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OBJECTIVE: Evaluate outcomes of valve-sparing root replacement (VSRR) in patients with bicuspid aortopathy (BAV) versus other connective tissue disorder (CTD). METHODS: Single-center cohort study of consecutive patients undergoing VSRR via reimplantation from 2000-2023 with BAV or CTD. Operative outcomes, Kaplan-Meier survival estimates, and cumulative risk of reoperation and recurrent aortic insufficiency (AI) with the competing risk of death were assessed. RESULTS: Of 516 VSRR patients, 109 (51.9%) had BAV and 101 (48.1%) had CTD. BAV patients were older (46.9±10.4 vs 38.4±14 years, p<0.001) and more likely male ( 89.0% vs 56.4%, p<0.001) and hypertensive (66.1% vs 28.7%, p<0.001). Preoperative AI was similar (p=0.57) between groups (30.3% mild, 18.3% moderate, 11.1% severe). Most patients had no/trivial immediate postoperative residual AI (96.3% vs 93.1%). Operative mortality was zero; postoperative adverse events were minimal. Mean clinical follow-up was 5.2±4.4 years; ten-year survival was 95.6% vs 95.7% (p=0.70). Echocardiographic follow-up was 3.9±4.1 years; incidence of >2+ AI (9.7% vs 10.1%, p=1.0) was similar between groups, while incidence of moderate or greater aortic stenosis (AS) was higher with BAV (7.5% vs 0%, p=0.02). Reoperation was low in both groups (3.7% vs 5.9%, p=0.65). Competing risk analysis found no difference in reoperation hazard between BAV and CTD groups (hazard ratio 0.36, 95% confidence interval 0.07-1.81, p=0.21). CONCLUSIONS: BAV and CTD patients have excellent operative outcomes, no mortality, and minimal residual AI after VSRR. While the incidence of recurrent AI was similar, BAV patients are at risk for AS.
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BACKGROUND: We compared the outcomes of aortic root replacement by composite valve grafts (CVG) and valve-sparing root replacement (VSRR) operations, with an emphasis on postoperative conduction block and the need for permanent pacemaker implantation (PPM). METHODS: From 1997 to 2023, 1712 consecutive patients underwent ARR by VSRR (501 [29%]) or CVG (1211 [71%]) at a high-volume aortic center. RESULTS: Patients undergoing CVG were older (59 ± 14 vs 49 ± 14 years, P < .001), with more cardiovascular comorbidities. Compared with CVG, there were more women undergoing VSRR (17% vs. 13%, P = .042) and more patients with connective tissue disease (22% vs 7.3%, P < .001). Multivariable analysis found that the risk for PPM was higher after CVG compared with VSRR (6.5% vs 1.2%; odds ratio [OR], 2.83; 95% CI, 1.23-7.69; P = .024). Other variables associated with PPM include older age (OR, 1.03; 95% CI, 1.01-1.05; P = .006) preoperative renal impairment (OR, 2.69; 95% CI, 1.24-5.6; P = .010), previous operation (OR, 2.76; 95% CI, 1.29-5.62; P = .007), and bicuspid aortic valve (OR, 3.63; 95% CI, 2.13-6.33; P < .001). Among the CVG population, patients who are at increased risk are especially those with some degree of aortic stenosis (OR, 2.06; 95% CI, 1.18-3.61; P = .011). Patients who required PPM had no additive risk for long-term mortality (hazard ratio, 1.01; 95% CI, 0.47-2.17; P = .986); however, they were more likely to have reduced ejection fraction (29.3% vs 16%, P = .014). CONCLUSIONS: The incidence of PPM after ARR is low, but rates were higher after CVG compared with VSRR.
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Aneurisma de la Aorta Torácica , Implantación de Prótesis Vascular , Humanos , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Resultado del Tratamiento , Procedimientos Endovasculares , Aorta Torácica/cirugía , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta ToracoabdominalRESUMEN
BACKGROUND: Both valve-sparing root replacement and composite valve graft (CVG) are acceptable options in aortic root replacement. We compare outcomes of these 2 approaches and durability of the aortic valve. METHODS: A consecutive 1635 patients without acute dissection underwent primary aortic root replacement from 1997 to 2022; 473 (29%) underwent valve-sparing root replacement, and 1162 (71%) received CVG. Propensity score matching was used to reduce baseline differences. RESULTS: The CVG group was older (59 ± 14 years vs 49 ± 14 years; P < .001) with more comorbidities, such as hypertension (88.4% vs 66.4%; P < .001), diabetes (7% vs 1.7%; P < .001), ischemic heart disease (5.1% vs 1.3%; P = .001), pulmonary disease (6.6% vs 1.3%; P < .001), renal impairment (8.6% vs 1.3%; P < .001), class III-IV heart failure (35% vs 9.2%; P < .001), bicuspid aortic valves (44.8% vs 24.1%; P < .001), and severe aortic insufficiency (50.2% vs 13.2%; P < .001). Operative mortality was 0.4% (0% in valve sparing); incidence of major postoperative complications was 2.9% (3.6% vs 1.1%; P = .009). Ten-year survival was 93.1% (91.2% vs 97.7%; hazard ratio [HR], 1.7; 95% CI, 0.9-3.3; P = .120). Mean follow-up was 65 ± 60 months; aortic valve reoperations were similar (5.8% vs 5.7%; HR, 0.8; 95% CI, 0.4-1.4; P = .401). Recurrent moderate-severe aortic insufficiency was less prevalent in CVG (6.1% vs 11.1%; HR, 0.14; 95% CI, 0.07-0.27; P < .001). Propensity score matching identified 225 pairs. There was no difference in 10-year survival or reoperations. Recurrent moderate-severe aortic insufficiency was higher with valve sparing. CONCLUSIONS: Both valve-sparing operations and CVG provide excellent early and late outcomes out to 10 years. Valve sparing is associated with a higher risk for development of aortic insufficiency but no difference in reoperations.
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Insuficiencia de la Válvula Aórtica , Enfermedad de la Válvula Aórtica Bicúspide , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Puntaje de Propensión , Resultado del Tratamiento , Válvula Aórtica/cirugía , Aorta/cirugía , Enfermedad de la Válvula Aórtica Bicúspide/cirugía , Insuficiencia de la Válvula Aórtica/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: Biomechanical effects of transcatheter (TAVR) versus surgical (SAVR) aortic valve interventions on the distal aorta have not been studied. This study utilized global circumferential strain (GCS) to assess post-procedural biomechanics changes in the descending aorta after TAVR versus SAVR. METHODS: Patients undergoing TAVR or SAVR for aortic stenosis were included. Transesophageal (TEE) and transthoracic (TTE) echocardiography short-axis images of the aorta were used to image the descending aorta immediately before and after interventions. Image analysis was performed with two-dimensional speckle tracking echocardiography and dedicated software. Delta GCS was calculated as: post-procedural GCS-pre-procedural GCS. Percentage delta GCS was calculated as: (delta GCS/pre-procedural GCS) × 100. RESULTS: Eighty patients, 40 TAVR (median age 81 y/o, 40% female) and 40 SAVR (median 72 y/o, 30% female) were included. The post-procedure GCS was significantly higher than the pre-procedural GCS in the TAVR (median 10.7 [interquartile range IQR 4.5, 14.6] vs. 17.0 [IQR 6.1, 20.9], p = 0.009) but not in the SAVR group (4.4 [IQR 3.3, 5.3] vs. 4.7 [IQR 3.9, 5.6], p = 0.3). The delta GCS and the percentage delta GCS were both significantly higher in the TAVR versus SAVR group (2.8% [IQR 1.4, 6] vs. 0.15% [IQR - 0.6, 1.5], p < 0.001; and 28.8% [IQR 14.6%, 64.6%] vs. 4.4% [IQR - 10.6%, 5.6%], p = 0.006). Results were consistent after multivariable adjustment for key clinical and hemodynamic characteristics. CONCLUSIONS: After TAVR, there was a significantly larger increase in GCS in the distal aorta compared to SAVR. This may impact descending aortic remodeling and long-term risk of aortic events.
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Estenosis de la Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Femenino , Anciano de 80 o más Años , Masculino , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Fenómenos Biomecánicos , Resultado del Tratamiento , Estenosis de la Válvula Aórtica/cirugía , Factores de RiesgoRESUMEN
The external stenting of saphenous vein grafts (SVGs) during coronary artery bypass grafting (CABG) has been proven to reduce intimal hyperplasia (IH) in animal models, paving the way for human randomized controlled trials (RCTs) to be conducted. Herein, we performed a study-level meta-analysis to assess the impact of the Venous External SupporT (VEST) device, an external stent, on the outcomes of SVGs. A systematic search was conducted to identify all RCTs comparing VEST-stented to non-stented SVGs in patients undergoing CABG. The primary outcome was graft occlusion. The main secondary outcomes were repeat revascularization, SVG IH area, and intimal-medial thickness. Two RCTs totaling 407 patients were included. At a mean follow-up of 1.5 years, there was no difference in graft occlusion between groups (incidence rate ratio: 1.11; 95% confidence interval (CI): 0.80-1.53). The rate of repeat revascularization was also similar (odds ratio: 0.66; 95% CI: 0.27-1.64). The IH area (standardized mean difference (SMD): -0.45; 95% CI: -0.79 to -0.10) and intimal-medial thickness (SMD: -0.50; 95% CI: -0.90 to -0.10) were significantly reduced in the VEST group. Our findings show that significant reductions in the IH area and the intimal-medial thickness in VEST-stented SVGs do not currently translate into a lesser need for repeat revascularization or less graft occlusion events compared to non-stented SVGs at 1.5 years after CABG.
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OBJECTIVE: To review the available literature on the use of coronary artery bypass grafting (CABG) as a treatment option for anomalous origin of coronary artery in adults. METHODS: A systematic literature search was performed in March 2023 (including Ovid MEDLINE, Ovid Embase, and the Cochrane Library databases) to identify studies reporting the use of CABG in adult patients with anomalous origin of coronary artery. RESULTS: A total of 31 studies and 62 patients were included, 32 patients (52%) were women, and the mean age was 45.1±16.1 years. The most common coronary anomaly was the right coronary artery arising from the left coronary sinus in 26 patients (42%), followed by an anomalous left coronary artery from the pulmonary artery in 23 patients (37%). A total of 65 conduits were used in 61 patients, and 1 case report did not report conduit type. Reported grafts included saphenous vein (23 of 65 [35.4%]), left internal thoracic artery (15 of 65 [23.1%]), right internal thoracic artery (23 of 65 [35.4%]), and radial artery (2 of 65 [3.1%]); right gastroepiploic artery and basilic vein were used once (1.5%) each. Ligation of the native coronary artery was performed in 42 (67.7%) patients. Patient follow-up was available in 19 studies with a mean of 31.2 months. Only 1 operative mortality was reported. CONCLUSIONS: Based on the limited available data, CABG can be performed with good early results. Use of arterial conduits and ligation of the native coronary artery may improve long-term graft patency.
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Vasos Coronarios , Arterias Mamarias , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Angiografía Coronaria , Puente de Arteria Coronaria/métodos , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Arterias Mamarias/trasplante , Arteria Radial/trasplante , Vena Safena/trasplante , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Saphenous vein grafts (SVGs) are the most frequently used conduits in coronary artery bypass grafting (CABG), but their higher rate of occlusion compared to arterial conduits remains a concern. Previous studies have shown that SVG failure is mainly driven by intimal hyperplasia, an adaptative response to higher pressures of the arterial circulation. The VESTTM device (Vascular Graft Solutions, Tel Aviv, Israel), an external support designed to mitigate intimal hyperplasia in SVGs, has been tested in few clinical trials (RCTs). Herein, we descriptively evaluated the randomized evidence on the VEST device.
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As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines.
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Anomalías de los Vasos Coronarios , Vasos Coronarios , Adulto , Humanos , Vasos Coronarios/cirugía , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Anomalías de los Vasos Coronarios/terapia , Estudios Retrospectivos , AortaRESUMEN
As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines.
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Anomalías de los Vasos Coronarios , Vasos Coronarios , Humanos , Adulto , Vasos Coronarios/cirugía , Anomalías de los Vasos Coronarios/complicaciones , Anomalías de los Vasos Coronarios/diagnóstico , Anomalías de los Vasos Coronarios/cirugía , AortaRESUMEN
Background: Spinal cord injury (SCI) is a rare but severe complication after open or endovascular repair of descending thoracic aneurysms (DTAs) or thoracoabdominal aortic aneurysms (TAAAs). This meta-analysis aims to provide a comprehensive assessment of SCI rates and factors associated with SCI. Methods: A systematic literature search was performed in September 2022 looking for studies on open and/or endovascular repair of DTA and/or TAAA published after 2018, to update the results of our previously published meta-analysis. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, 30-day and in-hospital mortality, follow-up mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications. Data were pooled as proportions using inverse-variance weighting. Results: A total of 239 studies (71 new studies and 168 from our previous meta-analysis) and 61,962 patients were included. The overall pooled rate of permanent SCI was 3.3% [95% confidence interval (CI), 2.9-3.8%]. Open repair was associated with a permanent SCI rate of 4.0% (95% CI, 3.3-4.8%), and endovascular repair was associated with a permanent SCI rate of 2.9% (95% CI, 2.4-3.5%). Permanent SCI was 2.0% (95% CI, 1.2-3.3%) after DTA repair, and 4.7% (95% CI, 3.9-5.6%) after TAAA repair; permanent SCI rate was 3.8% (95% CI, 2.9-5.0%) for Crawford extent I, 13.4% (95% CI, 9.0-19.5%) for extent II, 7.1% (95% CI, 5.7-8.9%) for extent III, 2.3% (95% CI, 1.6-3.5%) for extent IV, and 6.7% (95% CI, 1.7-23.1%) for extent V TAAA aneurysms. The pooled rate of CSF drain related complications was 1.9% (95% CI, 0.8-4.7%) for severe, 0.4% (95% CI, 0.0-4.0%) for moderate, and 1.8% (95% CI, 0.6-5.6%) for minor complications. Conclusions: Permanent SCI occurs after both endovascular and open DTA or TAAA repairs. Open repairs and TAAA repairs have higher risk of SCI compared with endovascular or DTA repairs. In particular, extent II aneurysms present the highest overall risk of SCI.
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BACKGROUND: Postoperative atrial fibrillation (POAF) is the most frequent complication of cardiac surgery. Despite clinical and economic implications, ample variability in POAF assessment method and definition exist across studies. We performed a study-level meta-analysis to evaluate the influence of POAF assessment method and definition on its incidence and association with clinical outcomes. METHODS AND RESULTS: A systematic literature search was conducted to identify studies comparing the outcomes of patients with and without POAF after cardiac surgery that also reported POAF assessment method. The primary outcome was POAF incidence. The secondary outcomes were in-hospital mortality, stroke, intensive care unit length of stay, and postoperative length of stay. Fifty-nine studies totaling 197 774 patients were included. POAF cumulative incidence was 26% (range: 7.3%-53.1%). There were no differences in POAF incidence among assessment methods (27%, [range: 7.3%-53.1%] for continuous telemetry, 27% [range: 7.9%-50%] for telemetry plus daily ECG, and 19% [range: 7.8%-42.4%] for daily ECG only; P>0.05 for all comparisons). No differences in in-hospital mortality, stroke, intensive care unit length of stay, and postoperative length of stay were found between assessment methods. No differences in POAF incidence or any other outcomes were found between POAF definitions. Continuous telemetry and telemetry plus daily ECG were associated with higher POAF incidence compared with daily ECG in studies including only patients undergoing isolated coronary artery bypass grafting. CONCLUSIONS: POAF incidence after cardiac surgery remains high, and detection rates are variable among studies. POAF incidence and its association with adverse outcomes are not influenced by the assessment method and definition used, except in patients undergoing isolated coronary artery bypass grafting.
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Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Accidente Cerebrovascular , Humanos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/epidemiología , Fibrilación Atrial/etiología , Incidencia , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/complicaciones , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Factores de RiesgoRESUMEN
OBJECTIVE: Total aortic arch replacement (TAR) after previous cardiovascular surgery is technically challenging and is becoming more frequent as outcomes for primary arch repair have improved. primary. We analyzed outcomes of reoperative compared with first-time TAR. METHODS: The institutional aortic database was queried to identify consecutive patients undergoing TAR between 1997 and 2022. In total, 426 patients underwent TAR, of whom 150 (35%) had previous cardiovascular surgery (reop TAR) and 276 (65%) underwent their first cardiovascular operation. RESULTS: The reop TAR group was younger (61 ± 13 vs 71 ± 11, P < .001) with more comorbidities such as ischemic heart disease (12% vs 4.3%, P = .006), previous stroke (36% vs 14.5%, P < .001), and renal impairment (24% vs 12.7%, P = .004). Reop TAR had longer cardiac ischemic times (119.3 ± 45.5 minutes vs 98 ± 31.9 minutes, P < .001), a greater operative mortality (3.3% vs 0.4%, P = .040), and incurred a 4-fold increased risk of major adverse event (95% confidence interval [CI], 1.41-11.49, P = .009). Ten-year survival was also lower in the reop TAR cohort (76% vs 82.2%; hazard ratio, 1.79; 95% CI, 1.12-2.86, P = .015) and there was greater need for late reinterventions, mainly on the downstream aorta (hazard ratio, 1.29; 95% CI, 1.03-1.62, P = .024). CONCLUSIONS: Reop TAR is a technically challenging operation and is associated with increased operative mortality and adverse events. Gratifying results can be obtained with meticulous surgical planning and focused attention on end-organ protection. Late reinterventions occur in a significantly greater percentage of patients undergoing reop TAR, and future studies should focus attention on identifying those at-risk groups who may benefit from a more aggressive index procedure.
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Objective: The 2 most acceptable techniques for reimplantation of the supra-aortic vessels in total arch replacement include the branched graft technique (debranching) or en bloc technique (island). We aim to review our experience with total arch replacement and report short- and long-term outcomes from a high-volume center dedicated to surgery for the thoracic aorta. Methods: The aortic surgery database was queried to identify all consecutive patients undergoing total arch replacement between 1997 and 2022. Of the 426 patients who underwent total arch replacement, 303 (71%) received the island technique and 123 (29%) received the debranching approach. Operative and long-term outcomes were compared using multivariable models. Results: The debranching group was younger (64 ± 14 years vs 69 ± 12 years, P = .001), had undergone more previous cardiac operations (54.5% vs 27.4%, P < .001), and had more connective tissue disorder (20.3% vs 4.6%, P < .001). The debranching approach was associated with longer total circulatory arrest time (47 ± 15 minutes vs 37 ± 10 minutes, P < .001) and cardiac ischemic time (116 ± 41 minutes vs 100 ± 37 minutes, P < .001). More patients in the debranching group received blood products intraoperatively or postoperatively (56.1% vs 42.9%, P = .018). All other early outcomes did not differ between groups. Overall operative mortality was 1.4% (2.4% vs 1%, P = .486); the incidence of major postoperative complications was 6.3% (5.7% vs 6.6%, P = .897). Ten-year survival was 80% (78% vs 80.9%, log-rank P = .356). Multivariable Cox regression analysis demonstrated that neither surgical approach was associated with survival advantage (hazard ratio, 1.18; 0.73-1.89; P = .495). Conclusions: Debranching requires a longer operative time, with similar early and long-term outcomes. Preoperative comorbidity, not surgical technique, predicts major adverse events and long-term survival.
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BACKGROUND: Detailed understanding of the association between intraoperative left atrial and left ventricular diastolic function and postoperative atrial fibrillation is lacking. In this post hoc analysis of the Posterior Left Pericardiotomy for the Prevention of Atrial Fibrillation after Cardiac Surgery (PALACS) trial, we aimed to evaluate the association of intraoperative left atrial and left ventricular diastolic function as assessed by transesophageal echocardiography (TEE) with postoperative atrial fibrillation. METHODS: PALACS patients with available intraoperative TEE data (n = 402 of 420; 95.7%) were included in this cohort study. We tested the hypotheses that preoperative left atrial size and function, left ventricular diastolic function, and their intraoperative changes were associated with postoperative atrial fibrillation. Normal left ventricular diastolic function was graded as 0 and with lateral e' velocity 10 cm/s or greater. Diastolic dysfunction was defined as lateral e' less than 10 cm/s using E/e' cutoffs of grade 1, E/e' 8 or less; grade, 2 E/e' 9 to 12; and grade 3, E/e' 13 or greater, along with two criteria based on mitral inflow and pulmonary wave flow velocities. RESULTS: A total of 230 of 402 patients (57.2%) had intraoperative diastolic dysfunction. Posterior pericardiotomy intervention was not significantly different between the two groups. A total of 99 of 402 patients (24.6%) developed postoperative atrial fibrillation. Patients who developed postoperative atrial fibrillation more frequently had abnormal left ventricular diastolic function compared to patients who did not develop postoperative atrial fibrillation (75.0% [n = 161 of 303] vs. 57.5% [n = 69 of 99]; P = 0.004). Of the left atrial size and function parameters, only delta left atrial area, defined as presternotomy minus post-chest closure measurement, was significantly different in the no postoperative atrial fibrillation versus postoperative atrial fibrillation groups on univariate analysis (-2.1 cm2 [interquartile range, -5.1 to 1.0] vs. 0.1 [interquartile range, -4.0 to 4.8]; P = 0.028). At multivariable analysis, baseline abnormal left ventricular diastolic function (odds ratio, 2.02; 95% CI, 1.15 to 3.63; P = 0.016) and pericardiotomy intervention (odds ratio, 0.46; 95% CI, 0.27 to 0.78, P = 0.004) were the only covariates independently associated with postoperative atrial fibrillation. CONCLUSIONS: Baseline preoperative left ventricular diastolic dysfunction on TEE, not left atrial size or function, is independently associated with postoperative atrial fibrillation. Further studies are needed to test if interventions aimed at optimizing intraoperative left ventricular diastolic function during cardiac surgery may reduce the risk of postoperative atrial fibrillation.