The Belgian experience with concomitant surgical ablation of atrial fibrillation: a multi-centre prospective registry.

Background: The Belgian 'National Institute for Health and Disability Insurance (RIZIV-INAMI)' requested prospective collection of data on all ablations in Belgium to determine the outcomes of surgical ablation of atrial fibrillation (AF) during concomitant cardiac surgery.Methods: 890 patients undergoing concomitant ablation for AF between 2011 and 2016 were prospectively followed. Freedom from AF with and without anti-arrhythmic drugs was calculated for 817 patients with follow-up beyond the 3-month blanking period and for 574 patients with sufficient rhythm-related follow-up consisting of at least one Holter registration or a skipped Holter due to AF being evident on ECG. Besides preoperative AF type, concomitant procedure and ablation, potential covariates were entered into uni- and multivariable regression models to determine predictors of outcome.Results: The overall freedom from AF beyond 3 months was 69.9% (571/817) and without anti-arrhythmic drugs at last follow-up 51.0% (417/817), respectively, 61.3% (352/574) and 44.4% (255/574) for patients with sufficient rhythm-related follow-up. Using a Kaplan-Meier estimate, freedom from AF was 89.3%, 74.9% and 59%, without antiarrhythmic drugs 74.4%, 47.8% and 32.3% at 6, 12 and 24 months, respectively. In-hospital mortality was 1.7% (15/890) and the overall survival was 95.0% at 1 year and 92.3% at 2 years. Preoperative left atrial diameter and AF type were significant predictive factors of freedom from AF in a multivariable analysis.Conclusion: Analysis of the Belgian national registry shows that concomitant surgical ablation of atrial fibrillation is safe, achieves favourable freedom from AF and, therefore, deserves to be performed in accordance to the guidelines.

Aortic and mitral valve repair for anterior mitral leaflet perforation caused by severe aortic regurgitation.

A 23-year-old man presented with acute onset of dyspnea on exert. Preoperative echocardiography showed a severe regurgitation of the bicuspid aortic valve (due to prolapse of the fused cusp) creating a jet directed through the defect in the anterior leaflet of the mitral valve. Both valves were repaired. Endocarditis was excluded with cultures and polymerase chain reaction (PCR). Postoperative course was uneventful.

Comparison of Two Minimally Invasive Techniques and Median Sternotomy in Aortic Valve Replacement.

BACKGROUND: Propensity score-matched analysis of the anterolateral minithoracotomy and the partial upper hemisternotomy vs the median sternotomy approach has not been reported to date for isolated aortic valve replacement. METHODS: From 2005 to 2013, isolated aortic valve replacement was performed through a partial upper hemisternotomy in 315 patients (38.9%), through a median sternotomy in 328 patients (40.5%), and through an anterolateral minithoracotomy in 167 patients (20.6%). After propensity score-matched analysis, both minimally invasive techniques were independently compared with median sternotomy in 118 matched pairs. RESULTS: In the anterolateral group, conversion to median sternotomy was significantly higher (17 [14.4%]), a second pump run (6 [5.1%]) and second cross clamp (12 [10.2%]) were significantly more often necessary, the median cross-clamp time (94 minutes; range, 43 to 231 minutes) and median perfusion time (141 minutes; range, 77 to 456 minutes) were significantly longer, and more groin complications occurred (17 [14.4%]), all compared with the median sternotomy group. No difference in perioperative results was identified between the partial upper hemisternotomy and the median sternotomy group. There was no significant difference in 1-year survival among the three groups, although a trend of better survival was observed in the partial upper hemisternotomy group. CONCLUSIONS: In minimally invasive isolated aortic valve replacement, the partial upper hemisternotomy shows similar perioperative outcome as the median sternotomy, whereas, the anterolateral minithoracotomy is associated with more perioperative complications. Therefore, only the partial upper hemisternotomy should be the preferred surgical technique for minimally invasive aortic valve replacement in the daily routine for a broad spectrum of surgeons.

The FORGOTTEN (TRICUSPID) VALVE; THIRD TIME, RIGHT TIME.

Tricuspid regurgitation (TR) remains a challenging condition, the indication, timing and type of surgery for which are not yet well established. A 42-year-old woman was referred to the authors' institution with recurrent, symptomatic TR at one year after she had undergone tricuspid valve repair for an Ebstein's anomaly. At 14 months after the first surgery a bioprosthesis was implanted for a detached annuloplasty ring, and she made a complete recovery. However, at 15 months after valve replacement she presented again with right heart failure and massive TR due to rare early pannus formation. A re-redo tricuspid valve replacement was performed. Tricuspid valve replacement with a bioprosthesis is a valid option if repair is unsuccessful. However, there is a need to be aware of concomitant problems such as a requirement for pacemaker implantation, the risk for prosthesis thrombosis or pannus formation, and the importance of anticoagulation therapy. Annual transthoracic echocardiographic follow up is advisable to exclude subclinical TR.

Negative-pressure wound therapy and laparoscopic omentoplasty for deep sternal wound infections after median sternotomy.

Deep sternal wound infection remains one of the most serious complications in patients who undergo median sternotomy for coronary artery bypass surgery.We describe our experience in treating 6 consecutive patients with our treatment protocol that combines aggressive débridement, broad-spectrum antibiotics, negative-pressure wound therapy, omentoplasty with laparoscopically harvested omentum, and the use of bilateral pectoral muscle advancement flaps.The number of débridements needed in order to attain clinically clean wounds and negative cultures varied between 1 and 10, with a median of 5. The length of stay after omentoplasty and bilateral pectoral muscle advancement flap placement varied between 11 and 22 days. One of the 6 patients developed a small wound dehiscence that was treated conservatively. No bleeding related to vacuum-assisted closure therapy was identified. Three patients had pneumonia. Two of the 3 patients had an episode of acute renal failure. The 30-day mortality rate was zero, although 1 patient died in the hospital 43 days after the reconstructive surgery, of multiple-organ failure due to pneumonia that was induced by end-stage pulmonary fibrosis. No patient died between hospital discharge and the most recent follow-up date (4-12 mo). Late local follow-up results, both functional and aesthetic, were good.We conclude that negative-pressure wound therapy-in combination with omentoplasty using laparoscopically harvested omentum and with the use of bilateral pectoral advancement flaps-is a valuable technique in the treatment of deep sternal wound infection because it produces good functional and aesthetic results.

Colonic ischemia and perforation associated with enteral feeding through an ileal tube.

Reported complications of enteral feeding through a jejunostomy include diarrhea, intraperitoneal leaks, bowel obstruction, fistula formation, wound infection, tube occlusion, and other mechanical malfunctions. However, the incidence of these complications is very low, and many physicians prefer to feed their patients by means of a jejunal tube instead of parenteral nutrition. A potentially lethal complication is ischemia of the bowel distal to the site of insertion of the feeding catheter. The described cases of bowel ischemia secondary to enteral nutrition invariably occurred at the level of the jejunum. This report describes an unusual case of perforation of the colon in a patient fed through an erroneously placed feeding catheter in the distal ileum, just proximal to the ileocecal valve. After weeks of continuous and intractable diarrhea and progressive weight loss, the patient developed diffuse colonic ischemia with subsequent free perforation of the left colon and peritonitis. Surgical treatment consisted of placement of a new feeding tube in the proximal jejunum and removal of the old one together with a short segment of small bowel, left hemicolectomy, and end colostomy. The patient tolerated the procedure well, the tube feedings were gradually restarted, and at the 6-month postoperative visit gastrointestinal function was normal. This case illustrates possible complications of an inadvertently placed feeding tube. Not only may it cause unexplained diarrhea and undernutrition, but it may lead to more serious events like colonic ischemia and perforation.