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OBJECTIVES: Myocardial ischaemia following coronary artery bypass grafting (CABG) is a potentially devastating complication. Nevertheless, the incidence, aetiology, and prognostic relevance of unplanned CAG remain understudied. We aimed to investigate the prevalence and outcome of patients undergoing urgent, unplanned coronary angiography in the postoperative period following CABG. METHODS: We screened all patients undergoing isolated elective CABG in an academic referral centre between 2016-2021 and identified patients undergoing unplanned CAG (uCAG) within 30 days of surgery. Within uCAG patients, a distinction was made between patients undergoing re-revascularization (REV) and patients receiving conservative management (CON). The primary outcomes were 30-day mortality and unadjusted and adjusted long-term survival. Secondary outcomes were the indication for and prevalence of uCAG and urgent revascularization. RESULTS: Of the 1918 patients undergoing isolated CABG, 78 individuals needed uCAG (4.1%), of which 45 underwent immediate revascularization (REV-group; 2.3% overall, 57% within the uCAG group, median age 69.9 years) and 33 were treated conservatively (CON-group; 1.7% overall, 42% within the uCAG group, median age 69.1 years). Patients undergoing uCAG (n = 78) had a higher 30-day mortality than patients not undergoing uCAG (n = 1840, 30-day mortality: 9.0% vs 0.4%, p < 0.001). Long-term survival was significantly decreased in patients undergoing uCAG in both unadjusted (hazard ratio [HR] 2.20, 95% CI 1.30-3.73), and EuroSCORE-, age-, and sex-adjusted models (HR uCAG 2.03, 95% CI 1.16-3.56). CONCLUSIONS: Unplanned postoperative CAG is performed in 4.1% of isolated CABG procedures, and patients in need of such urgent invasive evaluation are subjected to decreased short- and long-term survival.
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BACKGROUND: Early postoperative AF (POAF) is common after cardiac surgery and is associated with late-POAF recurrences. However, little is known about the burden of POAF, and its potential impact on long-term outcomes after cardiac surgery, particularly on the risk for late-POAF recurrences. OBJECTIVE: To establish the distribution of POAF burden and to determine the association between early-POAF burden and late-POAF recurrences during 2.5 years of continuous rhythm monitoring after cardiac surgery in patients with and without preoperative history of AF. METHODS: Patients undergoing cardiac surgery were prospectively enrolled and postoperatively continuously monitored with an implantable loop recorder (ILR) for 2.5 years. All patients underwent extensive clinical assessment at baseline. During the follow-up all AF episodes were registered, and AF-associated metrics, such as burden, were calculated for different time intervals. Early-POAF was defined as AF within first 90 postoperative days and late-POAF as AF after this interval. RESULTS: A total of 98 consecutive patients were included. POAF burden during the early postoperative phase was significantly higher as compared to the late postoperative phase (p<0.001). The longest individual POAF episode was strongly associated with increased POAF burden after adjusting for age, sex, and AF-history (standardized Beta: 0.91, p<0.001). Also, early-POAF burden was associated with late-POAF (re)occurrence after adjusting for age, sex, AF-history (adjusted Hazard Ratio=1.93, 95%CI: 1.42-2.62, p<0.001). CONCLUSION: POAF burden was significantly associated with the longest individual POAF episode duration. Additionally, greater early-POAF burden was associated with increased late-POAF incidence, highlighting its potential in estimating the risk for long-term POAF recurrences.
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Contrary to most vessels, the ascending thoracic aorta (ATA) not only distends but also elongates in the axial direction. The purpose of this study is to investigate the biomechanical behavior of the ascending thoracic aorta (ATA) in response to dynamic axial stretching during the cardiac cycle. In addition, the implications of neglecting this dynamic axial stretching when estimating the constitutive model parameters of the ATA are investigated. The investigations were performed through in silico simulations by assuming a Gasser-Ogden-Holzapfel (GOH) constitutive model representative of ATA tissue material. The GOH model parameters were obtained from biaxial tests performed on four human ATA tissues in a previous study. Pressure-diameter curves were simulated as synthetic data to assess the effect of neglecting dynamic axial stretching on estimating constitutive model parameters. Our findings reveal a significant increase in axial stress (~ 16%) and stored strain energy (~ 18%) in the vessel when dynamic axial stretching is considered, as opposed to assuming a fixed axial stretch. All but one artery showed increased volume compliance while considering a dynamic axial stretching condition. Furthermore, we observe a notable difference in the estimated constitutive model parameters when dynamic axial stretching of the ATA is neglected, compared to the ground truth model parameters. These results underscore the critical importance of accounting for axial deformations when conducting in vivo biomechanical characterization of the ascending thoracic aorta.
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Aorta Torácica , Modelos Cardiovasculares , Humanos , Aorta Torácica/fisiología , Fenómenos Biomecánicos , Estrés Mecánico , Aorta/fisiología , Masculino , Simulación por ComputadorRESUMEN
Ascending thoracic aortic aneurysm (ATAA) remains a significant medical concern, with its asymptomatic nature posing diagnostic and monitoring challenges, thereby increasing the risk of aortic wall dissection and rupture. Current management of aortic repair relies on an aortic diameter threshold. However, this approach underestimates the complexity of aortic wall disease due to important knowledge gaps in understanding its underlying pathologic mechanisms.Since traditional risk factors cannot explain the initiation and progression of ATAA leading to dissection, local vascular factors such as extracellular matrix (ECM) and vascular smooth muscle cells (VSMCs) might harbor targets for early diagnosis and intervention. Derived from diverse embryonic lineages, VSMCs exhibit varied responses to genetic abnormalities that regulate their contractility. The transition of VSMCs into different phenotypes is an adaptive response to stress stimuli such as hemodynamic changes resulting from cardiovascular disease, aging, lifestyle, and genetic predisposition. Upon longer exposure to stress stimuli, VSMC phenotypic switching can instigate pathologic remodeling that contributes to the pathogenesis of ATAA.This review aims to illuminate the current understanding of cellular and molecular characteristics associated with ATAA and dissection, emphasizing the need for a more nuanced comprehension of the impaired ECM-VSMC network.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Músculo Liso Vascular , Miocitos del Músculo Liso , Humanos , Aneurisma de la Aorta Torácica/patología , Aneurisma de la Aorta Torácica/genética , Aneurisma de la Aorta Torácica/metabolismo , Aneurisma de la Aorta Torácica/fisiopatología , Disección Aórtica/patología , Disección Aórtica/genética , Disección Aórtica/metabolismo , Animales , Músculo Liso Vascular/patología , Músculo Liso Vascular/metabolismo , Miocitos del Músculo Liso/patología , Miocitos del Músculo Liso/metabolismo , Aorta Torácica/patología , Aorta Torácica/fisiopatología , Remodelación Vascular , Matriz Extracelular/patología , Matriz Extracelular/metabolismo , FenotipoRESUMEN
OBJECTIVES: Thoracoscopic hybrid ablation is an effective and safe rhythm control strategy for patients with complex forms of atrial fibrillation. Its effect on left atrial function has not yet been studied. METHODS: In a retrospective single-centre analysis of patients undergoing thoracoscopic hybrid ablation, the left atrial emptying fraction was calculated using the biplane modified Simpson method in the apical 2- and 4-chamber views on transthoracic echocardiography. Left atrial strain (reservoir, conduction and contractility) was quantified using dedicated software. RESULTS: Sixty-seven patients were included (mean age 64 years, long-standing persistent atrial fibrillation in 69%, median atrial fibrillation history duration 64 months). At baseline, left atrial function and contractility were poor. The reservoir and contractile strain improved postprocedure compared to baseline [15 (standard deviation (SD): 8) and 17 (SD: 6); P = 0.013; 3 (SD: 5) and 4 (SD: 4), P = 0.008], whereas the left atrial volume indexed to the body surface area was reduced [51 ml/m2 (SD: 14) and 47 ml/m2 (SD: 18), P = 0.0024]. In patients with preoperative (long-standing) persistent atrial fibrillation and in patients with rhythm restoration, improvements in the emptying fraction, (reservoir and contractile) strain and the left ventricular ejection fraction were observed, whereas the left atrial volume decreased (P < 0.05). CONCLUSIONS: In this cohort of patients with severely diseased left atria, improvement in left atrial contractility and in the emptying fraction after thoracoscopic hybrid ablation for atrial fibrillation in patients with persistent atrial fibrillation is mainly due to rhythm restoration. Interestingly, the procedure itself also results in improved left atrial reservoir strain and reversed left atrial remodelling by reducing left atrial volume.
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BACKGROUND: Serum bone morphogenetic protein 10 (BMP10) blood levels are a marker for history of atrial fibrillation (AF) and for major adverse cardiovascular events in patients with AF, including stroke, AF recurrences after catheter ablations, and mortality. The predictive value of BMP10 in patients undergoing cardiac surgery and association with morphologic properties of atrial tissues are unknown. OBJECTIVES: This study sought to study the correlation between BMP10 levels and preoperative clinical traits, occurrence of early and late postoperative atrial fibrillation (POAF), and atrial fibrosis in patients undergoing cardiac surgery. METHODS: Patients with and without preoperative AF history undergoing first cardiac surgery were included (RACE V, n = 147). Preoperative blood biomarkers were analyzed, left (n = 114) and right (n = 125) atrial appendage biopsy specimens were histologically investigated after WGA staining, and postoperative rhythm was monitored continuously with implantable loop recorders (n = 133, 2.5 years). RESULTS: Adjusted multinomial logistic regression indicated that BMP10 accurately reflected a history of persistent AF (OR: 1.24, 95% CI: 1.10-1.40, P = 0.001), similar to NT-pro-BNP. BMP10 levels were associated with increased late POAF90 occurrence after adjustment for age, sex, AF history, and early POAF occurrence (HR: 1.07 [per 0.1 ng/mL increase], 95% CI: 1.00-1.14, P = 0.041). Left atrial endomysial fibrosis (standardized ß = 0.22, P = 0.041) but not overall fibrosis (standardized Β = 0.12, P = 0.261) correlated with circulating BMP10 after adjustment for age, sex, AF history, reduced LVF, and valvular surgery indication. CONCLUSIONS: Increased BMP10 levels were associated with persistent AF history, increased late POAF incidence, and LAA endomysial fibrosis in a diverse sample of patients undergoing cardiac surgery.
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Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Complicaciones Posoperatorias , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Apéndice Atrial/cirugía , Fibrilación Atrial/sangre , Fibrilación Atrial/epidemiología , Biomarcadores/sangre , Proteínas Morfogenéticas Óseas , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Fibrosis , Atrios Cardíacos/patología , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/epidemiologíaRESUMEN
BACKGROUND: Postoperative atrial fibrillation (POAF) is a frequent complication after cardiac surgery that is associated with late atrial fibrillation (AF) recurrences (late-POAF) and increased morbidity and long-term mortality. OBJECTIVES: This study sought to determine device-detected POAF incidence and to identify clinical variables associated with POAF, both in patients with and without preoperative AF history. METHODS: A total of 133 consecutive patients undergoing cardiac surgery were prospectively enrolled and continuously monitored with an implantable loop recorder for 2.5 years after surgery. Preoperative transthoracic echocardiography, 12-lead electrocardiogram, blood biomarkers, and clinical data were analyzed to develop prediction models for early- and late-POAF. RESULTS: In patients without preoperative AF history, early-POAF within the first 90 postoperative days occurred in 41 (47.1%) of 87 patients. Late-POAF after the first 90 postoperative days occurred in 22 (25%) of 87 patients, and 20 of these patients also had early-POAF during the first 90 days (20 of 22 [91%]). Increased right atrial minimum volume indexed for body surface area (RAVImin) and early-POAF were independently associated with late-POAF. A prediction model for late-POAF, which included RAVImin >11 mL/m2, age >65 years, and early-POAF, achieved an area under the curve of 0.82 (95% CI: 0.72-0.92). For patients with preoperative AF-history, late-POAF recurrences were frequent (22 of 33 [67%]). Increased RAVImin was independently associated with a higher incidence of late-POAF. CONCLUSIONS: In patients with and without AF history, late-POAF recurrences are frequent, including in patients undergoing surgical AF ablation. In patients with no history of AF, late-POAF might be predicted with excellent accuracy by using a combination of preoperative variables. In patients with a history of AF, signs of advanced AF substrate (eg, increased right atrial volumes) were associated with long-term AF recurrences. [Reappraisal of Atrial Fibrillation: Interaction Between Hypercoagulability, Electrical Remodeling, and Vascular Destabilisation in the Progression of AF; NCT03124576].
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Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Complicaciones Posoperatorias , Humanos , Fibrilación Atrial/epidemiología , Masculino , Femenino , Anciano , Estudios Prospectivos , Persona de Mediana Edad , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Complicaciones Posoperatorias/epidemiología , Ecocardiografía , Factores de Riesgo , Incidencia , Electrocardiografía , RecurrenciaRESUMEN
BACKGROUND: Atrial fibrillation (AF) is one of the most common complications after cardiac surgery. New-onset post-operative AF may signal an elevated risk of AF and associated outcomes in long-term follow-up. We aimed to estimate the rate of AF recurrence as detected by an implantable loop recorder (ILR) in patients experiencing post-operative AF within 30 days after cardiac surgery. METHODS: We searched MEDLINE, Embase and Cochrane CENTRAL to April 2023 for studies of adults who did not have known AF, experienced new-onset AF within 30 days of cardiac surgery and received an ILR. We pooled individual participant data on timing of AF recurrence using a random-effects model with a frailty model applied to a Cox proportional hazard analysis. RESULTS: From 8671 citations, 8 single-centre prospective cohort studies met eligibility criteria. Data were available from 185 participants in 7 studies, with a median follow-up of 1.7 (IQR: 1.3-2.8) years. All included studies were at a low risk of bias. Pooled AF recurrence rates following 30 post-operative days were 17.8% (95% CI 11.9%-23.2%) at 3 months, 24.4% (17.7%-30.6%) at 6 months, 30.1% (22.8%-36.7%) at 12 months and 35.3% (27.6%-42.2%) at 18 months. CONCLUSIONS: In patients who experience new-onset post-operative AF after cardiac surgery, AF recurrence lasting at least 30 s occurs in approximately 1 in 3 in the first year after surgery. The optimal frequency and modality to use for monitoring for AF recurrence in this population remain uncertain.
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Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Electrocardiografía Ambulatoria , Complicaciones Posoperatorias , Recurrencia , Humanos , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/etiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Electrocardiografía Ambulatoria/instrumentaciónRESUMEN
In this state-of-the art review on hybrid atrial fibrillation (AF) ablation, we briefly focus on the pathophysiology of AF, the rationale for the hybrid approach, its technical aspects and the efficacy and safety outcomes after hybrid AF ablation, both from meta-analyses and randomized control trial data. Also, we performed a systematic search to provide a provisional overview of real-world hybrid AF ablation efficacy and safety outcomes. Furthermore, we give an insight into the 'Maastricht approach', an approach that allows us to tailor the ablation procedure to the individual patient. Finally, we reflect on future perspectives with the objective to continue improving our thoracoscopic hybrid AF ablation approach. Based on the review of the available literature, we believe it is fair to state that thoracoscopic hybrid AF ablation is a valid alternative to catheter ablation for the treatment of patients with more persistent forms of AF.
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BACKGROUND: Atrial cardiomyopathy (atCM) is an emerging prognostic factor in cardiovascular disease. Fibrotic remodeling, cardiomyocyte hypertrophy, and capillary density are hallmarks of atCM. The contribution of etiological factors and atrial fibrillation (AF) to the development of differential atCM phenotypes has not been quantified. This study aimed to evaluate the association between histological features of atCM and the clinical phenotype. METHODS AND RESULTS: We examined left atrial (LA, n=95) and right atrial (RA, n=76) appendages from a European cohort of patients undergoing cardiac surgery. Quantification of histological atCM features was performed following wheat germ agglutinin/CD31/vimentin staining. The contributions of AF, heart failure, sex, and age to histological characteristics were determined with multiple linear regression models. Persistent AF was associated with increased endomysial fibrosis (LA: +1.13±0.47 µm, P=0.038; RA: +0.94±0.38 µm, P=0.041), whereas total extracellular matrix content was not. Men had larger cardiomyocytes (LA: +1.92±0.72 µm, P<0.001), while women had more endomysial fibrosis (LA: +0.99±0.56 µm, P=0.003). Patients with heart failure showed more endomysial fibrosis (LA: +1.85±0.48 µm, P<0.001) and extracellular matrix content (LA: +3.07±1.29%, P=0.016), and a higher capillary density (LA: +0.13±0.06, P=0.007) and size (LA: +0.46±0.22 µm, P=0.044). Fuzzy k-means clustering of histological features identified 2 subtypes of atCM: 1 characterized by enhanced endomysial fibrosis (LA: +3.17 µm, P<0.001; RA: +2.86 µm, P<0.001), extracellular matrix content (LA: +3.53%, P<0.001; RA: +6.40%, P<0.001) and fibroblast density (LA: +4.38%, P<0.001), and 1 characterized by cardiomyocyte hypertrophy (LA: +1.16 µm, P=0.008; RA: +2.58 µm, P<0.001). Patients with fibrotic atCM were more frequently female (LA: odds ratio [OR], 1.33, P=0.002; RA: OR, 1.54, P=0.004), with persistent AF (LA: OR, 1.22, P=0.036) or heart failure (LA: OR, 1.62, P<0.001). Hypertrophic features were more common in men (LA: OR=1.33, P=0.002; RA: OR, 1.54, P=0.004). CONCLUSIONS: Fibrotic atCM is associated with female sex, persistent AF, and heart failure, while hypertrophic features are more common in men.
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BACKGROUND AND AIMS: The current study proposes a novel volume-outcome (V-O) meta-analytical approach to determine the optimal annual hospital case volume threshold for cardiovascular interventions in need of centralization. This novel method is applied to surgery for acute type A aortic dissection (ATAAD) as an illustrative example. METHODS: A systematic search was applied to three electronic databases (1 January 2012 to 29 March 2023). The primary outcome was early mortality in relation to annual hospital case volume. Data were presented by volume quartiles (Qs). Restricted cubic splines were used to demonstrate the V-O relation, and the elbow method was applied to determine the optimal case volume. For clinical interpretation, numbers needed to treat (NNTs) were calculated. RESULTS: One hundred and forty studies were included, comprising 38 276 patients. A significant non-linear V-O effect was observed (P < .001), with a notable between-quartile difference in early mortality rate [10.3% (Q4) vs. 16.2% (Q1)]. The optimal annual case volume was determined at 38 cases/year [95% confidence interval (CI) 37-40 cases/year, NNT to save a life in a centre with the optimal volume vs. 10 cases/year = 21]. More pronounced between-quartile survival differences were observed for long-term survival [10-year survival (Q4) 69% vs. (Q1) 51%, P < .01, adjusted hazard ratio 0.83, 95% CI 0.75-0.91 per quartile, NNT to save a life in a high-volume (Q4) vs. low-volume centre (Q1) = 6]. CONCLUSIONS: Using this novel approach, the optimal hospital case volume threshold was statistically determined. Centralization of ATAAD care to high-volume centres may lead to improved outcomes. This method can be applied to various other cardiovascular procedures requiring centralization.
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Disección Aórtica , Hospitales de Alto Volumen , Humanos , Resultado del Tratamiento , Disección Aórtica/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: Ascending thoracic aortic aneurysm is a chronic degenerative pathology characterized by dilatation of this segment of the aorta. Clinical guidelines use aortic diameter and growth rate as predictors of rupture and dissection. However, these guidelines neglect the effects of tissue remodeling, which may affect wall thickness. The present study aims to systematically review observational studies to examine to what extent wall thickness is considered and measured in clinical practice. METHODS: Using PubMed and Web of Science, studies were identified with data on ascending aortic wall thickness, morphology, aortic diameter, and measurement techniques. RESULTS: 15 included studies report several methods by which wall thickness is measured. No association was observed between wall thickness and aortic diameter across included studies. Wall thickness values appear not materially different between aneurysmatic aortas and non-aneurysmal aortas. CONCLUSIONS: The effects on and consequences of wall thickness changes during ATAA formation are ill-defined. Wall thickness values for aneurysmatic aortas can be similar to aortas with normal diameters. Given the existing notion that wall thickness is a determinant of mechanical stress homeostasis, our review exposes a clear need for consistent as well as clinically applicable methods and studies to quantify wall thickness in ascending aortic aneurysm research.
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Current management guidelines for ascending thoracic aortic aneurysms (aTAA) recommend intervention once ascending or sinus diameter reaches 5-5.5 cm or shows a growth rate of >0.5 cm/year estimated from echo/CT/MRI. However, many aTAA dissections (aTAAD) occur in vessels with diameters below the surgical intervention threshold of <55 mm. Moreover, during aTAA repair surgeons observe and experience considerable variations in tissue strength, thickness, and stiffness that appear not fully explained by patient risk factors. To improve the understanding of aTAA pathophysiology, we established a multi-disciplinary research infrastructure: The Maastricht acquisition platform for studying mechanisms of tissue-cell crosstalk (MAPEX). The explicit scientific focus of the platform is on the dynamic interactions between vascular smooth muscle cells and extracellular matrix (i.e., cell-matrix crosstalk), which play an essential role in aortic wall mechanical homeostasis. Accordingly, we consider pathophysiological influences of wall shear stress, wall stress, and smooth muscle cell phenotypic diversity and modulation. Co-registrations of hemodynamics and deep phenotyping at the histological and cell biology level are key innovations of our platform and are critical for understanding aneurysm formation and dissection at a fundamental level. The MAPEX platform enables the interpretation of the data in a well-defined clinical context and therefore has real potential for narrowing existing knowledge gaps. A better understanding of aortic mechanical homeostasis and its derangement may ultimately improve diagnostic and prognostic possibilities to identify and treat symptomatic and asymptomatic patients with existing and developing aneurysms.
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Mechanical properties of an aneurysmatic thoracic aorta are potential markers of future growth and remodelling and can help to estimate the risk of rupture. Aortic geometries obtained from routine medical imaging do not display wall stress distribution and mechanical properties. Mechanical properties for a given vessel may be determined from medical images at different physiological pressures using inverse finite element analysis. However, without considering pre-stresses, the estimation of mechanical properties will lack accuracy. In the present paper, we propose and evaluate a mechanical parameter identification technique, which recovers pre-stresses by determining the zero-pressure configuration of the aortic geometry. We first validated the method on a cylindrical geometry and subsequently applied it to a realistic aortic geometry. The verification of the assessed parameters was performed using synthetically generated reference data for both geometries. The method was able to estimate the true mechanical properties with an accuracy ranging from 98% to 99%.
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BACKGROUND: Although catheter ablation (CA) is successful for the treatment of paroxysmal atrial fibrillation (AF), results are less satisfactory in persistent AF. Hybrid ablation (HA) results in better outcomes in patients with persistent atrial fibrillation (persAF), as it combines a thoracoscopic epicardial and transvenous endocardial approach in a single procedure. OBJECTIVES: The purpose of this study was to compare the effectiveness and safety of HA with CA in a prospective, superiority, unblinded, randomized controlled trial. METHODS: Forty-one ablation-naive patients with (long-standing)-persAF were randomized to HA (n = 19) or CA (n = 22) and received pulmonary vein isolation, posterior left atrial wall isolation and, if needed, a cavotricuspid isthmus ablation. The primary efficacy endpoint was freedom from any atrial tachyarrhythmia >5 minutes off antiarrhythmic drugs after 12 months. The primary and secondary safety endpoints included major and minor complications and the total number of serious adverse events. RESULTS: After 12 months, the freedom of atrial tachyarrhythmias off antiarrhythmic drugs was higher in the HA group compared with the CA group (89% vs 41%, P = 0.002). There was 1 pericarditis requiring pericardiocentesis and 1 femoral arteriovenous-fistula in the HA group. In the CA arm, 1 bleeding from the femoral artery occurred. There were no deaths, strokes, need for pacemaker implantation, or conversions to sternotomy, and the number of (serious) adverse events was comparable between groups (21% vs 14%, P = 0.685). CONCLUSIONS: Hybrid AF ablation is an efficacious and safe procedure and results in better outcomes than catheter ablation for the treatment of patients with persistent AF. (Hybrid Versus Catheter Ablation in Persistent AF [HARTCAP-AF]; NCT02441738).
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Fibrilación Atrial , Ablación por Catéter , Humanos , Resultado del Tratamiento , Estudios Prospectivos , Antiarrítmicos/uso terapéutico , Ablación por Catéter/efectos adversos , Ablación por Catéter/métodosRESUMEN
BACKGROUND: This study aims to get an effective machine learning (ML) prediction model of new-onset postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG) and to highlight the most relevant clinical factors. METHODS: Four ML algorithms were employed to analyze 394 patients undergoing CABG, and their performances were compared: Multivariate Adaptive Regression Spline, Neural Network, Random Forest, and Support Vector Machine. Each algorithm was applied to the training data set to choose the most important features and to build a predictive model. The better performance for each model was obtained by a hyperparameters search, and the Receiver Operating Characteristic Area Under the Curve metric was selected to choose the best model. The best instances of each model were fed with the test data set, and some metrics were generated to assess the performance of the models on the unseen data set. A traditional logistic regression was also performed to be compared with the machine learning models. RESULTS: Random Forest model showed the best performance, and the top five predictive features included age, preoperative creatinine values, time of aortic cross-clamping, body surface area, and Logistic Euro-Score. CONCLUSIONS: The use of ML for clinical predictions requires an accurate evaluation of the models and their hyperparameters. Random Forest outperformed all other models in the clinical prediction of POAF following CABG.
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Cardiovascular disease is the major cause of death worldwide. The success of medication and other preventive measures introduced in the last century have not yet halted the epidemic of cardiovascular disease. Although the molecular mechanisms of the pathophysiology of the heart and vessels have been extensively studied, the burden of ischemic cardiovascular conditions has risen to become a top cause of morbidity and mortality. Calcium has important functions in the cardiovascular system. Calcium is involved in the mechanism of excitation-contraction coupling that regulates numerous events, ranging from the production of action potentials to the contraction of cardiomyocytes and vascular smooth muscle cells. Both in the heart and vessels, the rise of intracellular calcium is sensed by calmodulin, a protein that regulates and activates downstream kinases involved in regulating calcium signalling. Among them is the calcium calmodulin kinase family, which is involved in the regulation of cardiac functions. In this review, we present the current literature regarding the role of calcium/calmodulin pathways in the heart and vessels with the aim to summarize our mechanistic understanding of this process and to open novel avenues for research.
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Calmodulina , Enfermedades Cardiovasculares , Humanos , Calmodulina/metabolismo , Calcio/metabolismo , Enfermedades Cardiovasculares/metabolismo , Proteínas Quinasas Dependientes de Calcio-Calmodulina/metabolismo , Miocitos Cardíacos/metabolismo , Proteína Quinasa Tipo 2 Dependiente de Calcio Calmodulina/metabolismoRESUMEN
Treatment of aortic arch aneurysms and dissections require highly complex surgical procedures with devastating complications and mortality rates. Currently, repair of the complete arch until the proximal descending thoracic aorta consists of a two-stage procedure, called elephant trunk (ET) technique, or a single stage a single-stage technique referred to as frozen elephant trunk (FET). There is conflicting evidence about the perioperative results of ET in comparison with FET. We carried out a meta-analysis to investigate possible differences in perioperative and early (up to 30 days) outcomes of ET vs. FET, particularly for mortality, spinal cord injury (SCI), stroke, and renal failure. We also performed a meta-regression to explore the effects of age and sex as possible cofactors. Twenty-one studies containing data from interventions conducted between 1997 and 2019 and published between 2008 and 2021 with 3153 patients (68.5% male) were included. ET was applied to 1,693 patients (53.7%) and FET to 1460 (46.3%). Overall mortality after ET was 250/1693 (14.8%) and after FET 116/1460 (7.9%). Relative risk (RR) and 95% confidence interval (CI) were 1.37 [1.04 to 1.81], p = 0.027. There was no significant effect of age and sex. SCI occurrence after the second stage of ET was 45/1693 (2.7%) and after FET 70/1,460 patients (4.8%) RR 0.53 [0.35 to 0.81], p = 0.004. Age and sex were not associated with the risk of SCI. No significant differences were observed between ET and FET in the incidence of stroke and renal failure. Our results indicate that ET is associated with higher early mortality but lower incidence of SCI compared to FET. When studies published in the last 5 years were analyzed, no significant differences in mortality or SCI were found between ET and FET. This difference is attributed to a decrease in mortality after ET, as the mortality after FET did not change significantly over time.
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BACKGROUND: Hybrid ablation (HA) of atrial fibrillation (AF) combines minimally invasive thoracoscopic epicardial ablation with transvenous endocardial electrophysiologic validation and touch-up of incomplete epicardial lesions if needed. While studies have reported on a bilateral thoracoscopic HA approach, data on a unilateral left-sided approach are scarce. AIM: To evaluate the efficacy and safety of a unilateral left-sided thoracoscopic approach. METHODS: Retrospective analysis of a prospectively gathered cohort of all consecutive patients undergoing a unilateral left-sided HA for AF between 2015 and 2018 in the Maastricht University Medical Centre. RESULTS: One-hundred nineteen patients were analyzed (mean age 64 ± 8, 28% female, mean body mass index 28 ± 4 kg/m2 , median CHA2 DS2 -VASc Score 2 [1-3], [longstanding]-persistent AF 71%, previous catheter ablation 44%). In all patients, a unilateral left-sided HA consisting of pulmonary vein (PV) isolation, posterior left atrial (LA) wall isolation, and LA appendage exclusion was attempted. Epicardial (n = 59) and/or endocardial validation (n = 81) was performed and endocardial touch-up was performed in 33 patients. Major peri-operative complications occurred in 5% of all patients. After 12 and 24 months, the probability of being free from supraventricular tachyarrhythmia recurrence was 80% [73-87] and 67% [58-76], respectively, when allowing antiarrhythmic drugs. CONCLUSION: Unilateral left-sided hybrid AF ablation is an efficacious and safe approach to treat patients with paroxysmal and (longstanding) persistent AF. Future studies should compare a unilateral with a bilateral approach to determine whether a left-sided approach is as efficacious as a bilateral approach and allows for less complications.