Open window mapping for redo accessory pathway ablation in Ebstein anomaly.

Accessory pathway ablation in Ebstein anomaly can be significantly more challenging than in structurally normal hearts. An alternative to the conventional approach to mapping APs is to detect points with a high-density mapping catheter based on an automated detection algorithm using open window mapping. It detects the sharpest signal at each point with high-density mapping rather than relying on the origin of the local electrogram to localize the pathway and determine a site for successful ablation. We herein report the first case in literature of a redo-accessory pathway ablation in Ebstein anomaly using this technique.

Surgical redo mitral valve replacement in high-risk patients: The real-world experience.

INTRODUCTION: Redo surgical mitral valve replacement (SMVR) remains the gold standard treatment in patients with a history of mitral valve surgery presenting with recurrent mitral valve pathologies. Whilst this procedure is demanding, it is an inevitable intervention for some indications, such as infective endocarditis, thrombosis, or multivalve procedures. In this study, we aim to evaluate our institutional experience with SMVR on a real-life cohort, identifying the factors that contribute to poor surgical outcomes whilst avoiding selection bias. METHODS: Between March 2012 and November 2020, 58 consecutive high-risk patients underwent a redo SMVR at our institution. The primary endpoints of this study were 30-day and 1-year mortality. The secondary endpoint was the development of any postoperative adverse events. We analyzed and compared the survival in patients undergoing an isolated SMVR and in those that required at least one concomitant procedure. RESULTS: The overall operative, 30-day, and 1-year mortality were 3.4%, 22.4%, and 25.9%, respectively. The mortality in patients undergoing isolated SMVR was significantly lower than in patients requiring concomitant procedures. The multivariable regression model showed that NYHA Class IV, infective endocarditis, and postoperative dialysis were significantly associated with 30-day mortality. Society of Thoracic Surgeons Score, infective endocarditis, concomitant procedures, and mechanical valve implantation appeared to predict long-term mortality. CONCLUSION: This study illustrates that SMVR after prior mitral valve surgery presents a demanding procedure with high operative risk, significant mortality, and morbidity. Whilst this procedure is inevitable for some indications, a careful patient selection and risk stratification provides acceptable surgical results in this cohort.

Recurrent Atrial Fibrillation Ablation after Initial Successful Pulmonary Vein Isolation.

BACKGROUND: Pulmonary vein isolation (PVI) is an effective treatment option for patients with symptomatic atrial fibrillation (AF). However, the electrical recovery of pulmonary veins (PVs) is the main trigger for AF recurrences. This study investigates the characteristics of patients admitted for redo AF ablation, the PV reconnection rates depending on previous ablation modalities and the impact of different ablation strategies for redo procedures. METHODS: Consecutive patients undergoing first redo AF ablation were included. Patients were grouped according to the electrical recovery of at least one PV. The impacts of the technique for first AF ablation on PV reconnection rates and patients with and without PV reconnection were compared. Different ablation strategies for redo procedures were compared and its recurrence rates after a mean follow-up of 25 ± 20 months were investigated. RESULTS: A total of 389 patients (68 ± 10 years; 57% male; 39% paroxysmal AF) underwent a first redo. The median time between the first and redo procedure was 40 ± 39 months. Radiofrequency was used in 278 patients, cryoballoon was used in 85 patients and surgical AF ablation was performed on 26 patients. In total, 325 patients (84%) had at least one PV reconnected, and the mean number of reconnected PVs was 2.0 ± 1.3, with significant differences between ablation approaches (p for all = 0.002); this was mainly due to differences in the left inferior PV and right superior PV reconnections. The presence of PV reconnection during redo was not associated with better long-term success compared to completely isolated PVs (67% vs. 67%; log-rank p = 0.997). Overall, the different ablation strategies for redos were comparable regarding AF recurrences during follow-up (p = 0.079), with the ablation approach having no impact in the case of left atrial low voltage or without. CONCLUSIONS: PV reconnections after initial successful PVI are common among all techniques of AF ablation. Long-term rhythm control off antiarrhythmic drugs was possible in 2/3 of all patients after the redo procedure; however, different ablation strategies with extra-PV trigger ablation did not improve long-term success. Patients with recurrent AF after PVI constitute a challenging group of patients.

Repairing left ventricular outflow after aortic composite graft pseudoaneurysm: case report.

BACKGROUND: We present a technique for aortic composite graft implantation after left ventricular outflow tract destruction due to its proximal dehiscence. CASE PRESENTATION: A 53-year-old gentleman with rheumatoid arthritis and history of Bentall procedure, presented with heart failure symptoms for the past month. Transthoracic echocardiogram identified prosthetic valve dysfunction, and transesophageal echocardiogram detected that its mechanism was by dehiscence. After excluding infectious etiology, it was hypothesized that the cause was the absence of endothelialization, owing to immunosuppressive therapy. Repair surgery was successful, and 2 years later, the patient is fully asymptomatic. CONCLUSIONS: Immunosuppressive drugs are a rare cause of aortic composite graft dehiscence. Left ventricular outflow tract surgical reconstruction remains an extremely complex and high-risk intervention, with the need for reentry into cardiopulmonary bypass and graft proximal segment implantation in a lower position.

Second-generation cryoballoon ablation for recurrent atrial fibrillation after an index cryoballoon procedure: a staged strategy with variable balloon size.

PURPOSE: Currently, information on the optimal approach of redo procedures for paroxysmal atrial fibrillation (PAF) is limited. Radiofrequency ablation is the preferred technique, with reported success rates of 50-70% at 1-2 years, whereas only few reports exist on redo cryoballoon (CB) ablations. We describe outcomes on a systematic approach of repeat procedures with a second-generation cryoballoon (CB-2) after a successful index CB ablation. METHODS: Cohort study of 40 consecutive patients with recurrent PAF (55% male), median CHA2DS2-VASc score 1 (IQR 0-3). Per protocol, a staged variable balloon size strategy was followed with a different balloon size during the redo as compared to the index procedure. Minimal follow-up was 12 months (median 17 months [IQR 14-39]). RESULTS: Overall, 120 pulmonary veins (PVs) (75%) showed chronic isolation: 64% (41/64) for first-generation cryoballoon (CB-1) and 82% (79/96) for CB-2 index procedures, respectively (p = 0.01). The overall mean number of reconnected PVs per patient was 1.0 (40/40): 1.4 for CB-1 and 0.7 for CB-2 index procedures (p = 0.008). Phrenic nerve palsies (n = 7) resolved before the end of the procedure. At 1 year, 70% of patients were free of recurrent AF. In multivariate analysis, the only independent predictor of recurrence was the number of prior cardioversions. CONCLUSIONS: A systematic approach of repeat procedures with a CB-2 using a different balloon size than during the index CB ablation is safe, with acceptable 1-year outcomes. Future comparative studies on the optimal redo technique and approach are warranted to further improve rhythm control in AF.

Redo Laparoscopic Gastric Bypass: One-Step or Two-Step Procedure?

BACKGROUND: The adjustable gastric band (AGB) is a bariatric procedure that used to be widely performed. However, AGB failure-signifying band-related complications or unsatisfactory weight loss, resulting in revision surgery (redo operations)-frequently occurs. Often this entails a conversion to a laparoscopic Roux-en-Y gastric bypass (LRYGB). This can be performed as a one-step or two-step (separate band removal) procedure. METHODS: Data were collected from patients operated from 2012 to 2014 in a single bariatric centre. We compared 107 redo LRYGB after AGB failure with 1020 primary LRYGB. An analysis was performed of the one-step vs. two-step redo procedures. All redo procedures were performed by experienced bariatric surgeons. RESULTS: No difference in major complication rate was seen (2.8 vs. 2.3 %, p = 0.73) between redo and primary LRYGB, and overall complication severity for redos was low (mainly Clavien-Dindo 1 or 2). Weight loss results were comparable for primary and redo procedures. The one-step and two-step redos were comparable regarding complication rates and readmissions. The operating time for the one-step redo LRYGB was 136 vs. 107.5 min for the two-step (median, p < 0.001), excluding the operating time of separate AGB removal (mean 61 min, range 36-110). CONCLUSIONS: Removal of a failed AGB and LRYGB in a one-step procedure is safe when performed by experienced bariatric surgeons. However, when erosion or perforation of the AGB occurs, we advise caution and would perform the redo LRYGB as a two-step procedure. Equal weights can be achieved at 1 year post redo LRYGB as after primary LRYGB procedures.