Sequential hybrid ablation vs. surgical CryoMaze alone for treatment of atrial fibrillation: results of multicentre randomized controlled trial.

AIMS: Data on the hybrid atrial fibrillation (AF) treatment are lacking in patients with structural heart disease undergoing concomitant CryoMaze procedures. The aim was to assess whether the timely pre-emptive catheter ablation would achieve higher freedom from AF or atrial tachycardia (AT) and be associated with better clinical outcomes than surgical ablation alone. METHODS AND RESULTS: The trial investigated patients with non-paroxysmal AF undergoing coronary artery bypass grafting and/or valve repair/replacement with mandatory concomitant CryoMaze procedure who were randomly assigned to undergo either radiofrequency catheter ablation [Hybrid Group (HG)] or no further treatment (Surgery Group). The primary efficacy endpoint was the first recurrence of AF/AT without class I or III antiarrhythmic drugs as assessed by implantable cardiac monitors. The primary clinical endpoint was a composite of hospitalization for arrhythmia recurrence, worsening of heart failure, cardioembolic event, or major bleeding. We analysed 113 and 116 patients in the Hybrid and Surgery Groups, respectively, with a median follow-up of 715 (IQR: 528-1072) days. The primary efficacy endpoint was significantly reduced in the HG [41.1% vs. 67.4%, hazard ratio (HR) = 0.38, 95% confidence interval (CI): 0.26-0.57, P < 0.001] as well as the primary clinical endpoint (19.9% vs. 40.1%, HR = 0.51, 95% CI: 0.29-0.86, P = 0.012). The trial groups did not differ in all-cause mortality (10.6% vs. 8.6%, HR = 1.17, 95%CI: 0.51-2.71, P = 0.71). The major complications of catheter ablation were infrequent (1.9%). CONCLUSION: Pre-emptively performed catheter ablation after the CryoMaze procedure was safe and associated with higher freedom from AF/AT and improved clinical outcomes.

Efficacy and safety of hybrid epicardial and endocardial ablation versus endocardial ablation in patients with persistent and longstanding persistent atrial fibrillation: a randomised, controlled trial.

Background: Endocardial catheter ablation (CA) has limited long-term benefit for persistent and longstanding persistent atrial fibrillation (PersAF/LSPAF). We hypothesized hybrid epicardial-endocardial ablation (HA) would have superior effectiveness compared to CA, including repeat (rCA), in PersAF/LSPAF. Methods: CEASE-AF (NCT02695277) is a prospective, multi-center, randomized controlled trial. Nine hospitals in Poland, Czech Republic, Germany, United Kingdom, and the Netherlands enrolled eligible participants with symptomatic, drug refractory PersAF and left atrial diameter (LAD) > 4.0 cm or LSPAF. Randomization was 2:1 to HA or CA by an independent statistician and stratified by site. Treatment assignments were masked to the core rhythm monitoring laboratory. For HA, pulmonary veins (PV) and left posterior atrial wall were isolated with thoracoscopic epicardial ablation including left atrial appendage exclusion. Endocardial touch-up ablation was performed 91-180 days post-index procedure. For CA, endocardial PV isolation and optional substrate ablation were performed. rCA was permitted between days 91-180. Primary effectiveness was freedom from AF/atrial flutter/atrial tachycardia >30-s through 12-months absent class I/III anti-arrhythmic drugs except those not exceeding previously failed doses. It was assessed in the modified intention-to-treat (mITT) population who had the index procedure and follow-up data. Major complications were assessed in the ITT population who had the index procedure. Thirty-six month follow-up continues. Findings: Enrollment began November 20, 2015 and ended May 22, 2020. In 154 ITT patients (102 HA; 52 CA), 75% were male, mean age was 60.7 ± 7.9 years, mean LAD was 4.7 ± 0.4 cm, and 81% had PersAF. Primary effectiveness was 71.6% (68/95) in HA versus 39.2% (20/51) in CA (absolute benefit increase: 32.4% [95% CI 14.3%-48.0%], p < 0.001). Major complications through 30-days after index procedures plus 30-days after second stage/rCA were similar (HA: 7.8% [8/102] versus CA: 5.8% [3/52], p = 0.75). Interpretation: HA had superior effectiveness compared to CA/rCA in PersAF/LSPAF without significant procedural risk increase. Funding: AtriCure, Inc.

Sequential hybrid ablation versus surgical CryoMaze alone for treatment of atrial fibrillation (SurHyb Trial): a protocol of the multicentre randomized controlled trial.

BACKGROUND: Atrial fibrillation is common in patients with structural heart disease who are undergoing cardiac surgery. Surgical CryoMaze has been shown to be an effective treatment in several trials, but success rates have varied considerably, between 47-95%. The sequential hybrid approach, combining surgical CryoMaze followed by radiofrequency catheter ablation, can achieve high freedom from atrial arrhythmias. However, in patients with concomitant surgical atrial fibrillation treatment, data comparing the hybrid approach to CryoMaze alone are lacking. METHODS: The SurHyb study was designed as a prospective, open-label, multicentre randomized trial. Patients with non-paroxysmal atrial fibrillation who were scheduled for coronary artery bypass grafting or valve repair/replacement were randomized to either surgical CryoMaze alone or surgical CryoMaze followed by radiofrequency catheter ablation 3 months post-surgery. The primary outcome measure was arrhythmia-free survival without class I or III antiarrhythmic drugs, which has been evaluated using implantable cardiac monitors. CONCLUSIONS: This is the first randomized study that compares concomitant surgical CryoMaze alone with the staged hybrid surgical CryoMaze followed by catheter ablation, in patients with non-paroxysmal atrial fibrillation using rigorous rhythm monitoring. The results may contribute to the optimization of the treatment in patients undergoing concomitant CryoMaze for atrial fibrillation.

The influence of epicardial and endocardial use of cryoenergy on the completeness of lesions in surgical ablation of atrial fibrillation.

INTRODUCTION: Cryoenergy is the most commonly used method of lesion formation in patients who have undergone surgical ablation of atrial fibrillation. Despite frequent use, the clinical effect of cryoenergy in endocardial and epicardial approaches is unknown. AIM: To compare the effect of various cryoenergy applications on the postoperative incidence of sinus rhythm and completeness of lesions performed. MATERIAL AND METHODS: A total of 55 patients underwent concomitant atrial fibrillation surgical ablation using cryoenergy under various conditions: epicardially during cardiac arrest, epicardially on beating heart, and endocardially. In the postoperative period, patients were invited to attend an electrophysiological examination to assess the completeness of surgical ablation lesions and, if necessary, to complete catheter ablation. RESULTS: Twenty-four patients underwent epicardial ablation on the arrested heart (group 1), 12 patients underwent epicardial ablation on the beating heart (group 2), and 19 patients underwent endocardial ablation (group 3). In the electrophysiological examination, sinus rhythm was present in 71% vs. 83% vs. 89% of patients, respectively. The completeness of pulmonary vein isolation was confirmed in 31% vs. 25% vs. 95% of patients, complete box lesions in 15% vs. 0% vs. 79% of patients, respectively. CONCLUSIONS: Despite the similar clinical effect of surgical ablation in all three approaches, the morphologically most effective use of cryoenergy is endocardial ablation. This approach has a very good result. Our findings further support the endocardial use of cryoenergy during surgical ablation of atrial fibrillation.

Clinical performance of a three-dimensional saddle-shaped, rigid ring for mitral valve repair.

OBJECTIVES: The Profile 3D annuloplasty ring is a complete, rigid, saddle-shaped ring indicated for reconstruction and/or remodelling of the pathological mitral valve (MV) in patients with mitral insufficiency. METHODS: This prospective, non-randomized, observational, postmarket release study characterized the patient population for which the study ring was chosen for MV repair, assessed the relief from MV dysfunction and determined the level of mitral regurgitation (MR) at follow-up (6-12 months postimplant). RESULTS: Between February 2013 and July 2015, 151 patients were enrolled at 7 centres; data were excluded for 3 patients. The mean age of the remaining 148 patients was 63.8 ± 12.3 years, and 85 patients (57.4%) were men. Ischaemic cardiomyopathy was present in 15 patients (10.1%) and dilated cardiomyopathy in 12 patients (8.1%). MR was severe in 86 of 145 patients with available data (59.3%). Implantation was successful in 141 of 147 attempted procedures. Two deaths (n = 148, 1.4%) occurred within 30 days, and 1 death (0.7%) occurred >30 days after implant. Analysis of patients with data from both visits (n = 111) demonstrated that MR was none or mild in 94.5% of patients, moderate in 3.6% and moderate to severe in 1.8% at follow-up. Nearly all (104 of 109, 95.4%) patients were in New York Heart Association Class I/II. Among patients with ischaemic cardiomyopathy or dilated cardiomyopathy preoperatively, 16 of 19 patients with available data (84.2%) had no or mild MR at follow-up. CONCLUSIONS: MV repair using the Profile 3D annuloplasty ring is a safe and effective treatment for MR. Further investigation is warranted to determine whether patients with ischaemic cardiomyopathy or dilated cardiomyopathy derive unique benefit from this saddle-shaped ring. Clinical trial registration number: www.clinicaltrials.gov, NCT01112566.

De Vega tricuspid valve annuloplasty - a rightly neglected surgical technique?

INTRODUCTION: There is a lot of discussion about the best surgical technique for tricuspid valve (TV) regurgitation in patients undergoing an operation for primary mitral valve disease. AIM: To review and compare our results and experiences regarding the two main surgical strategies: tricuspid valve annuloplasty with a prosthetic ring (RING group) and suture annuloplasty (De Vega group). MATERIAL AND METHODS: We reviewed 570 patients who underwent TV surgery between 2000 and 2016 with either ring annuloplasty (RING group: n = 490 (85.9%)) or De Vega suture annuloplasty (De Vega group: n = 69 (12.1%)). The aetiology of TV insufficiency was secondary in 96.3% (538/559) of the patients, but 47.6% of the patients with primary aetiology had endocarditis of the permanent pacemaker stimulating wires. RESULTS: The age of the two study groups was similar (p = 0.6589), with a mean age of 66.7 years for the ring annuloplasty group and 67.9 years for the De Vega suture technique. The overall 30-day mortality was 10.9% (n = 61) (RING group n = 58 (11.8%) and De Vega group n = 3 (4.3%)). Ten years after TV surgery with either ring annuloplasty or the De Vega suture technique, 5.8% of patients in both study groups presented with a recurrence of severe tricuspid regurgitation ≥ 3. CONCLUSIONS: Outcomes of tricuspid valve repair did not differ in terms of long-term stability and durability between the two evaluated techniques.

Correlates of Arrhythmia Recurrence After Hybrid Epi- and Endocardial Radiofrequency Ablation for Persistent Atrial Fibrillation.

BACKGROUND: Long-term efficacy of catheter-based treatment of persistent atrial fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently, but their efficacy has never been systematically tested. METHODS AND RESULTS: Seventy patients (median age, 63.5 years) with persistent atrial fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein isolation, linear ablation, Marshal ligament disruption, and exclusion of the left atrial appendage. The procedure was followed by electroanatomic mapping and ablation (EAM) 2 to 3 months later. Only 76% of patients were in normal sinus rhythm at the beginning of EAM. All 4 pulmonary veins and the left atrium posterior wall were found isolated in 69% and 23% of patients, respectively. Arrhythmia-free survival off antiarrhythmic drugs 12 months after EAM was 77%. Using previously ineffective antiarrhythmic drugs and reablation procedures, arrhythmia free-survival increased to 97% during follow-up (mean, 936±432 days; range, 346-1509 days). The majority of arrhythmia recurrences occurred during the first 12 months after EAM. In a multivariable-adjusted estimates, left atrium volume >165 mL, absent normal sinus rhythm at admission for EAM, and inducibility of any sustained tachyarrhythmia at the end of EAM procedure were identified as independent correlates of atrial fibrillation recurrence. CONCLUSIONS: Our report demonstrated that the majority of patients after epicardial ablation, using bipolar radiofrequency instruments, required endocardial catheter ablation to complete the linear ablation lesions and a significant proportion of patients required spot-ablations to complete electric pulmonary vein isolation. Noninducibility of any arrhythmia after a staged hybrid procedure seemed to be the strongest correlate of long-term arrhythmia-free survival. CLINICAL TRIAL REGISTRATION: URL: www.ablace.cz. Unique identifier: cz-060520121617.

Delayed Electroanatomic Mapping After Surgical Ablation for Persistent Atrial Fibrillation.

BACKGROUND: Long-term efficacy of catheter-based treatment of persistent atrial fibrillation is unsatisfactory. Minimally invasive surgical ablation techniques have been developed recently but their true efficacy has never been systematically tested. METHODS: Seventy patients (median age 63.5 years) with persistent atrial fibrillation underwent epicardial thoracoscopic radiofrequency pulmonary vein (PV) isolation, linear ablation, Marshal ligament disruption, and exclusion of the left atrial appendage. The procedure was followed by electroanatomic mapping 2 to 3 months later. RESULTS: Only 76% of patients were in sinus rhythm at the beginning of electroanatomic mapping. Right PVs were found isolated in a higher proportion of patients compared with left PVs (75.7% versus 91.4%, p < 0.001). All four PVs and the left atrial posterior wall were isolated in 68.6% and 22.9% of patients, respectively. Most of the gaps around left PVs were localized in the superior and anterior quadrants, whereas in right PVs, the gaps were found predominantly on the roof and posterior wall. A typical site of reconduction on the inferior connecting line was the segment adjacent to the right inferior PV. No typical reconduction sites were found on the roof line, as 58.5% of patients required completion of the roof line along its full length. CONCLUSIONS: Epicardial PV isolation was successful in the majority of patients, but was underwhelming with regard to isolation of the left PVs. Effective epicardially placed linear lines were rare. Our results highlight the significant limitations associated with a single-stage surgical approach and underline the necessity for a two-staged hybrid approach in the treatment of persistent atrial fibrillation.

Epicardial clip occlusion of the left atrial appendage during cardiac surgery provides optimal surgical results and long-term stability.

OBJECTIVES: Occlusion of the left atrial appendage (LAA) has become an integral and important part of the surgical treatment of atrial fibrillation. Different methods of surgical occlusion of the LAA have been associated with varying levels of short- and long-term success for closure. The purpose of this study was to evaluate long-term results of epicardial placement and endocardial occlusion in patients undergoing cardiac operative procedures. METHODS: A total of 101 patients (average age 65.7 years) undergoing cardiac operative procedures with the epicardial AtriClip Exclusion System of the LAA were enrolled in the study. The AtriClip was placed via a sternotomy or a thoracotomy or from a thoracoscopic approach. Postoperative variables, such as thromboembolic events, clip stability and endocardial leakage around the device, were examined by transoesophageal echocardiography (TEE) and/or computed tomography. RESULTS: Perioperative clip implantation was achieved in 98% of patients. TEE and/or computed tomography conducted during the follow-up period, comprising 1873 patient-months with a mean duration of 18 ± 11 months, revealed no clip migration, no leakage around the device and no clot formation near the remnant cul-de-sac. During the follow-up period, 4 of the cardiac patients experienced transitory ischaemic attacks, whereas no patient experienced a cerebrovascular attack. CONCLUSIONS: The Epicardial AtriClip Exclusion System of the LAA appears to be a feasable and safe operative method with a high success rate. Long-term follow-up confirmed clip stability, complete occlussion of the LAA and absence of any atrial fibrilation-related thromboembolic events. These results need to be confirmed by a larger, multicentre study.

[Closure of the left atrial appendage by means of the AtriClip System]. / Uzáver ouska levé síne systémem AtriClip.

INTRODUCTION: Atrial fibrillation (AFib) is related to a high risk of stroke. The main role in etiopathogenesis is played by the left atrial appendage (LAA). As many as 95 % of thrombi in nonvalvular atrial fibrillation are located in the appendage. Prevention of stroke then consists in permanent anticoagulation which, however, has its limits and risks. An alternative method is the left atrial appendage occlusion. In our report, we would like to present a new possibility of the closure using the epicardial system AtriClip (AtriCure). METHODOLOGY: In the period beginning in July 2012 - September 2015 we performed LAA closure in 101 patients. A mean age of 65 ± 6 years, 47 women, CHA2DS2 VASc (Ø) 2.47 (0-6). Monitoring 1 837 (Ø 18.5) months. A concomitant procedure was performed in 37 patients, endoscopic MAZE plus clip in 57 patients, and 7 patients underwent stand-alone implantation of the clip. The clip was implanted from full sternotomy, minitoracotomy or through thoracoscopy. Clip loading, residual recess and endoleak were assessed through endoscopic ultrasound according to the Cleveland criteria. RESULTS: The perioperative success rate of loading reached 98 %. The clip was loaded with a neck greater than 1 cm in 2 patients. No migration of the clip occurred, no endoleak was detected and no thrombus at the appendage base was detected. One case of periprocedural stroke was recorded. Within follow-up monitoring TIA occurred in 4 patients and no stroke was recorded. CONCLUSION: Epicardial LAA occlusion using the AtriClip system is a safe and reproducible method of LAA occlusion and an important alternative in the prevention of stroke.Key words: atrial fibrillation - occlusion of left atrial appendage - stroke.

Sequential Hybrid CryoMaze Ablation versus Surgical CryoMaze Alone for the Treatment of Atrial Fibrillation (SurHyb): study protocol for a randomized controlled trial.

BACKGROUND: Atrial fibrillation is common in patients with structural heart disease who are undergoing cardiac surgery. Surgical CryoMaze has been shown to be an effective treatment in several trials, but success rates have varied considerably, between 47-95 %. The sequential hybrid approach, combining surgical CryoMaze followed by radiofrequency catheter ablation, can achieve high freedom from atrial arrhythmias, even when rigorous methods to detect arrhythmias after the procedure are used. However, data from randomized trials comparing hybrid ablations to surgical ablations alone are lacking. METHODS/DESIGN: The SurHyb study is a prospective, multicenter, randomized study. Patients with persistent or long-standing persistent atrial fibrillation will be randomized to either surgical CryoMaze alone or surgical CryoMaze followed by catheter ablation 3 months post-surgery. The primary outcome measure is arrhythmia-free survival without class I or III antiarrhythmic drugs, which will be evaluated using 7-day ECG Holter monitoring at 24 months. A total of 260 patients will be investigated from three medical centers in the Czech Republic to obtain the relevant information. DISCUSSION: This is the first randomized study that compares surgical CryoMaze alone with the staged hybrid surgical CryoMaze followed by catheter ablation in patients with persistent or long-standing persistent atrial fibrillation. These results will contribute to the optimization of the treatment for these patients. TRIAL REGISTRATION: Czech Clinical Trials Registry, cz-301020151253 . Registered on 30 October 2015.

Sutureless aortic valve and mitral valve repair in redo cases - really an off-label approach?

Sutureless aortic valve replacement (AVR) was developed as an alternative treatment option to conventional open-heart surgery and transcatheter aortic valve implantation for "gray zone" patients. The need for concurrent mitral valve surgery is generally viewed as a contraindication to sutureless AVR. The purpose of this brief paper is to report our experiences with sutureless valves in patients after previous cardiac procedures with degenerated aortic bioprostheses and concomitant mitral valve disease.

How to manage left ventricular embolization of the transcatheter valve.

Transcatheter aortic valve implantation is a treatment alternative for high-risk patients with severe aortic stenosis who are not eligible for conventional open aortic valve replacement. We describe a case of a rare but serious complication in the form of ventricular embolization of an Edwards Sapien-XT aortic valve following its transapical implantation. The valve was successfully captured and reimplanted into the aortic annulus, which did not require conversion to median sternotomy or use of extracorporeal circulation.

Short-term and medium-term outcomes of transapical aortic valve implantation as a single-strategy approach: one center's experience.

INTRODUCTION: Transcatheter aortic valve replacement has been developed as an alternative option for surgical high-risk or inoperable patients with severe symptomatic aortic stenosis. AIM OF THE STUDY: Aim of the study was to evaluate the outcomes of patients undergoing transapical aortic valve replacement as a single-strategy option by a single-center multidisciplinary heart team. MATERIAL AND METHODS: Between June 2009 and December 2014, 41 patients underwent transapical transcatheter aortic valve implantation (TA-TAVI) at our institution. All patients received Edwards SAPIEN balloon expandable pericardial valves (Edwards Lifesciences, Irvine, CA, USA). Our center followed a "clear transapical strategy" for all patients. RESULTS: The mean age of the patients was 79.6 years, and the mean logistic EuroSCORE was 21.06 ± 12.82%. Fifteen patients (36.6%) underwent redo operations. Complications included stroke (n = 1), re-exploration for bleeding or cardiac tamponade (n = 4), renal failure requiring temporary hemodialysis (n = 4) and permanent pacemaker implantation (n = 3). There were no myocardial infarctions or coronary obstruction. The total 30-day mortality rate was 17.1% (7 patients). Postoperative intensive care unit stay was 4.6 ± 5.7 days, and mean hospitalization was 11.6 ± 7.2 days. CONCLUSIONS: The TA-TAVI approach provides good results in terms of early and midterm outcomes. This approach is feasible and safe for patients who have high surgical risk.

Sequential Hybrid Surgical CryoMaze and Transvenous Catheter Ablation of Atrial Fibrillation.

BACKGROUND: The aim of the study was to evaluate whether the sequential hybrid approach combining surgical CryoMaze followed by the radiofrequency (RF) catheter ablation can improve freedom from atrial arrhythmias. METHODS: Thirty-five patients with persistent atrial fibrillation underwent a CryoMaze procedure in conjunction with cardiac surgery for structural heart disease. Three months after surgery, all patients underwent a 7-day electrocardiogram Holter followed by an electrophysiological study and mapping of the left and right atria. All pulmonary veins were reisolated and all ablation lines were completed, if necessary, using RF energy. Patients were followed-up at 3 months, 6 months, and 12 months after the catheter ablation. RESULTS: Before the mapping study and RF ablation, nine patients (26%) had ongoing atrial fibrillation or atrial tachycardia, 10 patients (28%) had paroxysmal atrial tachyarrhythmia, and 16 patients (46%) had sinus rhythm on the 7-day Holter monitoring. During the electrophysiological procedure, complete cryoablation lines around the left pulmonary veins were found in 29 patients (83%), around the right pulmonary veins in 25 patients (71%), between the superior veins in 20 patients (57%), between the inferior veins in 27 patients (77%), across the mitral isthmus in 12 patients (34%), and across the cavotricuspid isthmus in one patient (3%). Arrhythmia-free survival rate of antiarrhythmic drugs after reisolation of the veins and completion of the lines was 86% at 12 months. CONCLUSION: Ablation lines created using surgical CryoMaze are often incomplete. Sequential surgical CryoMaze procedures followed by catheter ablation significantly increase freedom from arrhythmia in patients with persistent atrial fibrillation.

Thoracoscopic Occlusion of the Left Atrial Appendage.

OBJECTIVE: Left atrial appendage (LAA) plays a crucial role in the etiopathogenesis and the prevention of the stroke in patients with nonvalvular atrial fibrillation (AF). This paper presents our first experience with thoracoscopic LAA occlusion using an external clip. METHODS: We performed a total of 30 LAA occlusions with the AtriClip from left thoracoscopy approach during the period from July 2012 to July 2013. AtriClip was implanted during the bilateral thoracoscopic radiofrequency (RF) as part of left atrial ablation procedure. RESULTS: Among the 30 procedures, AtriClip was once periprocedurally partially positioned. In the remaining procedures, the implantation was successful without complications. Of the 30 patients, 29 underwent transesophageal echocardiography and computer tomography examination at 3 months after the procedure. Apart from the patient with the partial clip placement, a residual pouch of 18 mm was detected in another patient. In the remaining group (28/30 patients, 93%), the exclusion was complete. No migration or any other clip implantation-related complications occurred during the follow-up. None of the patients experienced an embolization event. CONCLUSIONS: Endoscopic AtriClip implantation appears to be a reproducible and safe method of LAA occlusion, with a minimal risk and a high efficiency. In our opinion, the AtriClip implantation is a reasonable part of thoracoscopic AF treatment and should be considered as an alternative tool for stroke risk reduction in patients with AF.

Sequential hybrid procedure for persistent atrial fibrillation.

BACKGROUND: Catheter ablation of persistent atrial fibrillation yields an unsatisfactorily high number of failures. The hybrid approach has recently emerged as a technique that overcomes the limitations of both surgical and catheter procedures alone. METHODS AND RESULTS: We investigated the sequential (staged) hybrid method, which consists of a surgical thoracoscopic radiofrequency ablation procedure followed by radiofrequency catheter ablation 6 to 8 weeks later using the CARTO 3 mapping system. Fifty consecutive patients (mean age 62±7 years, 32 males) with long-standing persistent atrial fibrillation (41±34 months) and a dilated left atrium (>45 mm) were included and prospectively followed in an unblinded registry. During the electrophysiological part of the study, all 4 pulmonary veins were found to be isolated in 36 (72%) patients and a complete box-lesion was confirmed in 14 (28%) patients. All gaps were successfully re-ablated. Twelve months after the completed hybrid ablation, 47 patients (94%) were in normal sinus rhythm (4 patients with paroxysmal atrial fibrillation required propafenone and 1 patient underwent a redo catheter procedure). The majority of arrhythmias recurred during the first 3 months. Beyond 12 months, there were no arrhythmia recurrences detected. The surgical part of the procedure was complicated by 7 (13.7%) major complications, while no serious adverse events were recorded during the radiofrequency catheter part of the procedure. CONCLUSIONS: The staged hybrid epicardial-endocardial treatment of long-standing persistent atrial fibrillation seems to be extremely effective in maintenance of normal sinus rhythm compared to radiofrequency catheter or surgical ablation alone. Epicardial ablation alone cannot guarantee durable transmural lesions. CLINICAL TRIAL REGISTRATION: URL: www.ablace.cz Unique identifier: cz-060520121617.

Health-related quality of life after cardiac surgery--the effects of age, preoperative conditions and postoperative complications.

BACKGROUND: Factors influencing the postoperative health-related quality of life (HRQOL) after cardiac surgery have not been well described yet, mainly in the older people. The study's aim was to explore differences in clinical conditions and HRQOL of patients before and after cardiac surgery taking into account the influence of age and to describe factors influencing changes of HRQOL in the postoperative period. METHODS: This was a prospective consecutive observational study with two measurements using the SF-36 questionnaire before surgery and 1 year after surgery. It considered main clinical characteristics of participants prior to surgery as well as postoperative complications. RESULTS: At baseline assessment the study considered 310 patients, predominantly male (69%). Mean age was 65 (SD 10.4) years and 101 patients (33%), who were older than 70, constituted the older group. This older group showed greater comorbidity, higher cardiac operative risk and lower HRQOL in the preoperative period as well as a higher prevalence of postoperative complications than the younger group. Thirty-day mortality was 1.4% in the younger group and 6.9% in the older group (p < 0.001). One year mortality was 3.3% in the younger group and 10.9% in the older group (p < 0.001). There was a significant improvement in all 8 health domains of the SF-36 questionnaire (p < 0.001) in the overall sample. There was no significant difference in change in a majority of HRQOL domains between the younger and the older group (p > 0.05). Logistic multivariate analysis identified a higher values of preoperative PCS (Physical component summary) scores (OR 1.03, CI 1.00 - 1.05, p = 0.0187) and MCS (Mental component summary) scores (OR 1.02, CI 0.997 - 1.00, p = 0.0846) as the only risk factors for potential non-improvement of HRQOL after cardiac surgery after correction for age, gender and type of surgery. CONCLUSIONS: Older patients with higher operative risk have lower preoperative HRQOL but show a similar improvement in a majority of HRQOL domains after cardiac surgery as compared with younger patients. The multivariate analysis has shown the higher preoperative HRQOL status as a only significant factor of potential non-improvement of postoperative HRQOL.

Two-staged hybrid treatment of persistent atrial fibrillation: short-term single-centre results.

OBJECTIVES: The treatment of persistent and long-standing persistent atrial fibrillation (AF) has unsatisfactory results using both medical therapy and/or catheter ablation, where incomplete ablation lines remain a significant problem. This study evaluates the feasibility, efficacy and safety of the sequential, two-staged hybrid treatment combining thoracoscopic surgical and transvenous catheter AF ablation. METHODS: Thirty patients with persistent and long-standing persistent AF underwent surgical thoracoscopic radiofrequency (RF) ablation procedure using a predefined protocol (pulmonary veins isolation, box lesion, isthmus line lesion, dissection of the ligament of Marshall, left atrial appendage exclusion with an epicardial clip and ganglionated plexi ablation) followed by diagnostic catheterization and RF ablation 3 months later. In this session, electrical mapping of the left atrium was performed and any incomplete isolation lines were completed. Mitral and cavotricuspid isthmus ablation lines were performed during this session as well. RESULTS: The preoperative mean duration time of AF was 33 ± 27 months with 17% patients with persistent and 83% patients with long-standing persistent AF. The mean size of the left atrium was 48 ± 5 mm. The complete surgical ablation protocol was achieved in 97% of patients, with no death, and no early stroke or pacemaker implantation in the early postoperative period. In 63% of patients, the left atrial appendage was excluded with an epicardial clip. An endocardial touch-up for achievement of bidirectional block of pulmonary veins was necessary in 10 patients (33%) and on the box, (roof and floor) lesions in 20 patients (67%). Freedom from atrial fibrillation was 77% after surgical ablation and 93% after the completed hybrid procedure. CONCLUSIONS: The sequential, two-staged hybrid strategy (surgical thoracoscopic followed by catheter ablation) is feasible and safe with a high post-procedural success and seems to represent the optimal treatment with low risk load and potentially long-term benefit for patients with a persistent and long-standing persistent form atrial fibrillation.

Re-exploration for bleeding or tamponade after cardiac operation.

The aim of this study was to determine the outcome of patients who had a chest resternotomy and to identify risk factors for higher in-hospital mortality after re-exploration for bleeding and/or tamponade after cardiac operations. We present our experience of an acceptably low re-exploration rate after cardiac surgery, and the outcomes of those re-explored. This was a retrospective analysis of medical records of all patients who had a chest re-exploration for the control of bleeding and cardiac tamponade over a 7-year period (2000-06), at the Cardiothoracic Centre of the Hospital Ceské Budejovice, Czech Republic. Between 2000 and 2006, 152 patients (3.4% of the total heart operations) underwent re-exploration after heart surgery. One hundred and seven (70.4%) were re-explored for bleeding, 36 (23.7%) for possible tamponade and nine (5.9%) for both. An identifiable source of bleeding was found in 72.4% patients. Risk factors associated with higher in-hospital mortality after re-exploration for bleeding and tamponade include delayed resternotomy, higher levels of lactate and lower levels of haematocrit before revision and other well-known risk factors such as older age, more complex cardiac procedures, redo operations, longer cardiopulmonary bypass, renal failure and diabetes mellitus. Patients who need re-exploration are at a higher risk of complications, morbidity and mortality if the time until re-exploration is prolonged.