92, 95% confidence interval 2.37 to 59.98, p = 0.026), whereas statin use was related to a decrease in arrhythmia (odds ratio 0.52, 95% confidence interval 0.28 to 0.96, p = 0.038). A higher TIMP-1/MMP-1 ratio at 24 hours after surgery was present in those who did not develop postoperative AF (p = 0.043). Statin use was associated with increased TIMP-1 levels and TIMP-1/MMP-1 ratio (p = 0.027 and 0.036, respectively). No significant relations to N-terminus pro-BNP were seen. In conclusion, previous AF and nonuse of statins are significantly associated with AF after coronary artery bypass grafting. Statin use may be protective against AF after coronary artery bypass grafting, possibly due to alterations in the extracellular matrix and remodeling after coronary artery bypass grafting.

Nine-year follow up of the omnicarbon prosthesis in the aortic position.

BACKGROUND AND AIM OF THE STUDY: Clinical experience with the Omnicarbon mechanical valve implanted in the aortic position is reported in this retrospective survey. METHODS: A total of 110 patients (mean age 56 years) undergoing isolated aortic valve replacement with Omnicarbon mechanical prostheses at the authors' institution between November 1991 and October 2000 was included. Follow was available in 94.5% of patients (mean follow up 4 years per patient; total follow up was 415 patient-years (pt-yr)). RESULTS: Hospital mortality was 3.6%. There were no instances of valve thrombosis or structural failure. The incidence of valve-related complications (linearized rates in events per 100 pt-yr/actuarial freedom at 9 years, in %) was: valve-related mortality 2.4+/-0.7 / 80.3+/-8.0; non-structural failure 0.7+/-0.4 / 93.8+/-4.2; thromboembolism 0.2+/-0.2 / 99.0+/-1.0; anticoagulant-related hemorrhage 0.9+/-0.5 / 93.7+/-3.3; prosthetic valve endocarditis 0.2+/-0.2 / 99.0+/-1.0; and reoperation 0.7+/-0.4 / 93.8+/-4.2. CONCLUSION: In the authors' experience the Omnicarbon mechanical prosthesis provides a good clinical performance for up to nine years in the aortic position.

Optimal location for temporary epicardial pacing leads following open heart surgery.

Temporary epicardial pacing wires are routinely placed in patients undergoing cardiac surgery. Eighteen suitable patients undergoing elective surgery were prospectively studied. Their sensing and stimulating characteristics were studied at various locations. Subepicardial pacing leads were applied to the lateral wall of the LV, apex of the LV, anterior wall of the RV, diaphragmatic wall of the RV, and diaphragmatic wall of the LV. Impedance, R wave amplitude, slew rate, and stimulation thresholds were measured on postoperative days 1 and 5. Impedance remained unchanged in time with no significant differences between locations. R waves and slew rates were significantly lower in the anterior RV wall. Stimulation thresholds displayed no differences on day 1, but they increased significantly in all locations on day 5. These thresholds were significantly lower in the lateral and diaphragmatic LV walls on day 5, and the rate of voltage increase was also lower in these two locations. Five patients presented phrenic nerve stimulation when stimulating the lateral LV wall. The authors advocate the diaphragmatic wall of the LV as the best location for placing temporary leads. The anterior wall of the RV is not recommended for pacing purposes.

[A comparative study of the follow-up and hemodynamics in vivo of 21 mm Carpentier-Edwards supra-annular and perimount bioprostheses]. / Estudio comparativo del comportamiento clínico y hemodinámico de las bioprótesis aórticas de Carpentier-Edwards Supra-Annular y Perimount de 21 mm.

INTRODUCTION AND OBJECTIVES: Analysis and comparison of the clinical performance and hemodynamics in vivo of 21 mm Carpentier-Edwards supra-annular (CESA) and Perimount (CEPM) aortic bioprostheses. METHODS: A follow-up study was made of 40 patients implanted a 21 mm CESA (n = 21) or CEPM (n = 19) prosthesis between October 1992 and September 1997. All eligible survivors (14 CESA, 12 CEPM) were assessed echocardiographically. RESULTS: There were no significant differences between models in the effective orifice area (1.6 cm2 for CESA, 1.44 cm2 for CEPM), peak flow rate (rest: 2.5 m/s for CESA, 2.3 m/s for CEPM; post-dobutamine: 3.4 m/s for CESA, 3.3 m/s for CEPM), mean flow rate (rest: 1.7 m/s for CESA, 1.6 m/s for CEPM; post-dobutamine: 2.5 m/s for CESA, 2.2 m/s for CEPM), peak gradient (rest: 28.3 mmHg for CESA, 21.6 mmHg for CEPM; post-dobutamine: 48.4 mmHg for CESA, 41.6 mmHg for CEPM), and mean gradient (rest: 15.8 mmHg for CESA, 12.0 mmHg for CEPM; post-dobutamine: 28.5 mmHg for CESA, 22.5 mmHg for CEPM). CONCLUSION: In our experience, these two prosthetic models have similar hemodynamic characteristics in small aortic annuli.