Minimally invasive extracorporeal circulation: excellent outcome and life expectancy after coronary artery bypass grafting surgery.

OBJECTIVE: Coronary artery bypass grafting (CABG) remains the gold standard for complex revascularisation in multivessel disease. The concept of the minimally invasive extracorporeal circulation circuit (MiECC) was introduced to minimise pathophysiological side effects of conventional extracorporeal circulation. This study presents early and long-term outcomes after CABG with use of MiECC in a single-centre consecutive patient cohort. METHODS: From 1 January 2005 to 31 December 2010, 2130 patients underwent isolated CABG with MiECC at our centre. We evaluated morbidity and mortality follow-up data with a median follow-up of 3.6 years. Kaplan-Meier curves and estimates of the primary end-point for all-cause mortality were compared with the life expectancy of the general population. RESULTS: Mortality in CABG patients was comparable to the general population beginning 1 year after surgery for the whole observation period. All-cause 30-day mortality was 0.8%. The mean estimated logistic EuroSCORE and EuroSCORE II were 5.8 ± 8.6 and 3.0 ± 5.1, respectively. Mean perfusion time was 71.1 ± 23.8 min with a cross-clamp time of 44.9 ± 16.3 min. Mortality was predicted by the presence of diabetes mellitus (odds ratio [OR] 1.85, 95% confidence interval [CI] 1.40-2.46; p <0.001), peripheral arterial disease (OR 2.36, 95% CI 1.64-3.38; p <0.001), severe obstructive pulmonary disease (OR 3.21, 1.42-7.24; p = 0.005), chronic renal failure (OR 3.68, 2.49-5.43; p <0.001) and transfusion of more than one unit of erythrocyte concentrate in the perioperative period (OR 1.46, 1.09-1.95; p = 0.015). Cerebrovascular events occurred in 36 patients (1.7%). CONCLUSION: CABG with use of MiECC is associated with a mortality rate comparable to the overall life expectancy of the general population. MiECC is the first choice for routine and emergency CABG at our centre with a 30-day mortality rate of 0.8% and a low complication rate.

Mid-term mechanical circulatory support: comparison of single-centre data with the EUROMACS registry.

OBJECTIVES: Mechanical circulatory support (MCS) is an established therapy for end-stage heart failure. The EUROMACS registry was created to promote research in patients with MCS and became a committee of the European Association for Cardio-Thoracic Surgery (EACTS) in 2014. Since 1 January 2011, increasing numbers of European centres implanting durable MCS have reported their patient data to EUROMACS. The aim of this study is to compare, as an example of internal quality control, data from a single centre (Bern) with those from the EUROMACS database with respect to mortality rates and preoperative patient characteristics and to describe complications in Bern. METHODS: Patients implanted with MCS between 1 January 2011 and 30 June 2014 in participating centres were included, with extended follow-up as of 31 December 2014. Patient characteristics, operative and postoperative data, clinically significant adverse events and routine follow-up data were reported to the registry. The entire EUROMACS cohort (including the Bern data) was compared with patients from Bern only. Baseline characteristics, operative data and outcomes were compared using standard 95% confidence intervals (CIs) for means, Wilson's continuity corrected CIs for categories and Kaplan-Meier estimates with CIs. RESULTS: Kaplan-Meier estimates show a higher survival rate in the Bern cohort than in the entire EUROMACS cohort at 6 (92%, CI 73-98, vs 66%, CI 62-69), 12 (85%, CI 57-95, vs 56%, CI 52-60) and 18 months (85%, CI 57-95, vs 51%, CI 47-55) after the index operation, respectively. This difference might be caused by the earlier implantation time in Bern (implantation at INTERMACS levels 3-4) versus that of the entire EUROMACS cohort (implantation at INTERMACS levels 2-3). The median number of follow-up records per patient was 2 in the entire EUROMACS cohort and 4 in the Bern (P = 0.001) cohort. During follow-up, neurological dysfunction occurred in 42% of patients, a bleeding event occurred in 42% of patients, significant infection occurred in 36% of patients and a device malfunction occurred in 31% of patients within 12 months of implantation in the Bern patients. CONCLUSIONS: MCS is a valuable therapeutic option with excellent survival rates; nevertheless, it is associated with clinically significant complication rates. International registries are important tools that allow, as an example, internal quality control of mortality, complication and morbidity rates from a single centre compared with the EUROMACS database.

The impact of functional vs degenerative mitral regurgitation on clinical outcomes among patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Among patients undergoing transcatheter aortic valve implantation (TAVI), concomitant mitral regurgitation (MR) has been associated with adverse prognosis. We aimed to assess long-term clinical outcomes according to MR etiology. METHODS: In a single-center registry of consecutive patients undergoing TAVI, we investigated the impact of functional (FMR) vs degenerative (DMR) MR on cardiovascular (CV) mortality throughout 2years of follow-up. RESULTS: Among 603 patients (mean age 82.4±5.7years, 55% female) undergoing TAVI, 149 patients had moderate or severe MR (24.7%). Functional MR and DMR were documented in 53 (36%) and 96 (64%) patients, respectively. At 2years, patients with FMR and DMR had higher rates of CV mortality (30.2% vs 32.4%) as compared with patients with no MR (14.6%; FMR vs no MR: hazard ratio [HR] 2.32, 95% CI 1.34-4.02, P=.003; DMR vs no MR: HR 2.56, 95% CI 1.66-3.96, P<.001). In adjusted analyses, DMR was associated with an increased risk of CV mortality throughout the 2-year follow-up (adjusted HR 2.21, 95% CI 1.4-3.49, P=.001) as compared with FMR (adjusted HR 1.13, 95% CI 0.59-2.18, P=.707). Relevant MR was postprocedurally significantly reduced in both the DMR and FMR groups, whereas improvement of a decreased left ventricular ejection fraction was predominantly seen in the FMR group as compared with baseline. CONCLUSION: Patients with severe, symptomatic aortic stenosis undergoing TAVI complicated by moderate or severe MR portend impaired prognosis. Particularly, patients with DMR are at increased risk for CV mortality during long-term follow-up.

The Electrocardiogram After Transcatheter Aortic Valve Replacement Determines the Risk for Post-Procedural High-Degree AV Block and the Need for Telemetry Monitoring.

OBJECTIVES: The study sought to identify predictors for delayed high-degree atrioventricular block (AVB) in patients undergoing transcatheter aortic valve replacement (TAVR) and determine the need and required duration of telemetry monitoring. BACKGROUND: Little is known about predictors and timing of high-degree AVB. METHODS: A total of 1,064 patients (52% women) without a permanent pacemaker undergoing TAVR at 3 centers in Switzerland were investigated. Electrocardiograms (ECGs) at baseline and post-TAVR were analyzed to identify atrioventricular and interventricular conduction disorders. RESULTS: Periprocedural high-degree AVB occurred in 92 (8.7%), delayed high-degree AVB in 71 (6.7%), up to 8 days post-procedure. In multivariate analysis, delayed high-degree AVB occurred more frequently in men (odds ratio: 2.4, 95% confidence interval: 1.3 to 4.5; p < 0.01), and in patients with conduction disorders post-TAVR (odds ratio: 10.8; 95% confidence interval: 4.6 to 25.5; p < 0.01). Patients in sinus rhythm without conduction disorders post-TAVR did not develop delayed high-degree AVB (0 of 250, 0%). Similarly, the risk in patients with atrial fibrillation but no other conduction disorders was very low (1 of 102, 1%). There was no patient developing delayed high-degree AVB who had a stable ECG for 2 days or more. CONCLUSION: Patients without conduction disorders post-TAVR did not develop delayed high-degree AVB. Such patients may not require telemetry monitoring. All other patients should be monitored until the ECG remains stable for at least 2 days. This algorithm should be validated in a separate patient population.

May sunshine protect women against paroxysms of atrial fibrillation?

Seasonal variation in the occurrence of atrial fibrillation (AF) has been documented, yet precise mechanisms and factors underlying the phenomenon remain unclear. We have previously observed the decrease in the number of AF paroxysms between May and August, when sunshine levels were highest. The objective of the present study was, in turn, to determine whether sunshine affects the incidence of AF episodes. Participants were 1,475 Caucasian subjects (mean age: 68.2 years) diagnosed with AF paroxysms, admitted to the Intensive Cardiac Care Unit (ICCU) between January 1, 2005 and December 31, 2008; 805 were women and 670 were men (mean age: 69.2 and 66.2, respectively). The average incidence of AF episodes was higher among female subjects, with 16.8 cases per month, compared to male subjects with 14.0 cases per month. Pearson's correlation coefficient (r) was used to find a relationship between monthly sums of sunshine duration and AF paroxysms. This relationship for women was clearly inversely proportional (r = -0.499); namely, most AF episodes were recorded from December to March, when sunshine levels were lowest. In contrast, there was no noticeable association in male patients between the occurrence of AF paroxysms and effective sunshine (r = -0.126). In conclusion, unlike in men, a marked, statistically confirmed relationship between AF episodes and effective sunshine was observed in women. Thus, sunshine may have a protective effect against AF paroxysms for women. Our findings may provide the basic information concerning the influence of environmental factors on human wellbeing and contribute to management of AF.

Episodes of atrial fibrillation and meteorological conditions.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. The natural history of AF tends to begin with short paroxysms which gradually evolve into longer episodes, frequently treatment-resistant, and finally take a permanent form. It is a polyaetiological condition and single paroxysms may be caused by a variety of factors. There is a prevailing belief that weather is a vital element affecting the functioning of the human organism. Accordingly, high variability in hospital admissions due to AF paroxysms may be associated with meteorological conditions. AIM: To investigate the relationship between the incidence of AF paroxysms and atmospheric phenomena. METHODS: A total of 739 patients participated in the study [52% females, aged 18-91 (mean=65 years)], hospitalised for AF paroxysms in the Cardiac Care Unit (CCU) in 2005-2006. Patients with AF secondary to acute coronary syndrome, recent myocardial infarction, myocarditis, pericarditis, thyrotoxicosis, and disorders of the respiratory system, were excluded from the analysis. Statistical relationships were sought between the frequency of AF paroxysms and meteorological elements, such as: temperature change, atmospheric pressure, relative humidity, cloudiness, and wind speed. Using synoptic maps, such phenomena as weather fronts occurrence and baric systems were analysed. RESULTS: A considerable influence of a cold front and occlusion of cold front type on increases in admissions to CCU for AF paroxysms was observed. The absence of arrhythmia for many consecutive days was noted during the presence of stationary high-pressure areas. There were no significant relationships between meteorological elements and AF paroxysms. A seasonal distribution of AF episodes was found, with the maximum incidence in winter months and a decrease in the number of patients hospitalised from May to August. The impact of cold fronts may be explained by the effect of electromagnetic waves occurring in the zone of atmospheric changes, which may penetrate into buildings. On account of the translocation speed of electromagnetic waves, the effects may be felt many hours before an atmospheric front approaches. CONCLUSIONS: Meteorological conditions may have some influence on the occurrence of paroxysms of atrial fibrillation. This study could serve as a starting point for further research investigating relationships between weather conditions and heart rhythm disorders.