Persistent atrial fibrillation ablation concomitant to coronary surgery.

OBJECTIVE: This analysis was undertaken to evaluate the results of persistent atrial fibrillation (pAF) ablation procedures concomitant to coronary surgery and to identify the risk factors for pAF recurrence. METHODS: Since 2001, a total of 126 consecutive patients with pAF (duration: 0.5-33 years) underwent ablation concomitant to coronary surgery (isolated or in combination with valve surgery), whereby two encircling isolation lesions around the left and the right pulmonary veins and a connecting lesion between both was created using radiofrequency ablation. Patients were reevaluated at discharge, 3 months and 3 years after surgery. RESULTS: Survivals at the time of reexamination were 96.8, 95.1 and 94.7 %, respectively. Stable sinus rhythm (SR) could be documented in 66.4, 75.1 and 75.9 % of surviving patients. Long-term pAF before surgery and a larger left atrium (LA) were predictive of postoperative pAF return ( P < 0.01). Statistical analysis demonstrated a cut-off point of 5 years for pAF and 50 mm for LA diameter: 89.1 % of patients with pAF duration of < 5 years and 86.2 % of patients with LA size of ≤ 50 mm were in stable SR at late follow-up. Cardiac rhythm at 3 months was predictive for long-term rhythm prognosis ( P < 0.01). Age, gender and concomitant diseases (e.g. arterial hypertension, diabetes, renal insufficiency), and the underlying cause of heart disease did not significantly influence the postoperative cardiac rhythm. CONCLUSIONS: The duration of pAF and the LA size are the most reliable preoperative variables to predict the success rate of ablation in patients undergoing coronary surgery. The probability of re-establishing stable SR is excellent when pAF duration is short and LA size is small.

Early and late results of permanent atrial fibrillation ablation surgery in aortic valve and CABG patients.

OBJECTIVE: The study investigates the early and late results of permanent atrial fibrillation (AF) ablation surgery concomitant to coronary artery bypass grafting (CABG) and/or aortic valve (AV) surgery. METHODS: Between February 2001 and April 2006, a selective group of 80 patients with permanent AF (median: 48 months [Perc25/75 24/110; range: 6 - 360 months]) underwent either bipolar (n = 60) or monopolar (n = 20) radiofrequency (RF) ablation procedures concomitant to CABG and/or AV surgery (CABG: n = 39; AV: n = 30; AV + CABG: n = 11). All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class early (3 +/- 1 months) and late after surgery (30 +/- 15 months). Data were analyzed exploratively. RESULTS: Survival at 3 and 30 months was 98 % and 96 %, respectively. Stable SR could be documented in 73 % and 77 % of patients. Long-term AF before surgery and larger LA size were predictive for AF return after surgery ( P = 0.004 and P = 0.032, respectively). Neither age, gender, the application modus of the RF energy nor the underlying cardiac disease influenced the postoperative cardiac rhythm significantly. NYHA class improved significantly after surgery ( P < 0.0005), particularly when stable SR was achieved ( P = 0.049). CONCLUSION: Preoperative permanent AF duration time and larger LA size are useful variables to predict the success rate of concomitant ablation surgery in CABG and/or AV patients. Further it could be demonstrated that established SR remained stable over time.

Early and late results of restrictive mitral valve annuloplasty in 121 patients with cardiomyopathy and chronic mitral regurgitation.

OBJECTIVE: This study investigated the early and late results of restrictive mitral valve (MV) annuloplasty in patients with chronic mitral regurgitation (MR) and advanced ischemic (ICM) or dilated cardiomyopathy (DCM). METHODS: From October 2001 to September 2006, 121 patients (age: 69 +/- 9 years) with a left ventricular ejection fraction (LVEF) of 30 +/- 9 % and chronic MR grade 3 - 4 (ICM: n = 102, DCM: n = 19) underwent restrictive prosthetic ring annuloplasty (downsizing of 2.7 +/- 0.8 ring sizes). Eighty-five ICM-patients had indications for concomitant coronary artery bypass grafting (CABG). All patients were restudied at 7 +/- 1 days, 3 +/- 1 and 30 +/- 12 months after surgery to assess survival, residual MR, New York Heart Association (NYHA) class and left ventricular (LV) function (end-systolic/end-diastolic dimensions/volume indexes and LVEF). Data were analyzed exploratively. RESULTS: 30-day mortality was 3.3 %; survival at follow-up was 95 % and 91 %, respectively. Postoperative recurrence of significant MR (> grade 2) was absent in all patients. NYHA class, LV dimensions/volume indexes and LVEF improved significantly after surgery in both groups ( P < 0.0005). A prediction of continuous postoperative improvement of myocardial function in the sense of reverse remodeling could be demonstrated by univariate logistic regression for ischemic etiology and concomitant CABG ( P = 0.0001). In DCM-patients or ICM-patients without CABG, the postoperative benefit on myocardial function was limited. CONCLUSION: Restrictive mitral valve (MV) annuloplasty corrected chronic MR in cardiomyopathy patients with low mortality and improved contractility. Surgery also prevented recurrence of significant MR, although the phenomenon of postoperative continuous reverse myocardial remodeling could not be verified in cases with a non-ischemic etiology or ICM without concomitant CABG.

Ablation surgery failure after combined permanent atrial fibrillation ablation and mitral valve surgery.

OBJECTIVE: The aim of this study was to evaluate the early and late results of a permanent atrial fibrillation (pAF) ablation concept carried out concomitantly with mitral valve (MV) surgery and to identify risk factors for ablation surgery failure. METHODS: Between February 2001 and April 2006, 109 patients with pAF over a median time of 48 months (Perc25/75; range 6 - 396 months) underwent monopolar endocardial radiofrequency ablation procedures concomitantly with MV surgery. All patients were restudied to assess survival, conversion rate to stable sinus rhythm (SR) and New York Heart Association (NYHA) class early (3 +/- 1 months) and late after surgery (36 +/- 19 months). For data assessment an explorative data analysis including univariate and multivariate binary logistic regression was performed. RESULTS: Early and late survival was 95 % and 91 %, respectively; at follow-up stable SR was documented in 76 % (74 %) of patients. NYHA class improved significantly after surgery ( P = 0.009), particularly when stable SR was achieved ( P = 0.042). Among these MV patients left atrial (LA) enlargement and pAF of long-time duration prior to surgery were detected as risk factors for postoperative recurrence and persistence of atrial fibrillation ( P = 0.026 and P = 0.002); furthermore, advanced age and significant tricuspidal regurgitation at the time of surgery were also relevant. The best prediction (95 % of patients) for SR, as demonstrated in a multivariate model, was based on the factors LA size and pAF duration ( P = 0.052 and 0.005). CONCLUSION: Particularly the preoperative LA size and pAF duration seem to be useful parameters to evaluate the success rate of ablation performed concomitantly with MV surgery. It could be demonstrated that an established SR remains stable over time.

Changes of myocardial function after combined coronary revascularization and mitral valve downsizing in patients with ischemic mitral regurgitation and advanced cardiomyopathy.

OBJECTIVE: At present not much data is available on changes in myocardial function after combined coronary artery bypass grafting (CABG) and downsizing of the mitral valve (MV) by restrictive prosthetic ring annuloplasty in patients with chronic ischemic mitral regurgitation (IMR) and advanced cardiomyopathy. METHODS: 63 patients with coronary artery disease, chronic IMR grade 3 - 4+, ischemic cardiomyopathy and reduced left ventricular (LV) function (LV ejection fraction [LVEF] of 30 +/- 9 %; range 12 - 45 %) underwent combined CABG and MV downsizing. Clinical follow-up and serial echocardiographic studies were performed to assess survival, New York Heart Association (NYHA) class, mitral regurgitation (MR), leaflet coaptation height (LCH), left atrial (LA) and LV end-systolic/end-diastolic dimensions/volumes and volume indices (LVESD, -EDD; LVESV, -EDV; LVESVI, -EDVI), fractional shortening (FS) and LVEF to evaluate the changes in myocardial function after surgery. RESULTS: Early mortality (< 30 days) was 1.6 %, survival at follow-up was 95 % (3 +/- 1 months) and 83 % (2 +/- 1 years), respectively. Functional class improved significantly after surgery; recurrence of relevant MR was absent in all patients. In general, LA/LV dimensions/volumes and volume indices, FS and LVEF improved significantly, even in patients with already severely reduced preoperative LV function (LVEF

Permanent atrial fibrillation ablation surgery in CABG and aortic valve patients is at least as effective as in mitral valve disease.

BACKGROUND: Data on combined permanent atrial fibrillation (pAF) surgery and coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) are scarce, and the mid- and long-term effects on survival and cardiac rhythm are unknown. MATERIAL AND METHODS: In a prospective analysis 125 patients (Group I: CABG and/or AVR, n = 50; Group II: mitral valve [MV] surgery, n = 75) with pAF (> or = 6 months) underwent either concomitant monopolar (Group I: n = 20; Group II: n = 75) or bipolar (Group I: n = 30) radiofrequency (RF) ablation procedures. Group I patients had a significantly smaller left atrial (LA) size than Group II patients (LA-diameter: 47.7 +/- 4.6 vs. 58.2 +/- 6.1 mm; p < 0.01). Regular follow-up was performed from 3 to 36 months after surgery to assess survival, NYHA-class, and conversion rate to stable sinus rhythm (SR). RESULTS: Early mortality (< 30 days) of Group I patients was 0% (Group II: 2.7%), cumulative survival at long-term follow-up was 0.95 vs. 0.82 (p = 0.31) and NYHA-class improved significantly in both groups, particularly in cases with stable SR. At follow-up 80% of Group I patients had SR (Group II: 70%). In Group I patients the bipolar approach was associated with significantly shorter ablation procedure times compared to the monopolar procedure (12.1 +/- 3.4 vs. 18.9 +/- 1.6 min; p < 0.05). CONCLUSIONS: Concomitant pAF ablation surgery in CABG and/or AVR is safe and at least as effective as in MV surgery, presumably because severe LA enlargement is exceptionally rare in this group.

Meta-analysis of the implantable cardioverter defibrillator secondary prevention trials. AVID, CASH and CIDS studies. Antiarrhythmics vs Implantable Defibrillator study. Cardiac Arrest Study Hamburg . Canadian Implantable Defibrillator Study.

AIMS: Three randomized trials of implantable cardioverter defibrillator (ICD) therapy vs medical treatment for the prevention of death in survivors of ventricular fibrillation or sustained ventricular tachycardia have been reported with what might appear to be different results. The present analysis was performed to obtain the most precise estimate of the efficacy of the ICD, compared to amiodarone, for prolonging survival in patients with malignant ventricular arrhythmia. METHODS AND RESULTS: Individual patient data from the Antiarrhythmics vs Implantable Defibrillator (AVID) study, the Cardiac Arrest Study Hamburg (CASH) and the Canadian Implantable Defibrillator Study (CIDS) were merged into a master database according to a pre-specified protocol. Proportional hazard modelling of individual patient data was used to estimate hazard ratios and to investigate subgroup interactions. Fixed effect meta-analysis techniques were also used to evaluate treatment effects and to assess heterogeneity across studies. The classic fixed effects meta-analysis showed that the estimates of ICD benefit from the three studies were consistent with each other (P heterogeneity=0.306). It also showed a significant reduction in death from any cause with the ICD; with a summary hazard ratio (ICD:amiodarone) of 0.72 (95% confidence interval 0.60, 0.87;P=0.0006). For the outcome of arrhythmic death, the hazard ratio was 0.50 (95% confidence interval 0.37, 0.67;P<0.0001). Survival was extended by a mean of 4.4 months by the ICD over a follow-up period of 6 years. Patients with left ventricular ejection fraction < or = 35% derived significantly more benefit from ICD therapy than those with better preserved left ventricular function. Patients treated before the availability of non-thoracotomy ICD implants derived significantly less benefit from ICD therapy than those treated in the non-thoracotomy era. CONCLUSION: Results from the three trials of the ICD vs amiodarone are consistent with each other. There is a 28% reduction in the relative risk of death with the ICD that is due almost entirely to a 50% reduction in arrhythmic death.

Ventricular tachycardia during follow-up in patients resuscitated from ventricular fibrillation: experience from stored electrograms of implantable cardioverter-defibrillators.

OBJECTIVE: The purpose of this study was to use the electrogram storage capabilities of the implantable cardioverter-defibrillator (ICD) to categorize any arrhythmic event during follow-up in a group of patients who had survived an episode of ventricular fibrillation (VF) and to possibly identify clinical predictors of future arrhythmic events. BACKGROUND: Little is known about the electrophysiologic characteristics of ventricular arrhythmias recurring during follow-up in survivors of VF as the sole documented arrhythmia at the time of resuscitation. METHODS: Forty patients (58+/-10 years; 73% men; left ventricular ejection fraction 42+/-18%; 70% with coronary artery disease) who had survived an episode of VF and subsequently received an ICD capable of intracardiac electrogram recording and storage were followed for 23+/-11 months. In all patients, the arrhythmogenic substrate was investigated by means of programmed electrical stimulation (PES). RESULTS: Among the 40 patients, 41 episodes of ventricular arrhythmias were documented in 13 patients (33%): 36 episodes of ventricular tachycardias (VT) were recorded in 11 patients (28%) and 5 episodes of VF were recorded in the remaining 2 patients (5%). Age, gender, cardiac disease and left ventricular ejection fraction failed to distinguish between patients with clinical recurrences and patients without. The sensitivity, specificity and positive accuracy of PES were 29%, 63% and 46%, respectively, for prediction of ventricular arrhythmia recurrence; 45%, 70% and 36%, respectively, for prediction of VT; and 50%, 98% and 50%, respectively, for prediction of VF during follow-up. CONCLUSIONS: In survivors of VF receiving ICD therapy, VT is the most common ventricular arrhythmia recorded on device-incorporated electrograms during follow-up. This finding, associated with the relatively well-preserved ventricular function, may account for the ability of these patients to survive at time of the index arrhythmia; the use of antitachycardia pacing as a modality to treat arrhythmia recurrences may contribute to reduce the incidence of shock during follow-up in these patients.

Prevalence of respiratory symptoms, bronchial hyperresponsiveness and atopy among adults: west and east Germany.

The prevalence of respiratory symptoms, atopic sensitization and bronchial hyperresponsiveness was compared in a random sample of adults, 20-44 yrs of age, in two cities in West and East Germany, Hamburg and Erfurt, respectively. There were much higher levels of outdoor air pollution due to sulphur dioxide and suspended particulates in Erfurt, and major differences in living conditions during the last 40 yrs. Within the European Respiratory Health Survey, a short questionnaire was answered by 3,156 (80% response rate) subjects in Hamburg and 3,272 (74%) in Erfurt. A subset of responders to the short questionnaire completed a long questionnaire, spirometry, methacholine or bronchodilator test, skin test, and total and specific immunoglobulin E (IgE) measurements, with a total number of 1,159 participants in Hamburg and 731 in Erfurt. Six out of 8 questions on respiratory symptoms and diagnoses were answered in the affirmative more frequently in Hamburg than in Erfurt. In Hamburg, mean forced expiratory volume in one second (FEV1)% of predicted was 105 vs 107% in Erfurt (p < 0.0001), and bronchial hyperresponsiveness was more frequently observed in Hamburg than in Erfurt (25 vs 19%; p < 0.05). Atopic sensitization was more prevalent in Hamburg than in Erfurt regarding the results of skin tests against grass pollen (24 vs 19%; p < 0.05), birch pollen (19 vs 8%; p < 0.0005), cat (10 vs 2%; p < 0.0005), and Dermatophagoides pteronyssinus (14 vs 10%; p < 0.05). This was reflected by the prevalences of positive specific IgE values, which were higher in Hamburg than in Erfurt for grass (26 vs 20%; p < 0.05), birch (20 vs 10%; p < 0.0005) and cat (12 vs 8%; p < 0.05). In Hamburg, compared to Erfurt, there was: a lower mean number of siblings (p < 0.005); a higher degree of childhood and current exposure to environmental tobacco smoke (p < 0.005); and a higher frequency of fitted carpets and reported mould or mildew inside the house (p < 0.005). Therefore, these data may support the hypothesis that childhood factors and exposure to indoor allergens and irritants may have been more relevant for the development of asthma and atopy than the potential long-term exposure to high concentrations of sulphur dioxide and particulate matter.