Should mitral valve replacement age guidelines be lowered due to better bioprosthetic mitral valve durability?

OBJECTIVE: Guideline recommendations for mechanical or bioprosthetic valve for mitral valve replacement by age remains controversial. We sought to determine bovine pericardial valve durability by age and risk of reintervention. METHODS: This retrospective study between 2 large university-based cardiac surgery programs examined patients who underwent bioprosthetic mitral valve replacement from 2004 to 2020. Follow-up was obtained through June 2022. Durability outcomes involving structural valve deterioration were compared by age decile. RESULTS: Of 1544 available patients, mean age was 66 ± 13 years and 652 (42%) were aged less than 65 years. Indications for mitral valve replacement were as follows: mitral regurgitation greater than 2+ in 53% (n = 813), mitral stenosis in 44% (n = 650), endocarditis in 18% (n = 277), and reoperation in 39% (n = 602). Concomitant procedures were aortic valve replacement in 28% (n = 426), tricuspid valve in 36% (n = 550), and coronary artery bypass in 19% (n = 290). Thirty-day mortality was 5.4%. In follow-up (clinical: median [interquartile range] 75 [25-129] months), reoperation for endocarditis and new stroke were low (0.30 and 1.06 per 100 patient/years, respectively). The cumulative incidence of mitral valve reintervention for structural valve deterioration among all patients was 6.2% at 10 years and 9.0% at 12 years with no statistical difference in structural valve deterioration in patients aged 40 to 70 years (P = .1). In 90 patients with mitral valve reintervention, 30-day mortality after reintervention was 4.7% (n = 2) for 43 with mitral valve-in-valve and 6.4% (n = 3) for 47 with reoperation. CONCLUSIONS: Bovine pericardial mitral valve replacement is a durable option for younger patients. The opportunity to avoid anticoagulation and the associated risks with mechanical mitral valve replacement may be of benefit to patients. These insights may provide data needed to revise the current guidelines.

Concomitant ablation of atrial fibrillation: New pacemakers and early rhythm recovery.

OBJECTIVE: New permanent pacemaker (PPM) implantation after concomitant atrial fibrillation (AF) ablation has been associated with surgical ablation (SA). We sought to determine factors for PPM use as well as early rhythm recovery. METHODS: From 2004 through 2019, 6135 patients underwent valve surgery and were grouped: No AF (n = 4584), AF no SA (n = 346), and AF with SA (n = 1205) to evaluate predischarge PPM and 3-month rhythm recovery (intrinsic heart rate >40 beats per minute). RESULTS: Overall, 282 (4.6%) patients required a predischarge PPM: atrioventricular node dysfunction in 75.3%, sick sinus syndrome in 19.1%, both (5%), and indeterminate (0.7%). Patients with AF had more PPMs: AF with SA (7.9%) versus AF no SA (6.9%) versus No AF (3.6%) (P < .001). For patients with AF, PPM rates were not significantly higher for ablation patients (7.6% SA vs 6.9% AF no SA; P = .56). There were differences in PPM by SA lesion set (biatrial 12.8%; left atrial only 6.1%; pulmonary vein isolation 3.0%; P < .001). Among patients with AF treated with 3-month PPM follow-up, rhythm recovery was common (35 out of 62 [56.5%]) and did not differ by lesion set. Rhythm recovery was seen in 63 out of 141 (44.7%) in the atrioventricular node dysfunction group versus 24 out of 35 (68.6%) in the sick sinus syndrome group (P = .011). In propensity score-matched groups, late survival was similar (P = .63) for new PPM patients. CONCLUSIONS: Avoiding conduction system trauma and delaying implantation reduces the need for postoperative PPM. Rhythm recovery within 3 months is frequent, especially for patients with sick sinus syndrome. A conservative approach to the implantation of a new PPMs is warranted.

Late results of chord transfer and other techniques for anterior leaflet repair without neochords.

OBJECTIVE: Anterior and bileaflet degenerative mitral regurgitation repairs are challenging. We examined our early and late outcomes for repair using 4 techniques, without neochord repair. METHODS: Between February 1, 2006, and June 30, 2021, a total of 2368 patients received mitral valve ± other surgery by 1 surgeon, including 1160 with degenerative mitral regurgitation. Clinical follow-up was conducted annually (mean 6.8 ± 4.4 years). RESULTS: Repair was performed in 1137 patients (98%) (mean age, 60.5 ± 11.9 years). Repair rate varied between groups: 99% for isolated posterior leaflet (794/799), 91% for isolated anterior leaflet (83/91), and 96% for bileaflet prolapse (260/270; P < .001). Thirty-day mortality was 0.2%. On a scale of 0 to 4+ mitral regurgitation, mean mitral regurgitation grade decreased from 3.8 ± 0.6 preoperatively to 0.07 ± 0.3 at discharge, including moderate (2+) in 0.6% (7/1137) overall and 0.9% (3/343) with anterior prolapse. None were more than 2+ at discharge. Among the 3 groups of leaflet prolapse, there was no significant difference in long-term survival (P = .26), freedom from mitral valve reintervention (P = .12; 99.4% overall), and freedom from more than moderate (2+) mitral regurgitation (P = .16; 98.3% overall). The 4 most common anterior leaflet repair techniques (chord transfer 17%; commissuroplasty 10%; Alfieri [edge-to-edge] 6%); ring with posterior resection (4.3%) had similar freedom from 10-year reintervention (99.4%, 94%, 100%, and 100%, respectively; P = .29). CONCLUSIONS: Complex anterior leaflet prolapse repairs are successful using a variety of techniques without neochord implantation. Although neochords are popular, there are other ways to repair complex valves that do not require as much judgment and experience.

Acupuncture after valve surgery is feasible and shows promise in reducing postoperative atrial fibrillation: The ACU-Heart pilot trial.

Objective: Acupuncture is an effective treatment for arrythmias and postoperative symptoms but has not been investigated after cardiac surgery. Acupuncture After Heart Surgery is a prospective, randomized, controlled pilot trial of daily inpatient acupuncture or standard care after valve surgery with the primary end point being feasibility and secondary end points being reduction in postoperative atrial fibrillation incidence and postoperative symptoms. Methods: A total of 100 patients without a history of atrial fibrillation underwent primary valve surgery via sternotomy and randomized 1:1 to acupuncture (51) or standard care (49). The acupuncture group received daily inpatient sessions starting on postoperative day 1. Postoperative symptoms (pain, nausea, stress, anxiety) were assessed once daily in the standard care group and before/after daily intervention in the acupuncture group. The groups were comparable except for age (acupuncture: 55.6 ± 11.4 years, standard care: 61.0 ± 9.3 years; P = .01). Results: The Acupuncture After Heart Surgery pilot trial met primary and secondary end points. There were no adverse events. An average of 3.8 (±1.1) acupuncture sessions were delivered per patient during a mean hospital stay of 4.6 days (±1.3). Acupuncture was associated with a reduction in pain, nausea, stress, and anxiety after each session (P < .0001), and patients receiving acupuncture had reduced postoperative stress and anxiety across admission compared with standard care (P = .049 and P = .036, respectively). Acupuncture was associated with reduced postoperative atrial fibrillation incidence (acupuncture: 7 [13.7%], standard care: 16 [32.7%]; P = .028), fewer discharges on amiodarone (acupuncture: 5 [9.8%], standard care: 13 [26.5%]; P = .03), and fewer hours in the intensive care unit (acupuncture: 30.3 ± 10.0, standard care: 37.0 ± 22.5; P = .057). Conclusions: Acupuncture after valve surgery is feasible, is well tolerated, and has clinical benefit. The reduction noted in postoperative atrial fibrillation incidence will inform larger trials designed to further investigate the impact of acupuncture on postoperative atrial fibrillation and medical outcomes.

One hundred percent utilization of a modified CryoMaze III procedure for atrial fibrillation with mitral surgery.

OBJECTIVES: Concomitant atrial fibrillation often goes untreated because of surgeon concerns regarding lesion set complexity and pump times. We describe a new cryoablation procedure to address this. METHODS: From June 2013 to March 2021, a modified CryoMaze III procedure was used using 3 left atrial ± 3 right atrial cryo-applications creating the key lesions of the Cox Maze III procedure. Since 2018, 3-minute cryo-lesions were used for the left atrial box lesion for total cryoablation times of 8 minutes for the left atrium ± 6 minutes for the right atrium. By using propensity matching, patients undergoing mitral valve surgery with no atrial fibrillation history were compared with CryoMaze III-treated patients. RESULTS: A total of 100% of the 277 patients with atrial fibrillation requiring mitral valve surgery ± other procedures received the modified CryoMaze III procedure. After propensity score matching (n = 161 each group), the modified CryoMaze III group had mean crossclamp and bypass times 10.5 and 13.4 minutes longer than the control group, respectively. There were no significant differences in 30-day mortality, morbidity, pacemaker use, renal dysfunction, or late survival between groups, but there were less postoperative strokes in the CryoMaze III group. Freedom from atrial fibrillation off antiarrhythmics was 77% (mean follow-up of 3.0 ± 2.1 years). At 12 months, freedom from atrial fibrillation off antiarrhythmics was 90% for the 3-minute ablation group. Late survival was similar to age- and sex-matched Centers for Disease Control and Prevention controls. CONCLUSIONS: The modified CryoMaze III technique is efficient, safe, and effective. Education of the surgical community regarding the late benefits of ablation and the simplicity of this new technique should improve adoption of the Class I Guidelines to treat concomitant atrial fibrillation.

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.

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.

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.

Fate of moderate aortic regurgitation after cardiac surgery.

OBJECTIVE: To determine the prevalence of concomitant aortic regurgitation (AR) in cardiac surgery and the outcomes of treatment options. METHODS: Between April 2004 and June 2018, 3289 patients underwent coronary artery bypass, mitral valve, or aortic aneurysm surgery without aortic stenosis. AR was graded none/trivial (score = 0), mild (score = 1+), or moderate (score = 2+). Patients with untreated 2+ AR were compared with those with 0 or 1+ AR, and to those with 2+ AR who had aortic valve surgery. Thirty-day and late survival, echocardiography, and clinical outcomes were compared using propensity score matching. RESULTS: One hundred thirty-eight patients (4.2%) had 2+ AR; and 45 (33%) received aortic valve repair (n = 9) or replacement (n = 36) in the treated group and were compared with 2765 untreated patients with 0 AR and 386 patients with 1+ AR. Valve surgery was more common with anatomic leaflet abnormalities: bicuspid aortic valve (9% vs 0%; P < .01), rheumatic valve disease (16% vs 3%; P < .01), and calcification (47% vs 27%; P = .021). In unadjusted analysis, lower preoperative AR grade was associated with increased 10-year survival (P < .001). At year 10, progression to more-than-moderate AR among moderate AR patients was 2.6% and late intervention rate was 3.1%. In the untreated 2+ AR group, on last follow-up echocardiogram, 58% had improvement in AR, 41% remained 2+, and only 1% progressed to severe AR. CONCLUSIONS: Aortic valve surgery in select patients with concomitant moderate AR can be added with minimal added risk, but untreated AR does not influence long-term survival after cardiac surgery and rarely required late intervention.

A multiparameter algorithm to guide repair of degenerative mitral regurgitation.

PURPOSE: Degenerative mitral regurgitation repair using a measured algorithm could increase the precision and reproducibility of repair outcomes. METHODS: Direct and echocardiographic measurements guide the repair to achieve a coaptation length of 5 to 10 mm and minimize the risk of systolic anterior motion. Leaflet reconstruction restored the normal 2 to 1 ratio of anterior to posterior leaflet length without residual prolapse or restriction. The choice of ring size was based on anterior leaflet length, the distance from the leaflet coaptation point to the septum, and the anterior-posterior ring dimension. Freedom from reoperation and mitral regurgitation recurrence were based on multistate models. RESULTS: One thousand fifty-one patients had mitral surgery and 1026 (97.6%) were repaired. A2 length was 27.2 ± 4.5 mm; and the reconstructed posterior leaflet was 13.9 ± 2.3 mm. Median ring size was 34 mm and strongly correlated to A2 length (R = 0.76; P < .001). The coaptation length at P2 after repair was 6.4 ± 1.7 mm and 87% of measurements were between 5 and 10 mm. Results at predischarge and 10 years, respectively, included mild regurgitation (7.5% and 26.1%), moderate (0.7% and 15.6%), moderate to severe (0% and 1.4%), and severe (0% and 0%), with mean mitral gradient values 3.5 ± 1.5 and 2.9 ± 1.2 mm Hg, respectively. Systolic anterior motion at discharge and last follow-up were 0.2% and 1.1%, respectively. Ten-year freedom from mitral valve reoperation was 99.7%. CONCLUSIONS: A simple, reproducible, measured algorithm for degenerative mitral valve repair provides excellent early and late results and is a useful adjunct to established surgical techniques.

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.

Concomitant treatment of atrial fibrillation during mitral valve surgery.

INTRODUCTION: Surgical management of atrial fibrillation (AF) is a well-established method of preventing complications and late mortality in patients presenting with AF before mitral valve (MV) surgery. However, despite a substantial body of evidence and a Class I recommendation to apply surgical ablation (SA) concomitant to MV surgery, the utilization of SA remains low. METHODS: In this study, we sought to summarize the current trends in the SA of AF during MV surgery and update the medical community on its advantages, including perioperative mortality and morbidity, freedom from AF, as well as long-term survival and stroke rates. RESULTS: The data indicate that SA can be added with no increased risk (and perhaps a reduction in perioperative risk) and improved late survival compared to patients with AF left untreated during MV surgery. DISCUSSION: Inconsistent application of SA may be related to inaccurate perceptions regarding the complexity of the procedure itself, extended cross-clamp and bypass times with attendant increased risks, views that it is ineffective, and increased need for an early pacemaker. CONCLUSION: Education in the proper performance of SA, including careful placement of the lesions and attainment of the full transmural effect, contributes to procedure success. Propagating the safety and positive outcomes may also address the concerns.

Asymptomatic degenerative mitral regurgitation repair: Validating guidelines for early intervention.

INTRODUCTION: Mitral repair for asymptomatic (New York Heart Association [NYHA] class I) degenerative mitral regurgitation (MR) is supported by the guidelines, but is not performed often. We sought to determine outcomes for asymptomatic patients when compared with those with symptoms. METHODS: Between 2004 and 2018, 1027 patients underwent mitral replacement (22) or repair with or without other cardiac surgery (1005), the latter being grouped by NYHA class: I (n = 470; 47%), II (n = 408; 40%), or III/IV (n = 127; 13%). Statistical analyses included propensity score matching and weighting, and multistate models. RESULTS: The proportion of patients designated as NYHA class I undergoing surgery increased steadily during this period (P < .001). Overall, 30-day mortality was 0.4%, and zero for patients designated NYHA class I. Unadjusted 10-year survival was significantly greater in patients designated NYHA class I compared with II and III/IV (P < .001). Freedom from reoperation at 10 years was 99.8% overall, and 100% for patients designated NYHA class I. In patients designated as NYHA class I, predischarge and 10-year moderate MR were 0.7% and 20.1%, whereas more than moderate was zero and 0.6%. Preoperative ejection fraction less than 60% was associated with late mortality (P = .025). After covariate-adjustments, freedom from MR and tricuspid regurgitation were not statistically significantly different by NYHA class. However, overall survival was significantly worse in patients with NYHA class III/IV, compared with class II. CONCLUSIONS: Mitral repair in asymptomatic patients is safe and durable. Careful monitoring until class II symptoms is appropriate. However, repair before ejection fraction decreases below 60% is important for late overall survival.

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.

The impact of intraoperative residual mild regurgitation after repair of degenerative mitral regurgitation.

OBJECTIVES: During degenerative mitral repair, surgeons must decide if further repair is warranted for residual mild mitral regurgitation. We examined the incidence of mild mitral regurgitation, late echocardiographic and clinical outcomes, and influence of surgical experience in decision making. METHODS: From April 2004 to June 2018, 1155 of 1195 patients with pure degenerative disease underwent repair (97% repair rate). Propensity score matching was performed between patients with trace/no mitral regurgitation and patients with mild residual mitral regurgitation. Late echocardiographic outcome and freedom from reoperation were compared using competing-risks models. A comparison of outcomes of the referent surgeon (89.8% of repairs) with all other surgeons was performed. RESULTS: Mild mitral regurgitation was present in 73 patients (6%). Propensity score-matched analyses compared 69 patients with mild mitral regurgitation with 198 patients without mitral regurgitation. Late moderate or greater mitral regurgitation was higher in those with mild mitral regurgitation than in those with no mitral regurgitation (17% vs 7%, P = .033), as was late moderate-severe or greater mitral regurgitation (6% vs 1%, P = .016). Ten-year freedom from reoperation was low in both groups (99.5% no vs 96.9% mild; P = .10). The referent surgeon had fewer patients with mild residual mitral regurgitation (6% vs 11%, P = .027) and less progression of mitral regurgitation compared with other surgeons (late moderate or greater mitral regurgitation 6% vs 15%, P = .002). CONCLUSIONS: Residual mild mitral regurgitation was uncommon, and late progression to moderate or greater mitral regurgitation was rare and never led to late mitral reoperation. Experienced surgeons may be better able to determine repairs likely to remain stable, and most mild residual mitral regurgitation does not require re-repair.

Ablation of atrial fibrillation during coronary artery bypass grafting: Late outcomes in a Medicare population.

BACKGROUND: This study compares outcomes of patients with preoperative atrial fibrillation undergoing coronary artery bypass grafting (CABG) with or without concomitant atrial fibrillation ablation in a nationally representative Medicare cohort. OBJECTIVES: This study examined early and late outcomes in CABG patients with a preoperative history of atrial fibrillation to determine the correlation between surgical atrial fibrillation ablation to mortality and stroke or systemic embolization. METHODS: In the Medicare-linked Society of Thoracic Surgeons database, 361,138 patients underwent isolated CABG from 2006 to 2013; 34,600 (9.6%) had preoperative atrial fibrillation; 10,541 (30.5%) were treated with surgical ablation (ablation group), and 23,059 were not (no ablation group). Propensity score matching was performed using a hierarchical mixed model. Long-term survival was summarized using Kaplan-Meier curves and Cox regression models with robust variance estimation. The stroke or systemic embolization incidence was modeled using the Fine-Gray model. Median follow-up was 4 years. RESULTS: Long-term mortality in propensity score-matched CABG patients (mean age 74 years; Society of Thoracic Surgeons risk score, 2.25) receiving ablation versus no ablation was similar (log-rank P = .30). Stroke or systemic embolization occurred in 2.2% versus 2.1% at 30 days and 9.9% versus 12.0% at 5 years (Gray P = .0091). Landmark analysis from 2 to 5 years showed lower mortality (hazard ratio, 0.89; 95% confidence interval 0.82-0.97; P = .0358) and lower risk of stroke or systemic embolization (hazard ratio, 0.73; 95% confidence interval, 0.61-0.87; P = .0006) in the ablation group. CONCLUSIONS: Concomitant ablation in CABG patients with preoperative atrial fibrillation is associated with lower stroke or systemic embolization and mortality in patients who survive more than 2 years.