Staged hybrid totally thoracoscopic maze and catheter ablation for atrial fibrillation.

INTRODUCTION: Atrial fibrillation (AF) is a growing health problem and is associated with increased risk of stroke. The Cox-Maze surgical procedure has offered the highest success rate, but utilization of this technique is low due to procedure invasiveness and complexity. Advances in catheter ablation and minimally invasive surgical techniques offer new options for AF treatment. METHODS: In this review, we describe current trends and outcomes of minimally invasive treatment of persistent and long-standing persistent AF. RESULTS: Treatment of persistent and long-standing persistent AF can be successfully treated using a team approach combining cardiac surgery and electrophysiology procedures. With this approach, the 1-year freedom from AF off antiarrhythmic drugs was 85%. DISCUSSION: There are a variety of techniques and approaches used around the world as technology evolves to help develop new treatment strategies for AF. Our report will focus on a hybrid treatment approach using surgical and electrophysiology approaches providing enhanced treatment options by replicating Cox-Maze IV lesions using skills from each specialty. Closure of the left atrial appendage as part of these procedures enhances protection from late stroke. A team approach provides a cohesive evaluation, treatment, and monitoring plan for patients. Development of successful, less invasive treatment options will help address the growing population of patients with AF.

A history of collaboration between electrophysiologists and arrhythmia surgeons.

INTRODUCTION: The notion that medically-refractory arrhythmias might one day be amenable to interventional therapy slowly began to appear in the early 1960's. At that time, there were no "interventional electrophysiologists" or "arrhythmia surgeons" and there was little appreciation of the relationship between anatomy and electrophysiology outside the heart's specialized conduction system. METHODS: In this review, we describe the evolution of collaboration between electrophysiologists and surgeons. RESULTS: Although accessory atrio-ventricular (AV) connections were first identified in 1893 and the Wolff-Parkinson-White (WPW) syndrome was described 37 years later (1930), it was another 37 years (1967) before those anatomic AV connections were proven to be responsible for the clinical syndrome. The success of the subsequent surgical procedures for the WPW syndrome, AV node reentry tachycardia, automatic atrial tachycardias, ischemic and non-ischemic ventricular tachycardias and atrial fibrillation over the next two decades depended on a close, sometimes daily, collaboration between electrophysiologists and surgeons. In the past two decades, that tight collaboration was largely abandoned until the recent introduction of "hybrid procedures" for the treatment of atrial fibrillation. CONCLUSIONS: A retrospective assessment of the 50 years of interventional therapy for arrhythmias clearly demonstrates the clinical benefits of a close collaboration between electrophysiologists and arrhythmia surgeons, regardless of which one is actually performing the intervention.

Does Active Chest Tube Clearance After Cardiac Surgery Provide Any Clear Benefits?

BACKGROUND: Retained blood syndrome (RBS) encompasses complications, acute and chronic, related to inflammation created by retained intrathoracic blood after cardiac surgery. Reports suggest that active chest tube clearance devices reduce RBS and may lower the rates of reoperation for bleeding and postoperative atrial fibrillation. METHODS: In a prospective study (April 2015-October 2017), 1367 patients meeting the study inclusion criteria (1113 control subjects with conventional chest tubes and 254 patients with active chest tube clearance devices [the ATC group]) underwent cardiac surgery through primary sternotomy. RESULTS: Groups were similar in their preoperative and intraoperative characteristics. No differences were found in overall RBS occurrence (4.3% in the ATC group vs 5.3% in the control group; P = .527), including the components of reexploration for bleeding (2.0% [5/254] for the ATC group and 2.4% [27/1113] for the control group; P = .664) and pleural effusion requiring intervention (3.1% [8/254] vs 3.6% [40/1113]; P = .729). Postoperative atrial fibrillation (20.8% [52/254] vs 20.2 % [221/1113]; P = .837) and 30-day mortality were also similar (3.5% vs 2.2%; P = .231). Postoperative blood product use was 31.9% (81/254) in the ATC group and 28.7% (319/1113) in the control group (P = .308). Some complications were more common in the ATC group, including septicemia (2.4% [6/254] vs 0.7% [8/1113]; P = .019) and renal failure (3.9% [10/254] vs 1.7% [19/1113]; P = .026). Median postoperative length of stay was shorter in the ATC group (5 days vs 6 days; P = .025). CONCLUSIONS: Active chest tube clearance devices were not associated with improved postoperative outcomes related to RBS at the study institution (Northwestern Medicine, Chicago, IL). Given the additional cost, the nursing effort to maintain the active chest tube clearance devices, and the lack of apparent benefit, this study did not demonstrate the value of using such devices in cardiac surgery.

Valve-sparing versus valve-replacing aortic root replacement in patients with aortic root aneurysm.

BACKGROUND: Valve-sparing aortic root replacement (VSARR) is an alternative to valve-replacing aortic root replacement (VRARR) with valved-conduits based on recent guidelines for clinical practice. This study investigated outcomes of these two procedures in patients with nonstenotic valves. METHODS: Between January 7, 2007 and June 30, 2019, 475 patients with aortic root aneurysm without aortic stenosis underwent VSARR (151) or VRARR (324) techniques. Propensity score-matching (PSM) was used to alleviate confounding. Endpoints were 30-day mortality, 8-year survival and reoperation, aortic regurgitation, and valve gradients. RESULTS: PSM created 69 pairs of patients with a mean age 52 ± 13 years (10.1% Marfan syndrome, 34.8% bicuspid aortic valve). There was no statistically significant difference in major perioperative morbidity or 30-day mortality (0% VSARR vs. 1.4% VRARR; p = 0.316). Overall survival was significantly higher (p = 0.025) in the VSARR group versus the VRARR group (8-year estimates 100% vs. 88.9%, respectively), while freedom from valve reoperation was similar (p = 0.97, 8-year estimates 90.9% vs. 96.7%, respectively). Freedom from > moderate-severe AR was not significantly different (p = 0.08, 8-year estimates 90.0% VSARR group vs. 100% VRARR), but mean valve gradients at last follow-up were better in the VSARR group (5.9 vs. 13.2 mmHg, p < 0.001). CONCLUSIONS: VSARR is a safe operation in patients with aortic root aneurysm and nonstenotic aortic valves in the hands of experienced surgeons. Freedom from reoperation is similar and the mode of aortic valve failure differs between the two groups.

Propensity Score-Matched Comparison of Right Ventricular Strain in Women and Men Before and After Left Ventricular Assist Device Implantation.

Objective: Adverse events following left ventricular assist device (LVAD) implantation are more common in women than in men, but the impact of gender differences on right ventricular (RV) failure is not well defined. Therefore, we calculated RV strain before and after LVAD implantation in matched groups of men and women to determine if gender differences in RV failure after LVAD might account for the gender differences in overall outcomes. Methods: RV free wall longitudinal strain (FWS) and fractional area change were calculated preoperatively and 3 months postoperatively using speckle-tracking echocardiography analysis. A total of 172 patients (86 women, 86 men) were then propensity score matched (1:1) for comparison. Results: Although women had higher preoperative CHA2DS2-VASc scores and more frequent moderate mitral regurgitation than men (P = 0.018), the preoperative hemodynamic parameters were similar. Preoperative RV-FWS was -6.7% in women and -6.0% in men (P = 0.65). Postoperatively, women had more progression to severe tricuspid regurgitation (TR) than men (15% vs 7%, P = 0.06). At 3 months the RV-FWS was -7.7% in women and -7.0% in men (P = 0.59). Postoperative TR was moderate-severe in 20% of women and in 9% of men (P = 0.001). Women had a higher incidence of venous thromboembolism, cardiac arrhythmias, and bleeding compared with men. Women also had higher mortality rates at discharge and 30 days after surgery, but the survival rates at 5 years were similar. Conclusions: RV strain measurements track standard hemodynamic and echocardiographic parameters and confirm that gender differences in outcomes following LVAD implantation are not related to gender differences in RV failure rates.

Preoperative left atrial strain abnormalities are associated with the development of postoperative atrial fibrillation following isolated coronary artery bypass surgery.

OBJECTIVE: Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG). Currently, there is no reliable way to determine preoperatively which patients will develop POAF following CABG. The aim of this study was to determine whether preoperative left atrial (LA) strain analysis might identify patients destined to develop POAF following CABG. METHODS: From 2016 to 2018, 211 patients who had a preoperative left ventricular ejection fraction >50% and adequate preoperative, predischarge, and follow-up echo images for interpretation underwent isolated CABG surgery. Postoperatively, patients had continuous rhythm monitoring until hospital discharge. Retrospective speckle-tracking analysis of preoperative echocardiograms was performed to calculate preoperative left ventricular global longitudinal strain and LA compliance and contraction strains in 92 matched patients. Multivariate logistic regression and Cox proportional hazards models were used to determine the predictors of POAF after CABG. RESULTS: POAF occurred in 50 patients (24%). They were older, had longer intensive care unit and hospital stays, and a slightly greater 30-day mortality (P = .07). Preoperative LA volume index was larger in the patients with POAF but still "normal" as defined by current guidelines. However, preoperative LA compliance and contraction strains were significantly lower in patients who developed POAF after CABG. CONCLUSIONS: Decreased preoperative LA strain measurements, especially LA-fractional area change, LA-emptying fraction, and LA-reservoir strain, taken jointly, are more specific and sensitive than other preoperative parameters in identifying patients who will develop POAF following CABG. The ability to identify patients preoperatively who are destined to develop POAF following CABG provides a basis for limiting POAF prophylactic therapy to only those patients undergoing CABG who are most likely to benefit from it rather than to all patients undergoing CABG.

Does gender bias affect outcomes in mitral valve surgery for degenerative mitral regurgitation?

OBJECTIVES: This study was conducted to determine if gender bias explains the worse outcomes in women than in men who undergo mitral valve surgery for degenerative mitral regurgitation. METHODS: Patients who underwent mitral valve surgery for degenerative mitral regurgitation with or without concomitant ablation surgery for atrial fibrillation were identified from the Cardiovascular Research Database of the Clinical Trial Unit of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital and were defined according to the Society of Thoracic Surgery National Adult Cardiac Surgery Database. Of the 1004 patients (33% female, mean age 62.1 ± 12.4 years; 67% male, mean age 60.1 ± 12.4 years) who met this criteria, propensity score matching was utilized to compare sex-related differences. RESULTS: Propensity score matching of 540 patients (270 females, mean age 61.0 ± 12.2; 270 males, mean age 60.9 ± 12.3) demonstrated that 98% of mitral valve surgery performed in both groups was mitral valve repair and 2% was mitral valve replacement. Preoperative CHA2DS2-VASc scores were higher in women and fewer women were discharged directly to their homes. Before surgery, women had smaller left heart chambers, lower cardiac outputs, higher diastolic filling pressures and higher volume responsiveness than men. However, preoperative left ventricular and right ventricular strain values, which are normally higher in women, were similar in the 2 groups, indicating worse global strain in women prior to surgery. CONCLUSIONS: The worse outcomes reported in women compared to men undergoing surgery for degenerative mitral regurgitation are misleading and not based on gender bias except in terms of referral patterns. Men and women who present with the same type and degree of mitral valve disease and similar comorbidities receive the same types of surgical procedures and experience similar postoperative outcomes. Speckle-tracking echocardiography to assess global longitudinal strain of the left and right ventricles should be utilized to monitor for myocardial dysfunction related to chronic mitral regurgitation.

The relationship of atrial fibrillation and tricuspid annular dilation to late tricuspid regurgitation in patients with degenerative mitral repair.

OBJECTIVES: Guidelines do not address preoperative atrial fibrillation when considering adding tricuspid annuloplasty to mitral surgery. Our purpose was to determine the occurrence of late tricuspid regurgitation in patients with less than moderate tricuspid regurgitation undergoing surgery for degenerative mitral regurgitation and the importance of atrial fibrillation and tricuspid annular dilation. METHODS: From 2004 to 2017, 1021 patients underwent surgery for degenerative mitral regurgitation; 869 (85%) had less than moderate tricuspid regurgitation, and 846 (97%) underwent repair. Preoperative atrial fibrillation was present in 199 patients and ablated in 194 patients (97%). Tricuspid annular diameter was measured in 657 of 869 patients (76%). RESULTS: For patients who did not receive tricuspid annuloplasty, recurrent moderate or more late tricuspid regurgitation was 8% (45/576) in the no atrial fibrillation group and 25% (38/154) in the atrial fibrillation group (P < .001; odds ratio, 2.42). In 75.2% of patients (494/657), the tricuspid annulus was less than 4.0 cm; in 17% of patients (112), the tricuspid annulus was 4.0 to 4.4 mm (mean 41.1 mm); and in 7.8% of patients (51), the tricuspid annulus was 45 mm or more (47.8 mm). Only tricuspid diameter 45 mm or more was a risk for late tricuspid regurgitation (P = .002; odds ratio, 3.25). Progression to moderate or higher tricuspid regurgitation was associated with an increase in long-term mortality: unadjusted hazard ratio, 3.58 (2.04-6.29) (P < .001); adjusted hazard ratio, 2.37 (1.23-4.57) (P = .010). CONCLUSIONS: Preoperative atrial fibrillation is an important risk factor for late tricuspid regurgitation despite concomitant ablation surgery. Tricuspid annular dilation was not associated with late tricuspid regurgitation until the annulus was 45 mm or greater. Progression to moderate or greater tricuspid regurgitation was associated with an increase in late mortality.

Surgery and Catheter Ablation for Atrial Fibrillation: History, Current Practice, and Future Directions.

Atrial fibrillation (AF) is the most common of all cardiac arrhythmias, affecting roughly 1% of the general population in the Western world. The incidence of AF is predicted to double by 2050. Most patients with AF are treated with oral medications and only approximately 4% of AF patients are treated with interventional techniques, including catheter ablation and surgical ablation. The increasing prevalence and the morbidity/mortality associated with AF warrants a more aggressive approach to its treatment. It is the purpose of this invited editorial to describe the past, present, and anticipated future directions of the interventional therapy of AF, and to crystallize the problems that remain.

Cryosurgery for Atrial Fibrillation: Physiologic Basis for Creating Optimal Cryolesions.

BACKGROUND: Although cryosurgery has been used to treat cardiac arrhythmias for nearly 5 decades, the mechanism of action and the surgical technique that produces optimal cryolesions for the treatment of atrial fibrillation are still poorly understood. This has resulted in surgical outcomes that can be improved by a better understanding the mechanisms of cryothermia ablation and the proper surgical techniques that take advantage of those mechanisms. METHODS: The cryobiology underlying cryosurgical ablation is described, as are the nuances of cryosurgical techniques that ensure the reliable creation of contiguous, uniformly transmural atrial cryolesions. The oft-misunderstood "2-minute rule" for the application of cryothermia is clarified in detail, along with its variations that depend on target myocardial temperature. RESULTS: The creation of optimal cryolesions depends on cryoprobe temperature, the temperature of the target myocardium, the duration of cryothermia application, and the presence or absence of a "heat sink" or "cooling sink" created by intracavitary blood circulation. Cryothermia kills myocardial cells during both the freezing and thawing phases of cryoablation cycle. The critical lethal temperature for myocardium is -30°C. The slower the target tissue thaws, the higher the percentage of cell death. CONCLUSIONS: The availability of cryosurgical techniques has revolutionized the surgical treatment of atrial fibrillation. By utilizing modern cryosurgical devices and adhering to the technical principles described, surgeons can now perform surgical procedures for atrial fibrillation that are quicker, safer, and as effective as the standard Maze-III/IV procedure.

Unique technical challenges in patients undergoing TAVR for failed aortic homografts.

OBJECTIVE: Surgical reoperation for aortic homograft structural valve degeneration (SVD) is a high-risk procedure. Transcatheter aortic valve replacement (TAVR) for homograft-SVD is an alternative to reoperation, but descriptions of implantation techniques are limited. This study compares outcome in patients undergoing into two groups by the type of previously implanted aortic valve prosthesis: TAVR for failed aortic homografts (TAVR-H) or for stented aortic bioprostheses (TAVR-BP). METHODS: From 2015 to 2017, TAVR was performed in 41 patients with SVD. Thirty-three patients in the TAVR-BP group (six for SVD of valved conduits), and eight patients in the TAVR-H group. The Valve Academic Research Consortium criteria were used for outcome reporting purposes. RESULTS: The patients with TAVR-BP had predominant prosthetic stenosis (94%, p = .002), whereas TAVR-H individuals presented mostly with regurgitation (88%, p = <.001). Patients with TAVR-H received: Sapien-3 (6), Sapien-XT (1), and CoreValve (1) devices. Low, 40% ventricular fixation in relation to homograft annulus was attempted to anchor the prosthesis on the homograft suture-line. One patient with TAVR-BP experienced intraoperative distal prosthesis migration and Type-B aortic dissection, and two patients in the TAVR-H group had late postoperative proximal device migration. In both groups, there was zero 30-day mortality, stroke, or pacemaker implantation. CONCLUSIONS: TAVR for failing aortic homografts may be a feasible and safe alternative to high-risk surgical reintervention. Precise, 40%-ventricular device positioning appears crucial for prevention of late paravalvular leak/late prosthesis migration and minimizing the risk of repeat surgical intervention.

Safety of Atrial Fibrillation Ablation With Isolated Surgical Aortic Valve Replacement.

BACKGROUND: Surgical ablation of atrial fibrillation (AF) concomitant with cardiac surgery is a Society of Thoracic Surgeons (STS) class I recommendation, although the AF is frequently ignored. Analysis of the STS Database 30-day outcomes of isolated surgical aortic valve replacement (AVR) with and without AF ablation is presented. METHODS: Data on 87,426 surgical aortic valve replacement patients were extracted from the STS database (version 2.81, 2014-2017) and patients were divided into 3 groups: (1) No preoperative AF, (2) Preoperative AF with concomitant ablation, and (3) Preoperative AF without ablation. The latter 2 groups were propensity score-matched in 1-(up)-to-2 ratio to alleviate covariate imbalances and reduce bias. Thirty-day outcomes were evaluated and compared. RESULTS: Preoperative AF was present in 17.8% (15,596 of 87,426 patients). Ablation was performed in 33.1% (5,167 of 15,596), and 57.7% (2,983) had left atrial appendage closure. Propensity score matching (AF ablated n = 3692; AF non-ablated n = 5724), revealed that there was no difference between the AF ablated and AF non-ablated groups in mortality (2.8% vs 3.0%, respectively; P = .65) or for stroke (1.6% vs 1.7%, respectively; P = .82), but postoperative pacemaker implantation was higher in the AF ablated patients (6.8% AF ablated vs 5.0% AF non-ablated, P < .001). CONCLUSIONS: Despite being a class I recommendation, AF ablation concomitantly with other cardiac surgical procedures remains lower than current guideline recommendation in surgical aortic valve replacement patients. Ablation for AF does not increase the 30-day operative mortality or perioperative morbidity compared with non-ablated patients, although new pacemaker requirements were higher in the AF ablated group.

Cardiac anatomy pertinent to the catheter and surgical treatment of atrial fibrillation.

In the 1980s when surgery was first introduced for the treatment of atrial fibrillation (AF), one would often hear comments like "Every little old grandmother has AF. Why on earth would you operate on someone like that?".

Predictors of Left Ventricular Dysfunction After Surgery for Degenerative Mitral Regurgitation.

BACKGROUND: This study was performed to determine whether strain can supplement the ability of left ventricular (LV) ejection fraction (LVEF) to predict postoperative ventricular dysfunction in patients undergoing mitral valve surgery for degenerative mitral regurgitation (DMR). METHODS: From 2004 to 2017, 520 patients with an LVEF of 60% or more underwent mitral valve surgery (98% repair) for DMR. All patients had preoperative, predischarge, and follow-up (mean, 5.0 ± 3.6 years) echocardiograms. Speckle tracking was performed in 119 of 520 patients (22.9%) to determine LV strain, right ventricular free-wall strain, and left atrial longitudinal strain. Multivariate logistic and Cox regression models were used in this subgroup to evaluate associations with early postoperative LV dysfunction and medium-term overall survival, respectively. RESULTS: Median preoperative LVEF of the entire cohort was 65%. Based on predischarge echocardiogram, 449 patients (86.3%) maintained postoperative LVEF of 50% or greater. Seventy-one patients (13.7%) had a predischarge LVEF of less than 50%, 49 (9.4%) had a predischarge LVEF of 40% to 49%, and 22 (4.2% overall) had a predischarge LVEF of less than 40%. Abnormal preoperative LV, right ventricular, and left atrial strain measurements were significantly associated with the development of postoperative LV dysfunction, but preoperative hemodynamic and non-strain echo parameters did not vary enough in absolute values to be clinically useful as predictors of postoperative LV dysfunction. CONCLUSIONS: Preoperative strain measurements in DMR patients were significantly associated with superior capabilities of detecting underlying LV dysfunction despite preserved preoperative LVEF. Strain analysis may serve as another marker for optimal timing of surgical intervention in DMR patients.

Comparison of Monitored Anesthesia Care and General Anesthesia for Transcatheter Aortic Valve Replacement.

OBJECTIVE: Transcatheter aortic valve replacement is a safe, minimally invasive treatment for severe aortic stenosis in patients with moderate-to-high surgical risk. Monitored anesthesia is administered by an anesthesiologist. This study compares transcatheter aortic valve outcomes under monitored anesthesia vs general anesthesia. METHODS: Data were prospectively collected for 286 patients undergoing transcatheter aortic valve replacement at a single academic hospital from March 2012 to August 2016. The patients were grouped by type of anesthesia: monitored vs general. A propensity score match was performed to compare intraoperative and post-operative outcomes between groups. RESULTS: General anesthesia was used in 102 patients and moderate sedation in 184. Propensity score matching produced 80 pairs. Compared to procedures under general anesthesia, patients receiving monitored anesthesia had shorter procedure (1.6 [1.4, 2.0] vs 2.0 [1.6, 2.5] hours;P < 0.001) and fluoroscopy times (17 [14.5, 22.5] vs 25 [17.9, 30.3] minutes;P < 0.001) and shorter hospital length-of-stay (3 [2.0, 4.0] vs 5 [3.0, 7.0] days;P < 0.001) but no difference in intensive care unit length-of-stay. Blood transfusion was more common in patients undergoing general anesthesia, but there was no difference in stroke, renal failure, postoperative atrial fibrillation, or need for permanent pacemaker. More patients were discharged to home after monitored anesthesia (90% vs 64%;P < 0.001). There was no difference in 30-day mortality (0% vs 3%;P = 0.15). CONCLUSIONS: Transcatheter aortic valve replacement under monitored anesthesia provides the safety of anesthesia-led sedation without intubation and general anesthetic. We found no compromise in patient safety or clinical outcomes.

Transcatheter Mitral Valve Replacement with Intrepid.

Transcatheter mitral valve replacement with the Intrepid device is intended for patients who need mitral valve replacement and who are at an increased risk for conventional surgery. The early published results of the early feasibility trial are reviewed as well as device design and the implant procedure. The Apollo trial is reviewed: a randomized trial of the Intrepid device versus conventional surgery including a single arm study for inoperable patients. The mitral valve structure, pathophysiology, and postimplant physiology pose unique hurdles for any transcatheter implant.

Is mitral valve disease treated differently in men and women?

PURPOSE: This study was performed to determine if there is a sex-based bias in referral practices, complexity of disease, surgical treatment, or outcomes in patients undergoing mitral valve surgery at our institution. METHODS: Data were collected from the Cardiovascular Research Database of the Clinical Trial Unit of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital and they were defined according to the Society of Thoracic Surgeons National Database ( www.sts.org ). All patients who had mitral valve replacement, mitral valve repair with annuloplasty ring placement, and mitral valve annuloplasty alone were evaluated, including patients who underwent concomitant tricuspid valve surgery, atrial fibrillation ablation, patent foramen ovale closure, and coronary artery bypass grafting. An unmatched comparison was made between the 836 men and 600 women in the entire cohort (N = 1436) and propensity score-matching was performed in 423 pairs of men and women. Additional propensity score-matching for 219 pairs of men and women with Type II mitral valve functional class and no coronary artery disease and for 68 pairs of men and women with Type 1 or Type IIIb mitral valve functional class. Propensity score matching was used to compare sex differences involving a greedy algorithm with a caliper of size 0.1 logit propensity score standard deviation units. RESULTS: Between 1 April 2004 and 30 June 2017, 1436 patients (41.8% women, mean age 61.1 ± 12.6 years (men), 62.9 ± 13.3 years (women)) underwent mitral valve surgery. The unmatched comparison for the entire cohort showed that, on average, at the time of surgery, women had higher Society of Thoracic Surgery risk scores, were older and had more heart failure, coronary artery disease, and mitral stenosis than men. Women received proportionately fewer mitral repairs and more atrial fibrillation ablation, and tricuspid valve surgery. Women had longer intensive care unit and hospital stays, required more dialysis, and suffered more transient ischemic attacks and cardiac arrests postoperatively, and 30-day mortality rate was higher for women. However, propensity score-matching of 846 of the patients (423 men; 423 women) indicated that both the surgical approaches and surgical outcomes were comparable for men and women who had similar levels of disease and co-morbidities. Additional propensity score-matching of only those patients with degenerative mitral regurgitation (DMR) (219 men; 219 women) and those with Type 1 or Type III mitral valve disease showed no differences in the surgical procedures performed or in 30-day mortality rates. CONCLUSIONS: Women appear to be referred for mitral valve surgery later in the course of their disease, which could possibly be on the basis of sex bias, but they may also have a more aggressive form of mitral valve disease than men. Regardless of the reasons for the later referral of women for mitral valve surgery, the clinical outcomes are dependent upon the severity of the mitral disease and associated co-morbidities at the time of surgery, not on the basis of sex bias.

A Hybrid Maze Procedure for Long-Standing Persistent Atrial Fibrillation.

BACKGROUND: Catheter ablation (CA) for long-standing persistent atrial fibrillation (LSPAF) is suboptimal, and open surgical ablation, although more successful, is too invasive to be a first-line therapy. Less invasive hybrid procedures that combine thoracoscopic surgery (TS) with CA have been only marginally more successful for LSPAF than CA alone. METHODS: Joint hybrid procedures for LSPAF are based on the assumption that AF surgery and CA procedures can be guided by intraoperative mapping. However, intraoperative mapping is not always dependable because of the transient nature of the sustaining reentrant drivers. The best results in patients with LSPAF have been attained with the non-guided, anatomy-based surgical Maze-III and Maze-IV procedures. Likewise, a staged TS/CA hybrid procedure that creates a combination of lesions that adhere to the concept of a Maze pattern, that is, a Hybrid Maze-IV procedure, should be more effective for LSPAF. RESULTS: Initial TS includes all lesions of the Maze-IV procedure except the mitral line, coronary sinus lesion, and one right atrial lesion. Follow-up CA at 3 months includes touching up any incomplete TS lesions, a cavotricuspid isthmus lesion, and a mitral line/coronary sinus lesion in the 10% to 15% of patients with post-TS perimitral flutter. This combination of TS and CA lesions creates a complete Maze-IV procedure. CONCLUSIONS: It is possible to create the complete lesion pattern of a Maze-IV procedure with a staged TS/CA hybrid procedure. The success of this Hybrid Maze procedure in patients with LSPAF should be the same as that attained with an open surgical Maze-IV procedure.