Number and Type of Blood Products Are Negatively Associated With Outcomes After Cardiac Surgery.

BACKGROUND: The association between blood transfusion and adverse outcome is documented in cardiac surgery. However, the incremental significance of each unit transfused, whether red blood cell (RBC) or non-RBC, is uncertain. This study examined the relationship of patient outcomes with the type and number of blood product units transfused. METHODS: Statewide data from 24 082 adult cardiac surgery patients were included. The relationship with blood transfusion was assessed for morbidity and 30-day mortality using total number of RBC and non-RBC units transfused, specific type of non-RBC units, and different combinations of transfusion (only RBC, only non-RBC, RBC + non-RBC). Multivariable logistic regressions examined these associations. RESULTS: Median age was 66 years (30% female patients), and 51% of patients received a transfusion (31%-66% across hospitals). Risk-adjusted analyses found each blood product unit was associated with 9%, 7%, and 4% greater odds for 30-day mortality, major morbidity, and minor morbidity, respectively (all P < .001). Odds for 30-day mortality were 13% greater with each RBC unit (P < .001) and 6% greater for each non-RBC unit (P < .001). Each unit of fresh frozen plasma (P < .001) and platelets (P < .001) increased the odds for 30-day mortality, but no effect was found for cryoprecipitate (P = .725). Odds for 30-day mortality were lower for non-RBC-only (odds ratio, 0.52; P = .030) and greater for RBC + non-RBC (odds ratio, 2.98; P < .001) compared with RBC-only transfusion. CONCLUSIONS: Independent of center variability on transfusion methods, each additional unit transfused was associated with increased odds for complications, with RBC transfusion carrying greater risk compared with non-RBC. Comprehensive evidence-based clinical approaches and coordination are needed to guide each blood transfusion event after cardiac surgery.

The long-term safety and efficacy of concomitant Cox maze procedures for atrial fibrillation in patients without mitral valve disease.

OBJECTIVE: Newly published guidelines made the highest level recommendation for surgical treatment for atrial fibrillation. However, the number of patients without a mitral valve procedure with atrial fibrillation who are treated with concomitant surgical ablation is still low (15%-25%), because surgeons are reluctant to perform procedures in patients who would not otherwise require left atriotomy. The purpose of this study was to compare the outcomes of concomitant Cox maze with and without mitral valve procedures. METHODS: Patients who underwent concomitant Cox maze procedures were prospectively followed since September 2005. Of the 711 patients, 238 did not receive mitral valve surgery. Propensity score matching was conducted to balance preoperative characteristics between patients with and without mitral valve procedures (164/group after matching). RESULTS: Before matching, patients in the mitral valve group were younger (65 vs 67 years, P = .047) and had higher euroSCORE II (European System for Cardiac Operative Risk Evaluation; 3.2% vs 2.6%, P = .002), larger mean left atrial size (5.3 vs 4.8 cm, P < .001), and shorter median atrial fibrillation duration (19 vs 25 months, P = .064). Early outcomes were similar for the matched groups. Cumulative 5-year freedom from stroke did not differ between matched mitral valve and non-mitral valve groups (96.1% vs 96.6%, P = .667). At each time point, the proportion in sinus rhythm off antiarrhythmic medications was similar for the matched groups, including 5 years after surgery (68% vs 63%, P = .492). CONCLUSIONS: The Cox maze procedure is safe and effective with comparable outcomes when performed concomitant to mitral valve or non-mitral valve surgery. Surgeons should base the decision to perform surgical ablation procedures on atrial fibrillation pathophysiology and the benefit to patients, not on the type of concomitant procedure.

Long-term outcome following concomitant mitral valve surgery and Cox maze procedure for atrial fibrillation.

OBJECTIVE: Atrial fibrillation (AF) is associated with increased early and long-term morbidity/mortality following valve surgery. This study examined long-term influence of concomitant full Cox maze (CM) and mitral valve procedures on freedom from atrial arrhythmia and stroke. METHODS: This sample comprised patients who underwent CM with a mitral valve procedure (N = 473). Data on rhythm, medication status, and clinical events captured according to Heart Rhythm Society guidelines at 6, 9, 12, 18, and 24 months and yearly thereafter up to 7 years. RESULTS: Mean age was 65 years, mean left atrium size was 5.3 cm, and 15% had paroxysmal AF. Perioperative stroke occurred in 2 patients (0.4%) and operative mortality was 2.7% (n = 13). Return to sinus rhythm regardless of antiarrhythmic drugs at 1, 5, and 7 years was 90%, 80%, and 66%. Sinus rhythm off antiarrhythmic drugs at 1, 5, and 7 years was 83%, 69%, and 55%. Freedom from embolic stroke at 7 years was 96.6% (0.4 strokes per 100 patient-years) with a majority of patients off anticoagulation medication. Greater odds of atrial arrhythmia recurrence during 7 years was associated with longer AF duration (odds ratio [OR], 1.07; P = .001), whereas lower odds were associated with cryothermal energy only (OR, 0.64; P = .045) and greater surgeon experience (OR, 0.98; P = .025). CONCLUSIONS: This study suggests that the addition of CM to mitral valve procedures, even with a high degree of complexity, did not increase operative risk. In long-term follow-up, the CM procedure demonstrated acceptable rhythm success, reduced AF burden, and remarkably low stroke rate. Individual surgeon experience and training may notably influence long-term surgical ablation for AF success.

The use of del Nido cardioplegia in adult cardiac surgery: A prospective randomized trial.

OBJECTIVES: The del Nido cardioplegia solution has been used extensively in congenital heart surgery for more than 20 years and more recently for adults. This randomized controlled trial examined whether expanding this technique to adult cardiac surgery confers benefits in surgical workflow and clinical outcome compared with blood-based cardioplegia. METHODS: Adult first-time coronary artery bypass grafting (CABG), valve, or CABG/valve surgery patients requiring cardiopulmonary bypass (CPB) were randomized to del Nido cardioplegia (n = 48) or whole blood cardioplegia (n = 41). Primary outcomes assessed myocardial preservation. Troponin I was measured at baseline, 2 hours after CPB termination, 12 and 24 hours after cardiovascular intensive care unit admission. Alpha was set at P < .001. RESULTS: Preoperative characteristics were similar between groups, including age, Society of Thoracic Surgeons risk score, CABG, and valve procedures. There was no significant difference on CPB time (97 vs 103 minutes; P = .288) or crossclamp time (70 vs 83 minutes; P = .018). The del Nido group showed higher return to spontaneous rhythm (97.7% vs 81.6%; P = .023) and fewer patients required inotropic support (65.1% vs 84.2%; P = .050), but did not reach statistical significance. Incidence of Society of Thoracic Surgeons-defined morbidity was low, with no strokes, myocardial infarctions, renal failure, or operative deaths. For del Nido group patients, troponin levels did not increase as much as for control patients (P = .040), but statistical significance was not reached. CONCLUSIONS: Evidence from this study suggests del Nido cardioplegia use in routine adult cases may be safe, result in comparable clinical outcomes, and streamline surgical workflow. The trend for troponin should be investigated further because it may suggest superior myocardial protection with the del Nido solution.

Maintaining Quality in Lower Volume Cardiac Surgery: A Blueprint From a Military Program.

Although there is a clear volume-outcome relationship in the field of cardiac surgery, the existence of high-performing programs with relatively low case volumes is well established. This report describes the programmatic and institutional processes in place at a lower volume cardiac surgery center in a US military hospital, which have been executed to optimally leverage available resources in the delivery of exemplary patient care. By implementing a highly collaborative practice, rigorous outcomes review, evidence-based standardized care pathways, consistent attending surgeon oversight for care delivery, careful case selection, and a mechanism for support from highly experienced outside cardiac surgeons, the cardiac surgery program at the authors' institution delivers care on par with its higher volume counterparts. A review of these practices and available supporting evidence may provide a model for other programs seeking success in this setting.

Endovascular stent-graft repair of penetrating descending thoracic aortic ulcer.

This article presents a case in which covered stent-graft cuffs were used to treat a penetrating ulcer of the descending thoracic aorta. An 80-year-old woman presented with penetrating ulcer in the descending thoracic aorta. Two endovascular stent graft cuffs were used for total exclusion of the penetrating ulcer, because the patient had a high operative risk. Her postoperative course was uneventful, and follow-up computed tomographic angiography showed complete coverage of the ulcer without evidence of leak. This case demonstrates that endoluminal stent-graft repair of penetrating descending thoracic aortic ulcers is a safe, less-invasive treatment, especially for elderly, high-risk patients.

Does Surgical Ablation Energy Source Affect Long-Term Success of the Concomitant Cox Maze Procedure?

BACKGROUND: The Cox maze (CM) procedure is routinely performed using surgical ablation technology. Reports are scarce on long-term outcomes of CM, especially for a large series of patients. This study examined the potential impact of surgical ablation energy source on safety and long-term efficacy of concomitant CM procedures. METHODS: The study sample consisted of 709 concomitant CM-treated patients operated on with cryothermal energy only (group 1; n = 386) or combination of cryothermal and bipolar radiofrequency (group 2; n = 323). Data were collected prospectively on perioperative outcomes, rhythm status, survival, and clinical events. Propensity score matching conducted by energy source resulted in 298 patients per group. RESULTS: Perioperative outcomes included stroke (n = 4), reoperation for bleeding (n = 23), renal failure requiring temporary dialysis (n = 18), readmissions before 30 days (n = 86), and operative death before 30 days (n = 16; ratio of observed to expected mortality [O/E ratio], 0.50). Independent predictors for 1-year and 5-year rhythm success were a shorter history of atrial fibrillation (1-year odds ratio [OR], 0.93, p = 0.001; 5-year OR, 0.93, p = 0.042) and cryothermia alone (1-year OR=1.77, p = 0.020; 5-year OR = 2.29, p = 0.009). After matching, group 1 had significantly higher sinus rhythm without antiarrhythmic drugs at 6 months (79% vs 70%; p = 0.016), 36 months (81% vs 69%; p = 0.010), and 60 months (75% vs 57%; p = 0.008). Stroke incidence was lower for group 1 (0.7% vs 3%; p = 0.033), with no difference in major bleeding (10% vs 11%; p = 0.597). Groups had similar survival rates (log rank, 0.6; p = 0.452). CONCLUSIONS: Concomitant CM procedures performed with cryothermal energy alone or combined with bipolar radiofrequency ablation are safe and exceedingly effective. The association of cryothermal energy alone with higher rates of sinus rhythm and stroke reduction should be investigated further.

The impact of a multidisciplinary blood conservation protocol on patient outcomes and cost after cardiac surgery.

OBJECTIVE: Although associations between transfusion and inferior outcomes have been documented, there is a lack of blood transfusion standardization in cardiac surgery. At the Inova Heart and Vascular Institute, a multidisciplinary, criterion-driven algorithm for transfusion management was implemented. We examined the effect of our blood conservation protocol on transfusion rates and outcomes after cardiac surgery and on stability of transfusion over time. METHODS: Patients undergoing first-time cardiac surgery from 2006 (full year before protocol) were compared with those in 2009 (after protocol) and propensity score matched to improve balance. Data were prospectively collected. Stability of transfusion incidence also was compared (2005-2006 vs 2008-2014). RESULTS: After matching, 890 patients from each year were included. Use of blood products decreased from 54% in 2006 to 25% in 2009 (P < .001). Patients in 2009 had a lower incidence of postoperative renal failure (2.6% vs 4%, P = .04), reoperations for bleeding (2% vs 4%, P = .004), and readmissions at less than 30 days (6% vs 12%, P < .001). No differences were found for operative mortality, deep sternal wound infection, or permanent strokes. Patients in 2009 had greater improvement in physical (P = .001) and mental (P = .02) quality of life than patients in 2006. Reduction of blood products led to significant cost savings for packed erythrocytes (P < .001) and platelets (P < .001). After protocol implementation, transfusion incidence remained 30% or less, with less than 28% in most years. CONCLUSIONS: A multidisciplinary blood conservation program can significantly control blood transfusion rates, improve outcomes, and be sustained over time. Efforts are needed to implement evidence-based protocols to standardize and decrease blood use in cardiac surgery to improve outcomes and reduce cost.

The Effect of Initiation of a Transcatheter Aortic Valve Replacement Program in the Treatment of Severe Aortic Stenosis.

We assessed the effect of a transcatheter aortic valve replacement (TAVR) program and Heart Team concept on our approach to severe isolated symptomatic aortic stenosis (AS) with regard to surgical practice, patient selection, perioperative outcomes, 1-year survival, and AVR volume. TAVR program began in August 2011. Patients having isolated surgical AVR between January 2008 and August 2011, when the program began (n = 282, 42 months), were compared with those after the program began until February 2015 (n = 344, surgical AVR and n = 126, TAVR, 42 months). Isolated surgical AVR accounted for 21% of all valve procedures (isolated and concomitant) before and after the TAVR program. However, the volume of all isolated AVR (surgical and transcatheter) increased to 27% of all valve procedures (isolated and concomitant) after the TAVR program implementation. Mean Society Of Thoracic Surgeons (STS)-predicted mortality risk was similar among patients who had surgical AVR pre-TAVR and post-TAVR implementation (2.3% vs 2.1%, P = 0.227), but addition of patients who had TAVR (STS risk = 7.1%) increased STS-predicted risk for all isolated AVR (surgical and transcatheter) procedures (2.3% vs 3.4%, P < 0.001). A similar trend was found for age, including a slight decrease in octogenarians for surgical AVR post-TAVR (18% vs 13%, P = 0.084). Operative mortality for isolated surgical AVR was similar in pre-TAVR and post-TAVR (2.1% vs 1.8%, P = 0.798), as were observed/expected (O/E) ratios (0.91 vs 0.82). For all isolated AVR, O/E ratio was 0.91 pre-TAVR and 0.82 post-TAVR (n = 470), including O/E = 0.79 for patients who had TAVR. No changes were found in proportion of isolated surgical AVR cases or patient risk and outcomes after introduction of TAVR program and Heart Team. However, volume of patients with severe AS treated increased significantly post-TAVR. Our results reflect growing awareness of TAVR availability and accompanying increases in patients referred to our Heart Team for AS treatment.

New Approach to Exclude the Left Atrial Appendage During Minimally Invasive Cryothermic Surgical Ablation.

OBJECTIVE: Atrial fibrillation (AF) is associated with an increased risk for embolic stroke originating from the left atrial appendage (LAA). A recently introduced LAA epicardial clip occluder, the AtriClip PRO, can be applied through midsternotomy or small thoracotomy. We assessed the safety and efficacy of a new surgical approach to apply the AtriClip PRO and exclude the LAA through right minithoracotomy and transverse sinus. METHODS: The AtriClip PRO was applied in 24 patients with the new approach. Intraoperative transesophageal echocardiography was used to exclude LAA thrombi at baseline and evaluate LAA perfusion and residual neck postoperatively. RESULTS: Mean (SD) age was 64.5 (8.6) years; 95% of the patients had nonparoxysmal AF with median AF duration of 39 months (interquartile range, 9.3-85.3 months), and mean (SD) left atrium diameter was 4.5 (0.7) cm (range, 3.1-5.7 cm). In one attempt, the clip was not deployed because of severe adhesions in the transverse sinus area. The procedural success rate was 95%. Nine minimally invasive mitral valve repairs were combined with surgical ablation; the rest were isolated right minithoracotomy Cox maze procedures. There was no remaining LAA neck in 71% of the patients. Perioperative outcomes were acceptable, and median length of stay was 5.5 days. CONCLUSIONS: The development of a reliable approach to LAA management during minimally invasive surgical ablation through right minithoracotomy has been challenging. This new approach is safe and effective and should offer a superior and consistent early and long-term solution compared with the current approach of endocardial stitch closure.

Minimally invasive mitral valve surgery without aortic cross-clamping and with femoral cannulation is not associated with increased risk of stroke compared with traditional mitral valve surgery: a propensity score-matched analysis.

OBJECTIVES: Open-heart surgery with fibrillatory arrest has been reported to be associated with an increased risk of stroke. We examined whether minimally invasive mitral valve surgery with fibrillatory arrest conferred a higher risk of stroke/transient ischaemic attack (TIA) and other major complications compared with median sternotomy and cardioplegic arrest. METHODS: Data were collected prospectively for 387 patients who had mitral valve surgery; 239 had a minimally invasive surgical approach and 148 had median sternotomy. All minimally invasive surgeries were performed by surgeons who were experienced in minimally invasive techniques. The effect of operative approach on risk of stroke/TIA and major morbidity was examined. After propensity score matching (PSM) was conducted between the two groups, 76 patients remained in each group. RESULTS: Before matching, the incidence of stroke/TIA did not differ between patients who had minimally invasive surgery (0.5%, n = 1) and those who had median sternotomy (1.4%, n = 2; P = 0.56). Patients who had minimally invasive surgery had a lower incidence of other major morbidity (0.8%, n = 2) than patients who had median sternotomy (6.1%, n = 9; P = 0.004). After adjustment for age and Society of Thoracic Surgeons predicted risk, there was no effect of operative approach on the odds for stroke/TIA (odds ratio [OR] = 0.41, P = 0.49) or other major morbidity (OR = 0.40, P = 0.31). After PSM, patients were balanced on preoperative characteristics. No patient in either matched group experienced permanent stroke/TIA, and major morbidity did not differ between the two groups (minimally invasive, 1.3%, n = 1; median sternotomy, 1.3%, n = 1; P > 0.99). CONCLUSIONS: A minimally invasive approach for mitral valve surgery on a fibrillating heart was not associated with a greater incidence of stroke/TIA than was median sternotomy. When performed by highly experienced surgeons, the minimally invasive approach with fibrillatory arrest did not increase the risk of perioperative stroke.

Operative risk and preoperative hematocrit in bypass graft surgery: Role of gender and blood transfusion.

BACKGROUND: The association between lower preoperative hematocrit (Hct) and risk for morbidity/mortality after cardiac surgery is well established. We examined whether the impact of low preoperative Hct on outcome is modified by blood transfusion and operative risk in women and men undergoing nonemergent CABG surgery. METHODS: Patients having nonemergent, first-time, isolated CABG were included (N=2757). Logistic regressions assessed effect of hematocrit on major perioperative morbidity/mortality separately by males (n=2232) and females (n=525). RESULTS: Mean age was 63.2±10.1years, preoperative hematocrit was 38.9±4.8%, and STS risk score was 1.3±1.8%. Blood transfusion was more likely in female patients (26% vs. 12%, P<0.001). Multivariate analyses revealed that lower body mass index and lower preoperative hematocrit predicted transfusion in males and females, whereas older age (OR=1.03, P=0.017) also predicted transfusion in females. Major morbidity was also more likely in female patients (12% vs. 7%, P<0.001). In multivariate analyses, blood transfusion was the only predictive factor for major morbidity in females (OR=4.56, P<0.001). In males, higher body mass index (OR=1.07, P<0.001), lower hematocrit (OR=0.94, P=0.017), interaction of STS score with hematocrit (OR=1.02, P=0.045), and blood transfusion (OR=9.22, P<0.001) were significant predictors for major morbidity. CONCLUSIONS: This study showed females were more likely to have blood transfusion and major morbidities after nonemergent CABG. Traditional factors that have been found to predict outcomes, such as hematocrit and STS risk, were related only to major morbidity in male patients. However, blood transfusion negatively impacted major outcome after nonemergent CABG surgery across all STS risk levels in both genders.

Potential Impact of Modifiable Clinical Variables on Length of Stay After First-Time Cardiac Surgery.

BACKGROUND: Recent financial challenges highlight the importance of accurate prediction of length of hospital stay (LOS). We assessed reliability of The Society of Thoracic Surgeons (STS) risk prediction for extended and shorter LOS and examined whether modifiable clinical variables are associated with LOS in first-time cardiac surgery patients. METHODS: Isolated aortic valve, mitral valve, and coronary artery bypass graft surgery patients since 2008 were included (n = 3,472). Multivariate regression was used to evaluate nonmodifiable and potentially modifiable (preoperative hematocrit, hemoglobin A1c, body mass index, current smoker, major perioperative morbidity, and blood product transfusion) predictors of LOS in days. RESULTS: Mean age was 63.9 ± 11.2 years, 76% were males, and mean STS mortality risk was 1.9% ± 3.2%. Median (interquartile range) LOS was 4 (3 to 6) days. Predicted STS risk was 6.2% ± 7.1% for extended LOS (>14 days) and 48.3% ± 20.2% for short LOS (<6 days). Extended LOS was observed in 5.2% of patients (observed versus expected, 0.84; p = 0.019). Observed short LOS was better than predicted (67.8%; observed versus expected, 1.40; p < 0.001). Inclusion of modifiable variables in the LOS prediction model was significant (p < 0.001). Significant modifiable predictors were lower hematocrit, higher hemoglobin A1c, major morbidity, and transfusion. Longer predicted LOS from the model correlated with longer actual LOS (rs = 0.63; p < 0.001). Applying the prediction equation from the model to a hypothetical average patient, predicted LOS was 4.6 days. CONCLUSIONS: The STS risk model was reliably predictive of short and extended LOS but did not allow prediction of exact LOS in days. Accounting for potentially modifiable clinical variables, such as low hematocrit and blood transfusion, especially in elective patients, should lead to shorter LOS, higher satisfaction, and reduced financial burden.

Effect of patient age on blood product transfusion after cardiac surgery.

OBJECTIVE: Blood product transfusion after cardiac surgery is associated with increased morbidity and mortality. Transfusion thresholds are often lower for the elderly, despite the lack of clinical evidence for this practice. This study examined the role of age as a predictor for blood transfusion. METHODS: A total of 1898 patients were identified who had nonemergent cardiac surgery, between January 2007 and August 2013, without intra-aortic balloon pumps or reoperations, and with short (<24 hours) intensive care unit stays (age ≥75 years; n = 239). Patients age ≥75 years were propensity-score matched to those age <75 years to balance covariates, resulting in 222 patients per group. Analyses of the matched sample examined age as a continuous variable, scaled in 5-year increments. RESULTS: After matching, covariates were balanced between older and younger patients. Older age significantly predicted postoperative (odds ratio = 1.39, P = .028), but not intraoperative (odds ratio = 0.96, P = .559), blood transfusion. Older age predicted longer length of stay (B = 0.21, P < .001), even after adjustment for blood product transfusion (B = 0.20, P < .001). As expected, older age was a significant predictor for poorer survival, even with multivariate adjustment (hazard ratio = 1.34, P = .042). CONCLUSIONS: In patients with a routine postoperative course, older age was associated with more postoperative blood transfusion. Older age was also predictive of longer length of stay and poorer survival, even after accounting for clinical factors. Continued study into effects of transfusion, particularly in the elderly, should be directed toward hospital transfusion protocols to optimize perioperative care.

Heart transplantation in a patient with isolated noncompaction of the left ventricular myocardium.

We describe a patient with isolated noncompaction of the left ventricle who presented with worsening congestive heart failure and was successfully treated with heart transplantation. The prognosis for these patients is poor because of accelerated event rates of fatal arrhythmias, thromboemboli, and profound left ventricular decompensation. Only 7 patients with isolated noncompaction of the left ventricle have been reported to have undergone heart transplantation. Herein we describe a patient with isolated noncompaction of the left ventricle who underwent successful heart transplantation.

Postoperative complications among octogenarians after cardiovascular surgery.

BACKGROUND: The octogenarian patient is often perceived as too fragile to undergo cardiothoracic surgery. Our study aimed to compare postoperative complications in patients aged less than 80 versus elderly patients (80 years or more) after surgical cardiac intervention (coronary artery bypass or valve replacement). METHODS: Subjects were all patients (n = 8,361) who had an open-heart procedure, either coronary artery bypass or valve implantation or replacement, at two medical centers located in northern Virginia using the same surgical group. A computerized medical record database was reviewed to determine preoperative risk factors and postoperative outcomes. Predictors of complications were identified by univariate and multivariate logistic regression. RESULTS: A total of 3,214 complications were recorded. The most prevalent complications were prolonged ventilation time in the intensive care unit, reoperation for bleeding, and pneumonia. The overall mortality rate was 2.4% (204 of 8,361). Persons aged over 80 years had nearly double the mortality rate compared with younger patients (4.1% [18 of 444] to 2.3% [186 of 7,917]). Age greater than 80 years (odds ratio = 2.65, 95% confidence interval = 2.18 to 3.22) and male gender (odds ratio = 0.62, 95% confidence interval = 0.56 to 0.69) were the best univariate predictors of a single postoperative complication. CONCLUSIONS: Octogenarian patients manifested twice the risk of death from a cardiac intervention with an average 2-day longer hospital stay compared with their younger counterparts. Furthermore, octogenarians were at markedly higher risk of nonfatal postoperative complications.

The effect of the Cox-maze procedure for atrial fibrillation concomitant to mitral and tricuspid valve surgery.

OBJECTIVES: Atrial fibrillation (AF) is associated with less favorable outcomes in patients undergoing mitral valve and tricuspid valve surgery. Despite growing evidence on the potential benefits of surgical ablation for AF there is significant variability among surgeons in treatment of AF. The purpose of our study was to assess the effect of the Cox-maze procedure on operative and follow-up outcomes. METHODS: In our prospective study, patients who underwent isolated mitral valve or mitral valve+tricuspid valve surgery without history of AF (n = 506), with untreated AF (n = 75), or with Cox-maze procedure (n = 236) were included (N = 817). Sinus rhythm was captured according to Heart Rhythm Society guidelines. Patients who underwent the Cox-maze procedure were propensity score matched to patients without history of AF resulting in 208 pairs of patients. RESULTS: Operative outcomes were comparable after propensity score matching (Cox-maze procedure vs no AF) stroke/transient ischemic attack (0.5% vs 0.5%; P = 1.00), renal failure (2.9% vs 1.4%; P = .34), and operative mortality (1.4% vs 1.4%; P = 1.00). High return to sinus rhythm was documented at 6, 12, and 24 months (92%, 91%, and 86%, respectively) as well as sinus rhythm off antiarrhythmic drugs (79%, 84%, and 82%, respectively). Incidence of embolic stroke in patients who underwent Cox-maze procedure was 1.7% (4 out of 232 patients) and 5.1 cases per 1000 person-years. No difference in 4-year cumulative survival between propensity score-matched groups (91.9% vs 86.9%; log rank, 1.67; P = .20), but higher for patients who underwent Cox-maze procedure versus patients with untreated AF (hazard ratio, 2.47; P = .048). Higher additive European System for Cardiac Operative Risk Evaluation (odds ratio, 1.40; P < .001) and limited surgeon experience with Cox-maze procedure (odds ratio, 3.60; P < .001) were significant predictors for failure to perform Cox-maze procedure. CONCLUSIONS: In our center, 76% of patients undergoing mitral valve or mitral valve+tricuspid valve surgery experiencing AF underwent concomitant Cox-maze procedure, which is considerably higher than the national average. No increased morbidity was associated with the Cox-maze procedure with the benefit of very low thromboembolic rate. These results suggest the need for performance-based education for AF surgical ablation to achieve optimal outcomes.

Minimally invasive fibrillating heart surgery: a safe and effective approach for mitral valve and surgical ablation for atrial fibrillation.

BACKGROUND: Minimally invasive (MI) approaches to mitral valve surgery (MVS) and surgical ablation for atrial fibrillation (AF) are now performed routinely, and avoidance of aortic manipulation and cardioplegic arrest may further simplify the procedure. We present our experience with MI fibrillatory cardiac operations without aortic cross-clamping for MVS and AF ablation. METHODS: Between January 2007 and August 2012, 292 consecutive patients underwent MVS (n = 177), surgical ablation (n = 81), or both (n= 34), with fibrillating heart through a right minithoracotomy. Baseline characteristics, perioperative outcomes, and long-term survival were evaluated. RESULTS: The mean age was 56.8 years (range, 20-83 years). Reoperations were performed in 25 patients (9%). The overall MV repair rate was 93.4% (198/211), including 13.1% (26/198) with anterior leaflet repair. Repair was performed in 100% of patients with myxomatous MV disease. Of isolated posterior mitral valve repairs, 60.5% underwent repair with neochords (W.L. Gore and Associates, Flagstaff, AZ), and 29.7% underwent triangular resection. There was 1 operative mortality (0.3%), no intraoperative conversions to sternotomy, 4 reoperations (1.4%), 1 stroke (0.3%), and 1 transient ischemic attack (0.3%). The 12-month return to sinus rhythm was 93%, and sinus rhythm without class I and class III antiarrhythmic medication was 85%. One- and 2-year cumulative survival was 98.5% and 97.8%, respectively. At mean follow-up of 27.3 months, our outcomes compared favorably with the 2011 Society of Thoracic Surgeons (STS) nationally reported outcomes. CONCLUSIONS: We demonstrated that low operative mortality and low stroke rate with MI fibrillating cardiac operations without cross-clamping allows for MVS and AF ablation. Our results suggest that the MI fibrillating heart approach is safe and effective.