Effect of Continuous Electrocardiogram Monitoring on Detection of Undiagnosed Atrial Fibrillation After Hospitalization for Cardiac Surgery: A Randomized Clinical Trial.

Importance: Postoperative atrial fibrillation (POAF) occurring after cardiac surgery is associated with adverse outcomes. Whether POAF persists beyond discharge is not well defined. Objective: To determine whether continuous cardiac rhythm monitoring enhances detection of POAF among cardiac surgical patients during the first 30 days after hospital discharge compared with usual care. Design, Setting, and Participants: This study is an investigator-initiated, open-label, multicenter, randomized clinical trial conducted at 10 Canadian centers. Enrollment spanned from March 2017 to March 2020, with follow-up through September 11, 2020. As a result of the COVID-19 pandemic, enrollment stopped on July 17, 2020, at which point 85% of the proposed sample size was enrolled. Cardiac surgical patients with CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex) score greater than or equal to 4 or greater than or equal to 2 with risk factors for POAF, no history of preoperative AF, and POAF lasting less than 24 hours during hospitalization were enrolled. Interventions: The intervention group underwent continuous cardiac rhythm monitoring with wearable, patch-based monitors for 30 days after randomization. Monitoring was not mandated in the usual care group within 30 days after randomization. Main Outcomes and Measures: The primary outcome was cumulative AF and/or atrial flutter lasting 6 minutes or longer detected by continuous cardiac rhythm monitoring or by a 12-lead electrocardiogram within 30 days of randomization. Prespecified secondary outcomes included cumulative AF lasting 6 hours or longer and 24 hours or longer within 30 days of randomization, death, myocardial infarction, ischemic stroke, non-central nervous system thromboembolism, major bleeding, and oral anticoagulation prescription. Results: Of the 336 patients randomized (163 patients in the intervention group and 173 patients in the usual care group; mean [SD] age, 67.4 [8.1] years; 73 women [21.7%]; median [interquartile range] CHA2DS2-VASc score, 4.0 [3.0-4.0] points), 307 (91.4%) completed the trial. In the intent-to-treat analysis, the primary end point occurred in 32 patients (19.6%) in the intervention group vs 3 patients (1.7%) in the usual care group (absolute difference, 17.9%; 95% CI, 11.5%-24.3%; P < .001). AF lasting 6 hours or longer was detected in 14 patients (8.6%) in the intervention group vs 0 patients in the usual care group (absolute difference, 8.6%; 95% CI, 4.3%-12.9%; P < .001). Conclusions and Relevance: In post-cardiac surgical patients at high risk of stroke, no preoperative AF history, and AF lasting less than 24 hours during hospitalization, continuous monitoring revealed a significant increase in the rate of POAF after discharge that would otherwise not be detected by usual care. Studies are needed to examine whether these patients will benefit from oral anticoagulation therapy. Trial Registration: ClinicalTrials.gov Identifier: NCT02793895.

Evaluating the efficacy of self-study videos for the surgery clerkship rotation: an innovative project in undergraduate surgical education.

Background: Educational videos have become valuable resources and can address some of the pitfalls of traditional learning. To ensure clerkship students have adequate exposure to curriculum objectives, a series of objective-aligned self-directed learning video podcasts covering core surgical concepts were developed by medical students and surgical residents. The objective of the study was to evaluate the efficacy of the video podcasts in the surgery clerkship rotation. Methods: Nineteen video podcasts were created, housed at www.surgicaleducationportal.com, and distributed to third-year medical students completing their surgical clerkship. A 10-question multiple-choice quiz was administered before and after students viewed each video, and they were also asked to complete a satisfaction survey. Results: A total of 302 paired pretests and posttests were completed. There was a mean increase of 2.7 points in posttest scores compared with pretest scores (p < 0.001). On a Likert scale from 1 to 5, with 5 being excellent, students rated the usefulness of the videos as 4.3, the quality of the content as 4.3 and the quality of the video as 4.2. Ninety-eight percent of students would recommend these videos to their classmates. Conclusion: Video podcasts are an effective modality for engaging medical students and may improve standardization of learning during their surgical clerkship.

Contexte: Les vidéos de formation sont devenues d'inestimables ressources et elles peuvent combler certaines des lacunes de l'enseignement traditionnel. Pour que les résidents bénéficient d'une exposition adéquate aux objectifs curriculaires, une série de balados vidéo d'autoapprentissage centrés sur des objectifs reliés aux principaux concepts de chirurgie a été réalisée par des étudiants en médecine et des résidents en chirurgie. L'objectif de l'étude était d'évaluer l'efficacité des balados pour les stages de chirurgie. Méthodes: Dix-neuf balados vidéo ont été réalisés (accessibles en anglais au www.surgicaleducationportal.com) et distribués à des étudiants de troisième année de médecine qui effectuent leur stage de chirurgie. Un questionnaire en 10 points à choix multiples leur a été administré avant et après le visionnement de chaque vidéo; ils ont ensuite été invités à répondre à un questionnaire d'évaluation. Résultats: En tout 302 pré- et post-tests appariés ont été effectués. On a observé une augmentation de 2,7 points aux scores post-test, comparativement aux scores pré-test (p < 0,001). Sur une échelle de Likert allant de 1 à 5, 5 correspondant à excellent, les étudiants ont accordé un score de 4,3 pour l'utilité des balados vidéo et de 4,2 pour leur qualité. Quatre-vingt-dix-huit pour cent des étudiants recommanderaient ces balados vidéo à leurs camarades. Conclusion: Les balados vidéo sont une modalité efficace pour mobiliser les étudiants en médecine et pourraient faciliter l'uniformisation de l'apprentissage lors des stages de chirurgie.

A novel echocardiographic hemodynamic index for predicting outcome of aortic stenosis patients following transcatheter aortic valve replacement.

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) reduces left ventricular (LV) afterload and improves prognosis in aortic stenosis (AS) patients. However, LV afterload consists of both valvular and arterial loads, and the benefits of TAVR may be attenuated if the arterial load dominates. We proposed a new hemodynamic index, the Relative Valve Load (RVL), a ratio of mean gradient (MG) and valvuloarterial impedance (Zva), to describe the relative contribution of the valvular load to the global LV load, and examined whether RVL predicted patient outcome following TAVR. METHODS: A total of 258 patients with symptomatic severe AS (indexed aortic valve area (AVA)<0.6cm2/m2, AR≤2+) underwent successful TAVR at the University of Ottawa Heart Institute and had clinical follow-up to 1-year post-TAVR. Pre-TAVR MG, AVA, percent stroke work loss (%SWL), Zva and RVL were measured by echocardiography. The primary endpoint was all cause mortality at 1-year post TAVR. RESULTS: There were 53 deaths (20.5%) at 1-year. RVL≤7.95ml/m2 had a sensitivity of 60.4% and specificity of 75.1% for identifying all cause mortality at 1-year post-TAVR and provided better specificity than MG<40 mmHg, AVA>0.75cm2, %SWL≤25% and Zva>5mmHg/ml/m2 despite equivalent or better sensitivity. In multivariable Cox analysis, RVL≤7.95ml/m2 was an independent predictor of all cause mortality (HR 3.2, CI 1.8-5.9; p<0.0001). RVL≤7.95ml/m2 was predictive of all cause mortality in both low flow and normal flow severe AS. CONCLUSIONS: RVL is a strong predictor of all-cause mortality in severe AS patients undergoing TAVR. A pre-procedural RVL≤7.95ml/m2 identifies AS patients at increased risk of death despite TAVR and may assist with decision making on the benefits of TAVR.

Impact of visualization on simulation training for vascular anastomosis.

OBJECTIVE: There is mounting evidence supporting the benefit of surgical simulation on the learning of skills independently and in a patient-safe environment. The objective of this study was to examine the effect of visualization of surgical steps via instructional media on performance of an end-to-side microvascular anastomosis. METHODS: Thirty-two first- and second-year surgical trainees from the University of Ottawa received an expert-guided, didactic lecture on vascular anastomosis and performed an end-to-side anastomosis on a procedural model to assess baseline skills. Assessments were performed by 2 blinded, expert observers using validated measurements of skill. Subjects were then proctored to perform anastomoses using the model. Subjects were then randomized to watch an instructional video on performance of vascular anastomosis using visualization as the education strategy. One week later, subjects were again assessed for technical skill on the model. The primary outcome was the score achieved on the Objective Structured Assessment of Technical Skill (OSATS) scale. Secondary outcomes included an anastomosis-specific End-Product Rating Score and time to completion. RESULTS: Compared with residents who received expert-guided simulator training alone, those who used the supplementary multimedia scored significantly greater on OSATS (17.4 ± 2.9 vs 14.2 ± 3.2, P = .0013) and on End-Product Rating Score (11.24 ± 3.0 vs 7.4 ± 4.1, P = .011). However, performance time did not differ between groups (15.7 vs 14.3 minutes, P = .79). CONCLUSIONS: Residents with supplemental instructional media performed an end-to-side anastomosis more proficiently as assessed by OSATS and with a greater quality end-product. This suggests that both didactic simulation training as well as use of visualization multimedia improves learning and performance of vascular anastomosis and should be incorporated into surgical curricula.

Simulation-Based Skill Training for Trainees in Cardiac Surgery: A Systematic Review.

BACKGROUND: Simulation-based training has been an important part of the solution to address the shortfalls in cardiac surgery training. This review was conducted to identify and systematically summarize existing evidence on outcomes and methodological quality of simulation-based skills training for cardiac surgery trainees. METHODS: MEDLINE, Embase, and ERIC (Education Resources Information Center) databases were searched. Studies included peer-reviewed publications with simulation-based skill training in cardiac surgery programs with outcome measures of performance. Data extraction covered the type of skills training, simulator type and fidelity, the level of trainees, assessment tools, assessors, study design and its components, strengths and limitations, and elements required for the Medical Education Research Study Quality Instrument score. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: Of 16 studies that met the criteria, only four (25%) randomized controlled trials were identified, and the remaining were observational studies. Seven observational studies (43.7%) were single-group pre-post tests. The mean number of trainees was 20.4 (SD, 14.1). Low-fidelity simulators were used in 13 studies (81.2%). Most of the studies (81.3%) were high quality based on a Medical Education Research Study Quality Instrument score of 12 or more. Evidence of assessment tool validation was absent among all studies. No study outcome measures were directed to skills transfer to the operating room or patient outcomes. Overall learning outcomes' effect sizes were consistently high (2.2; SD, 1.6), with junior residents benefitting most (effect size, 2.8; SD, 2.2) CONCLUSIONS: Simulation-based skill training is associated with improved learning outcomes for cardiac surgery trainees with large effect sizes, but more behavior-level outcomes are required to fully assess its value.

Development of Mitral Stenosis After Mitral Valve Repair: Importance of Mitral Valve Area.

BACKGROUND: The development of mitral stenosis (MS) is not uncommon after mitral valve (MV) repair for degenerative mitral regurgitation (MR), but the significance of MS in this setting has not been defined. METHODS: We prospectively studied 110 such patients who underwent supine bicycle exercise testing to assess intracardiac hemodynamics at rest and at peak exercise. B-type natriuretic peptide (BNP) levels were measured at rest and after the exercise test. The patients also performed the 6-minute walk test and completed the 36-Item Short Form Survey (SF-36). Follow-up was performed by a review of the medical record and telephone interview. RESULTS: Of 110 patients, 22 had MS defined by a mitral valve area (MVA) ≤ 1.5 cm2. The resting and peak exercise mitral gradients and pulmonary artery systolic pressure were significantly higher in patients with MS compared with patients with an MVA > 1.5 cm2. BNP levels at rest and after exercise were also higher in the patients with MS, who also had lower exercise capacity and worse perception of well-being in 3 domains (physical function, vitality, and social function) on the SF-36. MVA had higher specificity and positive predictive value in predicting outcome events compared with a mean gradient of 3 or 5 mm Hg. CONCLUSIONS: In patients who had MV repair for degenerative MR, an MVA ≤ 1.5 cm2 occurs in about one-fifth of patients and is associated with adverse intracardiac hemodynamics, lower exercise capacity, and adverse outcomes.

Should We Ablate Atrial Fibrillation During Coronary Artery Bypass Grafting and Aortic Valve Replacement?

BACKGROUND: This study evaluates the safety and efficacy of concomitant atrial fibrillation (AF) ablation in patients with AF undergoing coronary artery bypass grafting (CABG) or aortic valve replacement (AVR) or both. METHODS: This is a single-center retrospective study of patients with AF presenting for CABG or AVR or both between 2009 and 2013. They were divided into an ablation group that underwent concomitant AF ablation and a control group that did not. Follow-up data were obtained using telephone interviews. The data were 100% complete with a median follow-up of 30 months. RESULTS: A total of 375 patients with AF presented for CABG (44%), AVR (27%), or CABG and AVR (29%). The ablation (129 patients) and control (246 patients) groups had similar baseline characteristics. The ablation group had significantly longer cardiopulmonary bypass and cross-clamp times, adding a mean of 31 ± 3 and 22 ± 3 minutes (p < 0.01 for both), respectively. There were similar unadjusted rates of hospital mortality (4.7% versus 5.3%, p = 0.79), stroke (3.1% versus 3.3%, p = 0.94), and reopening (4.7% versus 6.5%, p = 0.46) between the groups. The intensive care and hospital length of stays were similar. The ablation group had a lower incidence of postoperative AF (27% versus 78%, p < 0.01). Adjusted operative mortality was similar, but the intervention group had significantly lower odds of postoperative AF (odds ratio 0.11, p < 0.01). Although there was no difference in mid-term survival, the ablation group had higher mid-term AF-free survival (p < 0.01) and a trend toward higher anticoagulation-free (p = 0.09) and stroke-free survival (p = 0.08). CONCLUSIONS: Concomitant AF ablation in patients with AF undergoing CABG or AVR or both does not increase perioperative rates of mortality or morbidity. Moreover, concomitant AF ablation is effective at reducing postoperative AF burden and increases mid-term AF-free survival.

Paracrine Engineering of Human Explant-Derived Cardiac Stem Cells to Over-Express Stromal-Cell Derived Factor 1α Enhances Myocardial Repair.

First generation cardiac stem cell products provide indirect cardiac repair but variably produce key cardioprotective cytokines, such as stromal-cell derived factor 1α, which opens the prospect of maximizing up-front paracrine-mediated repair. The mesenchymal subpopulation within explant derived human cardiac stem cells underwent lentiviral mediated gene transfer of stromal-cell derived factor 1α. Unlike previous unsuccessful attempts to increase efficacy by boosting the paracrine signature of cardiac stem cells, cytokine profiling revealed that stromal-cell derived factor 1α over-expression prevented lv-mediated "loss of cytokines" through autocrine stimulation of CXCR4+ cardiac stem cells. Stromal-cell derived factor 1α enhanced angiogenesis and stem cell recruitment while priming cardiac stem cells to readily adopt a cardiac identity. As compared to injection with unmodified cardiac stem cells, transplant of stromal-cell derived factor 1α enhanced cells into immunodeficient mice improved myocardial function and angiogenesis while reducing scarring. Increases in myocardial stromal-cell derived factor 1α content paralleled reductions in myocyte apoptosis but did not influence long-term engraftment or the fate of transplanted cells. Transplantation of stromal-cell derived factor 1α transduced cardiac stem cells increased the generation of new myocytes, recruitment of bone marrow cells, new myocyte/vessel formation and the salvage of reversibly damaged myocardium to enhance cardiac repair after experimental infarction. Stem Cells 2016;34:1826-1835.

Transfemoral vs Non-transfemoral Access for Transcatheter Aortic Valve Implantation: A Systematic Review and Meta-analysis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is the definitive therapy for high-risk patients with severe aortic stenosis. The aim of this study was to determine the effect of non-transfemoral access on clinical outcomes in TAVI. METHODS: We conducted a computerized literature search on SCOPUS and selected all studies published in the English language, from 2002 until March 12 2014, that compared transfemoral access with a non-transfemoral access cohort. Two independent reviewers evaluated the studies and extracted data for analysis. RESULTS: A total 17,020 patients (11,079 transfemoral, 5941 non-transfemoral) encompassing 28 studies underwent TAVI between 2007 to 2013. Overall, the 30-day mortality was 4.7% with the transfemoral approach and 8.1% with a non-transfemoral approach (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.49-0.64; P < 0.01). The 1-year mortality was 16.4% with transfemoral access and 24.8% with non-transfemoral access (OR, 0.68; 95% CI, 0.60-0.75; P < 0.01). Transfemoral access was associated with a greater incidence of vascular complications (OR, 2.1; 95% CI, 1.48-2.99; P < 0.01) but a lower rate of surgical conversion (OR, 0.59; 95% CI, 0.42-0.81; P < 0.01) and similar bleeding (OR, 1.01; 95% CI, 0.81-1.27; P = 0.91) compared with non-transfemoral access. The incidence of cerebrovascular events was similar in both groups (1.6% vs 2.1%; OR, 0.86; 95% CI, 0.64-1.15; P = 0.31). CONCLUSIONS: Transfemoral access was associated with lower rate of 30-day and 1-year mortality compared with non-transfemoral access for TAVI. Randomized studies are needed to ascertain the effect of alternative access sites on clinical outcomes in prohibitive-risk, high-risk, and intermediate-risk populations, using currently available technologies.

Transcatheter aortic valve implantation in patients with bicuspid aortic valve: A patient level multi-center analysis.

OBJECTIVE: We sought to evaluate the safety and efficacy of transcatheter aortic valve implantation (TAVI) in patients with bicuspid aortic valve (BiAV). BACKGROUND: BiAV remains a relative contraindication to TAVI resulting in exclusion from TAVI trials and thus limiting data on the clinical performance of transcatheter valves in these patients. METHODOLOGY: We conducted an international patient level multicenter analysis on outcomes in patients with BiAV undergoing TAVI. The primary outcome of the study was the combined early safety endpoint--a composite of 30 day mortality, stroke, life-threatening bleeding, acute kidney injury, coronary artery obstruction, major vascular complication and valve related dysfunction. Secondary endpoints included the individual components of the primary endpoint as well as post-TAVI paravalvular leak (PVL), rehospitalization, new pacemaker insertion and device success rates at 30 days and 1 year. RESULTS: A total of 108 patients with BiAV were identified in 21 centers in Canada, Spain, Italy, Poland and Singapore who underwent TAVI between January 2005 and March 2014. The composite primary outcome occurred in one quarter of patients (26.9%)--mainly driven by re-intervention for valve malposition (9.3%). The 30-day and 1 year mortality rates were 8.3% and 16.9% respectively with AR ≥ 3+ occurring in 9.6% of patients. Device success was achieved in 85.2% of cases with pacemaker insertion in 19.4%. While PVL was not associated with an increased risk of 30 day or 1 year mortality--Type I BiAV anatomy with left and right cusp fusion had significantly better outcomes than other valve variants. CONCLUSION: In selected patients with BiAV and severe aortic stenosis, TAVI appears both safe and feasible with acceptable clinical outcomes. Clinical studies of TAVI in this patient population are warranted.

Subannular prosthetic valve embolization complicating transapical transcatheter aortic valve implantation: management without sternotomy.

Transapical transcatheter aortic valve implantation can be complicated by subannular device embolization. We describe 2 cases of transapical extraction without conversion to sternotomy, with a discussion of contributing factors and our strategy for salvage.

Aortic root geometry in bicuspid aortic insufficiency versus stenosis: implications for valve repair.

OBJECTIVES: The contribution of aortic annular and root disease in bicuspid aortic valve (BAV) insufficiency remains unclear. We compared aortic root geometry between BAV stenosis and aortic insufficiency (AI), before and after repair. METHODS: Patients presenting for surgery for BAV insufficiency (n = 58) were compared with patients with BAV stenosis (n = 58). Clinical and transoesophageal echocardiographic data were collected, including end-diastolic diameters of the ventriculo-aortic junction (VAJ), aortic root, sinotubular junction (STJ) and ascending aorta (AA). RESULTS: AI patients were younger and more likely to be male compared with aortic stenosis (AS) patients. VAJ, aortic root and STJ diameters were significantly larger in AI compared with AS patients (30 ± 0.5 vs 25 ± 0.4 mm, P < 0.001; 41 ± 0.8 vs 34 ± 0.6 mm, P < 0.001; 36 ± 0.9 vs 30 ± 0.6 mm, P < 0.001, respectively). Following multivariable adjustment for age, sex, body surface area and ascending aortic diameter, these diameters remained larger in AI patients with a mean difference of 3, 6 and 4 mm, respectively (all P < 0.001). Mean AA diameter in the AI group was similar to the AS group (37 ± 1.0 vs 34 ± 0.8 mm, P = 0.06). Forty (69%) AI patients had BAV repair with a mean reduction in VAJ and STJ diameters of 5 and 9 mm compared with prerepair (P < 0.0001). CONCLUSIONS: Despite the absence of aortic aneurysms, aortic annulus and root dimensions are significantly larger in patients with BAV insufficiency compared with stenosis. Alterations in aortic root geometry contribute to the pathophysiology of BAV insufficiency and require correction for a successful repair.

Mapping and ablation of autonomic ganglia in prevention of postoperative atrial fibrillation in coronary surgery: MAAPPAFS atrial fibrillation randomized controlled pilot study.

BACKGROUND: Postoperative atrial fibrillation (POAF) remains common after coronary artery bypass grafting (CABG). Limited efforts to intervene on cardiac autonomic ganglionic plexi (AGP) during surgery show mixed results. In this pilot study, we evaluated the safety and feasibility of map-guided ablation of AGPs during isolated CABG in the prevention of POAF. METHODS: In this pilot study, patients undergoing isolated CABG were randomized into an intervention group (mapping and ablation of AGP [AGP+] group), and a control group (no mapping and ablation [AGP-] group). Using high-frequency stimulation, active AGPs were identified and ablated intraoperatively using radiofrequency. Continuous rhythm monitoring, serum electrolytes, postoperative medications, and postoperative complications were recorded until discharge. RESULTS: Randomization of 47 patients (24 AGP+ and 23 AGP-) resulted in similar baseline characteristics, past medical history, and preoperative medication use. The intervention added a median of 14 minutes to the operative time. The incidence of POAF, mean time in POAF, and median length of stay in hospital were: AGP+ 21% vs AGP- 30%; AGP+ 298 minutes vs AGP- 514 minutes; AGP+ 5 days vs AGP- 6 days; respectively). Postoperative complications, medication use, and daily serum electrolyte profiles were similar in both groups. CONCLUSIONS: This pilot study demonstrated the safety and feasibility of mapping and ablation of AGP during CABG with minimal added operative time. Results further suggest a potentially clinically significant effect on POAF. A multicentre trial is warranted.

An unusual case of cardiogenic shock: common cause from uncommon etiology.

Mechanical complications of an acute coronary syndrome can lead to hemodynamic instability out of proportion to the degree of left ventricular dysfunction. We present the case of a patient with cardiogenic shock secondary to severe mitral regurgitation in the setting of an acutely occluded obtuse marginal artery. Echocardiography and pathologic findings revealed an uncommon cause of anterolateral papillary muscle rupture. Using the unique features of this case, we present a clinical self-assessment exercise highlighting the challenges involved in the management of this type of patient.

The impact of prosthesis-patient mismatch after aortic valve replacement varies according to age at operation.

OBJECTIVES: Age may modify the impact of prosthesis-patient mismatch (PPM) on outcomes after aortic valve replacement (AVR), as physical functioning decreases with age, and comorbidities become more prevalent. We hypothesised that the consequences of PPM in patients 70 years old or older may be less important than in younger patients. METHODS: In total, 707 aortic stenosis patients were followed for a maximum of 17.5 years after AVR. PPM was defined as an in vivo indexed effective orifice area ≤0.85 cm2/m2, and severe PPM as ≤0.65 cm2/m2. RESULTS: In patients less than 70 years of age with normal LV function, the presence of PPM did not significantly alter survival. However, in patients under 70 with LV dysfunction, PPM was associated with decreased survival (HR 2.2; p=0.046). In patients aged 70 years of age or older, PPM had no effect on survival, regardless of LV function. Similarly, PPM was predictive of postoperative congestive heart failure (CHF) in patients under 70 with LV dysfunction (HR 3.6; p=0.046) but not in older patients. Similar results were observed for the composite endpoint of death or CHF. Postoperative LV mass regression was impaired by increased age (p=0.019), and by PPM in patients aged 70 years of age or older with LV dysfunction (by 28.8 g/m2; p=0.026). CONCLUSIONS: The impact of PPM on outcomes after AVR depends on age at operation. PPM in patients under age 70 years with LV dysfunction is associated with decreased survival and lower freedom from CHF. In patients 70 years of age or older, PPM does not impact mortality or symptoms, but impairs LV mass regression beyond that explained by age alone.

Transfemoral Edwards SAPIEN aortic valve implantation through aortofemoral endograft.

We present the case of an 86-year-old woman with an aortobifemoral endograft and porcelain aorta who underwent transfemoral transcatheter aortic valve implantation (TAVI). A femoral cutdown was performed to the left limb of the endograft, and the needle puncture into the graft required sequential incisions and dilation to allow access of the 18F Edwards SAPIEN expandable eSheath (Edwards Lifesciences, Irvine, CA). A 26-mm Edwards SAPIEN transcatheter aortic valve was then successfully deployed. The cutdown was closed and hemostasis was achieved without any iatrogenic narrowing of the graft. Transfemoral TAVI through surgical cutdown with dilation of a femoral endograft is safe and feasible.

Atrial fibrillation therapies: lest we forget surgery.

Atrial fibrillation (AF) is a disease that causes a significant burden in a patient's life. It is a known risk factor for heart failure, stroke, and premature death. The classic therapeutic strategies include rate control, rhythm control, and prevention of stroke. Pharmacological rhythm control with antiarrhythmic drugs can only be achieved 50% of the time while simultaneously subjecting patients to deleterious adverse reactions. With recent advances in catheter ablation procedures, rhythm control can be safely attained anywhere from 57%-80% of the time, depending on the number of repeat catheter ablation procedures that are performed and concomitant use of antiarrhythmic drugs. The Cox-Maze procedure is a technically challenging cut-and-sew atrial lesion set with associated morbidity, yet is still considered the gold standard for rhythm control. Fortunately, this procedure has been modified in efforts to improve the safety profile (shorter cross clamp and cardiopulmonary bypass time), to simplify lesion set creation with newer energy sources, and to perform this operation in a minimally invasive setting. Minimally invasive surgical AF ablation techniques have excellent safety profiles and can achieve rhythm control in up to 90% of patients. In contrast, patients undergoing open heart surgery can undergo either concomitant endocardial or epicardial AF ablation procedures without jeopardizing the surgery along with success rates from 60% to 88%. Thus, there has been an increase in current surgical options for treating AF because of novel approaches and energy sources which yield effective long-term results in patient care and minimize perioperative complications and thereby optimize the risk/benefit ratio profile.

Atrioesophageal fistula in the era of atrial fibrillation ablation: a review.

The purpose of this review is to understand the epidemiology, clinical features, etiopathogenesis, and management of atrioesophageal fistula (AEF) after atrial fibrillation (AF) ablation. The incidence of AEF after AF ablation is 0.015%-0.04%. The principal clinical features include fever, dysphagia, upper gastrointestinal bleeding, sepsis, and embolic strokes. The close proximity of the esophagus to the posterior left atrial wall is responsible for esophageal injury during ablation. Prophylactic proton pump inhibitors, esophageal temperature monitoring, visualization of the esophagus during catheter ablation, esophageal protection devices, and avoidance of energy delivery in close proximity to the esophagus play an important role in preventing esophageal injury. Early surgical repair or esophageal stenting are the mainstay of treatment. Eliminating esophageal injury during AF ablation is of utmost importance in preventing AEF. A high index of suspicion and early intervention is necessary to prevent fatal outcomes.

Functional significance of elevated mitral gradients after repair for degenerative mitral regurgitation.

BACKGROUND: We have observed that elevated mitral gradients can develop in some patients after mitral valve repair for degenerative mitral regurgitation. METHODS AND RESULTS: We screened 275 patients who had mitral valve repair involving >1 leaflet scallop between October 2001 and July 2010. Mitral valve hemodynamics were assessed at rest and at peak exercise using the cycle ergometer. B-type natriuretic peptide levels were measured at rest and after exercise. The patients also performed a 6-minute walk test and short-form 36-Item Health Survey questionnaire. We enrolled 110 patients, with resting mean mitral diastolic gradient of ≤3 mm Hg in 35 patients (group 1) and >3 mm Hg indicative of elevated mitral gradients in 75 patients (group 2). Posterior mitral leaflet plication (P=0.04) and the use of a complete mitral annuloplasty ring (P<0.0001) were associated with elevated mitral gradients. Group 2 patients had larger left atrial volume (P=0.02), higher mitral gradients at peak exercise and higher pulmonary artery systolic pressure at rest and at peak exercise, and lower exercise capacity (101±40 versus 122±51 W; P=0.02). Group 2 patients also had higher B-type natriuretic peptide levels and lower scores in 3 short-form 36-Item Health Survey health concepts. Multivariate regression analyses showed that mitral valve area was an independent predictor of maximum exercise capacity (P=0.003). CONCLUSIONS: After mitral valve repair for degenerative mitral regurgitation, elevated mitral gradients is not uncommon and is associated with worse intracardiac hemodynamics, higher B-type natriuretic peptide levels, lower exercise capacity, and poorer quality of life. Further refinement in the surgical technique may reduce the incidence of this complication.