The Prognostic Scoring System Establishment and Validation for Chronic Atrial Fibrillation Patients Receiving Modified Cox-Maze IV and Concomitant Cardiac Surgery.

OBJECTIVES: Traditional Cox maze III is the gold standard for treatment of atrial fibrillation (AF). Because of its invasiveness, it has been replaced by a simplified procedure involving radiofrequency ablation of modified Cox maze IV. Although the modified Cox maze IV has the advantages of simplicity and less morbidity, a lower rate of sinus rhythm conversion has been reported. We try to establish a scoring system to predict the outcome of this procedure. METHODS AND RESULTS: The derivation group consisted of 287 patients with structural heart disease and chronic AF who underwent cardiac surgery and modified Cox-maze IV procedure between August 2005 and March 2013. Demographics, clinical and laboratory variables were retrospectively collected as sinus conversional predictors. Overall sinus conversion rate was 75.8%. The parameters of the Soft Markers Scoring system included AF duration, preoperative left atrial (LA) size, rheumatic pathology and postoperative LA remodeling. We compared 80 patients from another hospital between January 2004 and December 2011 as a validation group to evaluate the power of the scoring system. Soft Markers Score indicated a good discriminative power by using the areas under the receiver operating characteristic curve (AUROC: 0.759 ± 0.032). The score was further divided into three groups: low (0-2), intermediate (3-5), and high (6-10), with predicted sinus conversion rates of 92.4%, 74.2%, and 47.8%, respectively. CONCLUSIONS: In patients with chronic AF receiving modified Cox-maze IV procedure, the Soft Markers Score demonstrated good discriminative power of predicting sinus recovery in our patients and applied well to the other validation populations.

Surgical risk and outcome of repair versus replacement for late tricuspid regurgitation in redo operation.

BACKGROUND: Late tricuspid regurgitation after previous cardiac operation remains controversial in terms of when to repair and who will benefit. We reviewed our surgical experiences and stratified the risk factors for death and morbidity. METHODS: From September 2005 to September 2010, 77 consecutive patients (36 men [47%]) underwent redo open heart operations with the tricuspid valve (TV) procedure. Their mean age was 56±13 years (range, 27 to 83 years). TV repair was performed in 44 (57%) and TV replacement in 33 (43%): 23 received bioprostheses; 10 received mechanical prostheses. RESULTS: Fourteen (18%) patients died after the operation. Risk factors of hospital death by multivariate analysis were age (>65 years), preoperative renal insufficiency (creatinine>2 mg/dL), and preoperative severe liver cirrhosis (Child classification C). Compared with the group that underwent TV repair, those who underwent TV replacement tended to have had previous TV operations (46% vs 9%; p<0.001) and preoperative Child class C liver cirrhosis (21% vs 2%; p=0.018). Although in-hospital mortality was insignificant (24% vs 14%; p=0.232), postoperative morbidities of tracheotomy, gastrointestinal bleeding, and late death were higher in the replacement group. CONCLUSIONS: Patients who had previous TV operations and preoperative severe liver cirrhosis were more likely to undergo TV replacement in tricuspid reoperations. Compared with patients in the repair group, patients in the replacement group had higher morbidities and low late survival. Earlier intervention, before decompensated heart failure occurs, is warranted to improve the outcome.

Selective treatment algorithm for mitral valve annuloplasty in nonischemic functional mitral regurgitation.

BACKGROUND: The success rate of mitral annuloplasty (MA) for functional mitral regurgitation (FMR) varies. This study evaluated the effectiveness of this procedure in nonischemic dilated cardiomyopathy (DCM) patients after a selective treatment protocol was followed. METHODS AND RESULTS: This study analyzed 42 patients with nonischemic DCM and FMR (mean regurgitation grade, 3.6 +/- 0.3), aged a mean 56.5 +/- 15 years (range, 25 to 78 years), who underwent MA from April 2003 to December 2007. The analysis excluded patients with coronary artery disease, or mitral leaflets or subvalvular pathologies. All patients had taken maximal medications for at least 3 months and were still in New York Heart Association (NYHA) functional class III to IV (mean, 3.2 +/- 0.4). Mean ejection fraction (EF) was 31.4% +/- 12.9% (range, 8% to 58%), and left ventricular end-diastolic diameter (LVEDD) was 66.0 +/- 8.3 mm (range, 55 to 85 mm). Downsized Carpentier Physio ring (Carpentier-Edwards, Irvine, California) annuloplasty, mean size 26.3 +/- 2.3 (range, 24 to 30), was the preferred procedure. Concomitant procedures included 23 tricuspid valve repairs and 10 Maze operations for atrial fibrillation. Echocardiography was performed at early (12 months; mean 29.5 +/- 13.4 months) follow-up. All late deaths and readmissions were recorded. One (2.4%) in-hospital death occurred due to low cardiac output. Follow-up was completed in 40 of 41 (97.6%) patients (mean duration, 31.9 +/- 16.1; range, 3.9 to 59.2 months). Eight (19.5%) patients were readmitted for heart failure, including 2 late MRs due to ring dehiscence and infective endocarditis. Three of 5 deaths during the follow-up period were attributed to cardiac death. Actuarial survival after 1 and 3 years was 88.9% and 79.2%, respectively. The number of patients treated with beta-blockers increased after operation, from 52.4% to 75.6% (P = .028). NYHA class decreased from 3.2 +/- 0.4 to 1.3 +/- 0.6 (P < .0001). Echo examination revealed left heart reverse remodeling and improved performance in all follow-up time frames. CONCLUSION: This study shows that MA in patients with non-ischemic DCM and FMR is feasible and associated with reasonable short and long term outcomes.

Impact of preexisting organ dysfunction on extracorporeal life support for non-postcardiotomy cardiopulmonary failure.

BACKGROUND: Extracorporeal life support (ECLS) is associated with a high mortality rate in patients with preexisting multiple organ failure. To achieve better outcomes of ECLS in this high risk group, an understanding of the real impact of preexisting organ dysfunction on ECLS-associated mortality is necessary. METHODS: From January 2003 to March 2007, a total of 45 patients (mean age: 48 years) were placed on ECLS for acute cardiopulmonary failure and survived longer than 24h. The medical records of these 45 patients were retrospectively reviewed. The indications for ECLS were acute respiratory distress syndrome (n=23), acute myocarditis (n=10) and acute myocardial infarction (n=12). Organ failure was assessed based on the Sequential Organ Failure Assessment (SOFA) score, which was calculated daily until ECLS termination. The demographic variables, SOFA score variables, and ECLS-related complications, including renal dialysis, severe brain damage and limb ischemia, were analysed. RESULTS: Twenty-seven patients (60%) were weaned from ECLS and 21 (47%) survived to discharge. Multivariate analysis revealed that the necessity of renal dialysis was an independent risk factor associated with failure to wean and non-survival, and the necessity of cardiopulmonary resuscitation (CPR) before ECLS was an independent risk factor for non-survival. Preexisting organ dysfunction, quantified by the pre-ECLS SOFA score, was predictive of survival to discharge. A pre-ECLS SOFA score greater than 14 predicted mortality in this study. CONCLUSIONS: SOFA score is a practical assessment tool and is predictive of ECLS-associated mortality in non-postcardiotomy patients. Patients having cardiac arrest requiring CPR or acute renal failure requiring dialysis before ECLS may have inferior ECLS outcomes.