1-year outcomes of patients implanted with the Perceval sutureless valve: the Japanese post-marketing surveillance study.

Sutureless offers an alternative to standard valves in surgical aortic valve replacement (SAVR). We sought to confirm the efficacy and safety of the Perceval sutureless valve in Japanese patients. Prospective observational study of 204 patients who underwent SAVR with Perceval at 19 sites in Japan between March and December 2019. The primary outcomes were 30-day mortality and postoperative complications; the secondary outcome was all-cause mortality at 1 year. Efficacy outcomes were changed in New York Heart Association (NYHA) class, pressure gradients, effective orifice area (EOA), EOA indexed to body surface area (EOAi) and severity of aortic regurgitation. Mean age was 77.7 years, 62.7% were female. Procedural success rate was 99.0%. The median cross-clamp and cardiopulmonary bypass times were 68.0 and 108 min. Perceval size S and M were implanted in 95 (46.6%) and in 76 (37.3%) of patients, respectively. The 30-day and late mortality rate were 0.5% and 4.4%, while the new permanent pacemaker implantation rate was 4.4%. Mean pressure gradient was 13.0 mmHg at discharge, reaching 11.0 mmHg at 1 year; while the mean EOA was 1.5 cm2 at discharge remaining stable up to 1 year. No moderate or severe leakages were present at discharge or at 1 year. NYHA class improved by ≥ 1 level in 55.1% of the patients at discharge and in 69.4% of the patients at 1 year. 1-year outcomes of SAVR with the Perceval sutureless valve in Japanese patients were favorable. This valve offers a promising alternative to conventional biological AVR in this Japanese population.

Sutureless Valve in Bicuspid Aortic Stenosis: Modified Technique and Midterm Outcome.

BACKGROUND: The sutureless valve has gained popularity for degenerative aortic valve stenosis but not congenital bicuspid aortic valve (BAV) due to anatomical challenges. We reviewed our modified implant techniques for patients with BAV. METHODS: From June 2015 to June 2019, 66 patients with aortic valve stenosis were treated with the Perceval sutureless valve, 20 of whom had BAV. The demographics, type of BAV (the Sievers classification), and associated pathologies, surgical outcomes, and midterm hemodynamics were recorded. RESULTS: The median age was 64 (range: 49-81) years and the Society of Thoracic Surgeons score was 2.186 (range: 0.407-6.384). Annular plication was performed in 9 (75%) of 12 type 0 and 3 (37.5%) of 8 type I, with implanted valve sizes of M, L, and XL in 6, 10, 4 cases, respectively. Three patients, all type 0 in the initial learning periods, required intraoperative redeployment due to malposition of the valve. The final implant was successful in all without conversion to traditional prosthesis. The median extubation time was 4 hours and the durations of intensive care unit and hospital stay were 1 and 6 days. At a median follow-up of 46 (23-72) months, there was one late mortality due to hemorrhagic stroke sequel. The last echo revealed none had more than mild paravalvular leakage and the mean transvalvular pressure gradient remained stable at 9.70 (range: 6.94-15.0) mm Hg. CONCLUSION: The sutureless valve can achieve satisfactory outcomes in BAV without paravalvular leakage and excellent hemodynamics. It may serve as the benchmark for transcatheter aortic valve implantation in this unique population.

Comparison of treatment outcomes between convergent procedure and catheter ablation for paroxysmal atrial fibrillation evaluated with implantable loop recorder monitoring.

INTRODUCTION: While catheter ablation (CA) is an established treatment for symptomatic paroxysmal atrial fibrillation (AF), convergent epicardial and endocardial ablation procedure (CVP) has been primarily used to treat persistent AF. The aim of this single-center, prospective, randomized study was to compare treatment efficacy of CA and CVP in paroxysmal AF patients by monitoring AF, atrial tachycardia (AT), and atrial flutter (AFL) recurrence with Implantable Loop Recorder (ILR). METHODS AND RESULTS: Fifty patients (74% male) with history of paroxysmal AF were randomized between CA and CVP. Outcomes were determined by ILRs; every episode of AF/AT/AFL lasting 6 minutes or more was defined as a recurrence. AF burden (AFB) and required AF reinterventions (cardioversions and repeat ablations) were quantified after a 3-month blanking period. Total procedural (266 ± 44 vs. 242 ± 39 minutes) and ablation duration (52 ± 10 vs. 48 ± 12 minutes) was similar in both groups. Recurrence of AF/AT/AFL was more likely in the CA group compared to the CVP group (OR 3.78 (95% CI (1.17, 12.19), P  =  0.048)). During the follow-up period (mean 30.5 ± 6.9 months), higher AF burden and more reinterventions for recurrent AF were recorded in the CA group. There were more periprocedural complications in the CVP group (12.5%) compared to the CA group (0%). CONCLUSION: Treatment of paroxysmal AF with CVP showed less arrhythmia recurrence compared to CA. In addition, patients after CVP had fewer reinterventions and lower AF burden, but more periprocedural complications.

Improvement of Atrial and Ventricular Remodeling with Low Atrial Fibrillation Burden after Hybrid Ablation of Persistent Atrial Fibrillation.

BACKGROUND: An endoscopic transdiaphragmatic epicardial radiofrequency ablation procedure combined with percutaneous endocardial radiofrequency ablation--a hybrid procedure--is a potentially curative treatment option for patients with persistent atrial fibrillation (AF). Long-term effects of arrhythmia elimination on atrial and ventricular remodeling are not completely understood. Therefore, the aim of our study was to quantify echocardiographic structural and functional changes of the left atrium (LA) and left ventricle (LV) following a hybrid procedure. METHODS AND RESULTS: Thirty-seven consecutive patients with symptomatic drug refractory persistent AF underwent a hybrid procedure to achieve complete pulmonary vein and LA posterior wall electrical isolation. AF burden was measured using an insertable electrocardiographic (ECG) monitor. Patients were divided into responders to ablation and nonresponders according to postoperative AF burden at 12-month follow-up (responder < 0.5% vs nonresponder ≥ 0.5%). Median AF burden was 0.32 (0.04-27.5)% for all patients. In responders (19/37 patients), significant echocardiographic reduction of LA volume index from 47 to 41 mL/m(2) (P < 0.05) and improvement of LA function parameters (LA stiffness from 73.3 to 41.3 [P < 0.05], LA emptying fraction from 21% to 45% [P < 0.05], LA global longitudinal strain from 11.2% to 18.8% [P < 0.5]) was documented. In addition, LV systolic function significantly improved in comparison with nonresponders. CONCLUSION: Hybrid ablation of persistent AF achieved stable sinus rhythm in a significant proportion of patients, as evidenced by continuous ECG monitoring, resulting in important LA and LV reverse remodeling after 12 months.

A first-in-man study of the role of flexible robotics in overcoming navigation challenges in the iliofemoral arteries.

OBJECTIVE: Current interventional techniques rely heavily on operator familiarity with catheters and wires and on physician skills in effectively navigating through and managing target lesions. A novel robotic technology allows endovascular specialists to remotely control catheter tip deflection and advancement and to coordinate manipulation of currently available wires. The aim of this study was to successfully demonstrate feasibility and safety of navigation to and treatment of iliac and femoral artery lesions using Hansen Medical's vascular control catheter (VCC). METHODS: A total of 20 limbs were included in this analysis for a first-in-man trial of the VCC and vascular catheter control system. The local Institutional Review Board approved the trial, and all patients included had symptomatic femoropopliteal occlusive disease. Preoperative imaging was available on all patients. Target lesions in the contralateral superficial femoral artery ranged from mild stenosis to chronic total occlusions (TransAtlantic Inter-Society A through D). Exclusion criteria included previously treated iliac and femoral lesions in the symptomatic leg and a body mass index >35. The operators comprised three experienced interventionalists (two vascular surgeons and an interventional radiologist) and a novice (cardiac surgeon). The primary end point of the study was to demonstrate successful cannulation of the target vessel (ie, navigation to the lesion with wire and catheter) with the Hansen VCC, with no device-related serious adverse events. Secondary end points were to assess the ability to treat lesions using the flexible catheter defined by successful insertion of a guidewire, angiography of the target vessel, delivery of balloon, and/or stent. Procedure times and radiation delivered were analyzed for the group and by operator, and t-test was performed to determine statistical significance. Complications were assessed by clinical examination and ultrasound. RESULTS: Lesions were successfully and safely cannulated in all limbs treated. The VCC performed as designed in all cases. All interventionalists, regardless of experience, navigated the VCC with ease. However, statistically significant differences in navigation time and radiation per case were observed between the experienced and inexperienced interventionalists. There were no access site complications (hematoma, thrombosis, pseudoaneurysm) as evaluated by ultrasound. CONCLUSIONS: This initial experience in flexible robotics demonstrates that this technology is both efficacious and safe in the arterial tree. Although robotics provides superior maneuverability compared with current techniques, endovascular experience is crucial to taking full advantage of the extra capabilities. Valuable future considerations will include off-the-wall (center lumen) navigation with three-dimensional imaging.

Influence of type of aortic valve prosthesis on coronary blood flow velocity.

BACKGROUND: Severe aortic valve stenosis is associated with high resting and reduced hyperemic coronary blood flow. Coronary blood flow increases after aortic valve replacement (AVR); however, the increase depends on the type of prosthesis used. The present study investigates the influence of type of aortic valve prosthesis on coronary blood flow velocity. METHODS: The blood flow velocity in the left anterior descending coronary artery (LAD) and the right coronary artery (RCA) was measured intraoperatively before and after AVR with a stentless bioprosthesis (Sorin Freedom Solo; n = 11) or a bileaflet mechanical prosthesis (St. Jude Medical Regent; n = 11). Measurements were made with an X-Plore epicardial Doppler probe (Medistim, Oslo, Norway) following induction of hyperemia with an adenosine infusion. Preoperative and postoperative echocardiography evaluations were used to assess valvular and ventricular function. Velocity time integrals (VTI) were measured from the Doppler signals and used to calculate the proportion of systolic VTI (SF), diastolic VTI (DF), and normalized systolic coronary blood flow velocities (NSF) and normalized diastolic coronary blood flow velocities (NDF). RESULTS: The systolic proportion of the LAD VTI increased after AVR with the St. Jude Medical Regent prosthesis, which produced higher LAD SF and NSF values than the Sorin Freedom Solo prosthesis (SF, 0.41 ± 0.09 versus 0.29 ± 0.13 [P = .04]; NSF, 0.88 ± 0.24 versus 0.55 ± 0.17 [P = .01]). No significant changes in the LAD velocity profile were noted after valve replacement with the Sorin Freedom Solo, despite a significant reduction in transvalvular gradient and an increase in the effective orifice area. AVR had no effect on the RCA flow velocity profile. CONCLUSION: The coronary flow velocity profile in the LAD was significantly influenced by the type of aortic valve prosthesis used. The differences in the LAD velocity profile probably reflect differences in valve design and the systolic transvalvular flow pattern.

The Sutureless Biological Bentall Procedure: A New Technique to Create a Modular Valve-Conduit Construct.

The Perceval sutureless valve (Corcym, Saluggia, Italy) has been effectively adopted by surgeons for the treatment of degenerative aortic valve stenosis. Its simplified true sutureless implantation technique has proven useful for minimally invasive cases, but the use of Perceval as part of more complex root replacement has not previously been described. We present a novel technical modification to the manufactured biologic Bentall, called the sutureless biological Bentall. This technique allows for a true modular valve-conduit construction that will simplify future reintervention.

Low rate of atrial fibrillation recurrence verified by implantable loop recorder monitoring following a convergent epicardial and endocardial ablation of atrial fibrillation.

OBJECTIVE: Evaluate long-term outcomes in patients undergoing the Convergent procedure (CP) for the treatment of atrial fibrillation (AF). BACKGROUND: The CP provides a multidisciplinary approach, combining endoscopic creation of epicardial linear lesions followed by endocardial mapping and ablation and targets persistent and longstanding persistent AF patients who are at increased risk of heart failure, stroke, and mortality. METHODS: Outcomes from a prospective nonrandomized study were recorded for consecutive patients by interrogation of implanted Reveal monitors. Rhythm status and AF burden were quantified 6-24 months postprocedure, and compared relative to AF type, gender, age, body mass index, left atrial size, left ventricular ejection fraction, and congestive heart failure, hypertension, age >75 years, age between 65 and 74 years, stroke/TIA/TE, vascular disease (previous MI, peripheral arterial disease or aortic plaque), diabetes mellitus, female (CHA(2) DS(2) VASc). RESULTS: A total of 50 patients were enrolled with 94% having persistent or longstanding persistent AF. There were 2 atrioesophageal fistulas reported. In one patient, the fistula resulted in death at 33 days postprocedure; in the second, the fistula was surgically repaired but patient died 8 months postprocedure from a CVI. After CP, 95% of patients were in sinus rhythm at 6-month follow-up; 88% at 12 months; and 87% at 24 months. The median AF burden recorded with Reveal XT monitors was 0.0%, 0.1%, and 0.1% at 6, 12, and 24 months with 81%, 81%, and 87% of patients reporting a burden less than 3%, respectively. CONCLUSION: Using 24 × 7 continuous loop recording, the CP demonstrated success in treating persistent and longstanding persistent AF patients. Endocardial mapping and catheter ablation with diagnostic confirmation of procedural success complemented the endoscopic creation of epicardial linear lesions in restoring sinus rhythm.

A Common Polymorphism in the MTHFD1 Gene Is a Modulator of Risk of Congenital Heart Disease.

Several environmental and genetic factors may influence the risk of congenital heart defects (CHDs), which can have a substantial impact on pediatric morbidity and mortality. We investigated the association of polymorphisms in the genes of the folate and methionine pathways with CHDs using different strategies: a case-control, mother-child pair design, and a family-based association study. The polymorphism rs2236225 in the MTHFD1 was confirmed as an important modulator of CHD risk in both, whereas polymorphisms in MTRR, FPGS, and SLC19A1 were identified as risk factors in only one of the models. A strong synergistic effect on the development of CHDs was detected for MTHFD1 polymorphism and a lack of maternal folate supplementation during early pregnancy. A common polymorphism in the MTHFD1 is a genetic risk factor for the development of CHD, especially in the absence of folate supplementation in early pregnancy.

Thrombocytopenia following implantation of the stentless biological sorin freedom SOLO valve.

BACKGROUND AND AIM OF THE STUDY: Stentless biological valves have proven advantages in hemodynamic performance and left ventricular function compared to stented biological valves. Following a marked postoperative fall in the platelet count of patients after implantation of the Freedom SOLO valve, the study aim was to confirm clinical observations that this effect was more severe in patients receiving Freedom SOLO valves than in those receiving St. Jude Medical (SJM) mechanical aortic valves. METHODS: Preoperative and postoperative platelet counts were compared in two groups of patients who underwent aortic valve replacement (AVR) without any concomitant procedures between January and December 2007. Patients received either a Freedom SOLO valve (n = 28) or a SJM mechanical valve (n = 41). Mean values of platelet counts were compared using three multiple linear regression models. RESULTS: Platelet counts were significantly lower in the Freedom SOLO group than in the SJM group from the first postoperative day (POD 1) up to POD 6 (p <0.001). In three patients of the Freedom SOLO group the platelet count fell below 30x10(9)/l, while the lowest level in the SJM group was 75x10(9)/l. Based on multiple linear regression models, the type of valve implanted had a statistically significant influence on postoperative platelet counts on POD 1, POD 3, and POD 5 (p <0.001). CONCLUSION: Whilst the reason for this phenomenon is unknown, the use of consistent monitoring should prevent severe falls in platelet count from becoming dangerous for the patient. Further studies are required to investigate the phenomenon since, despite a shorter cardiopulmonary bypass time, the fall in platelet count was more profound in the Freedom SOLO group.

Anatomical circumstances and aortic cross-clamp time in minimally invasive aortic valve replacement.

OBJECTIVES: Prolonged operative times, potentially leading to increased morbidity, are a possible drawback of minimally invasive aortic valve replacement. The aim of this study was to assess the impact of anatomical circumstances in the chest on aortic cross-clamp time. METHODS: This retrospective study included 68 patients who underwent minimally invasive aortic valve replacement with the Perceval sutureless valve via right-anterior thoracotomy or with ministernotomy. Anatomical variables were measured during preoperative computer tomography scans. RESULTS: Aortic cross-clamp time was shorter in those having ministernotomy than in the right-anterior thoracotomy group (41.1 vs 52.3 min; P < 0.001). Cardiopulmonary bypass (CPB) time was not significantly different between groups (P = 0.09). A multivariable linear-regression model (P = 0.018) showed the aortic dextroposition variable to be a significant predictor of the aortic cross-clamp method and CPB times (P = 0.005 and P = 0.003) independent of other anatomical variables in the right thoracotomy group (10 mm deviation from optimal position prolonged the times for 240 and 600 s). For the whole cohort, a correlation between aortic valve dimensions and operative times was found (P = 0.046, P = 0.009). A linear-regression model (P = 0.046) predicted 90 s longer aortic cross-clamp time and 231 s longer CPB time for every 1 mm smaller aortic valve diameter. CONCLUSIONS: The anatomical variables are associated with the operative times in minimally invasive aortic valve replacement with sutureless valves. Considering this association, preplanning the procedure is recommended.

Successful Aortic Valve Replacement With Perceval Bioprosthesis for Aortic Stenosis With Membranous Ventricular Septum Aneurysm.

Membranous ventricular septum aneurysm (MVSA) is extremely rare, especially when coexisting with aortic stenosis (AS), and reports regarding the available treatment for MVSA with AS are limited. Aortic valve replacement (AVR) can be challenging because of anatomical reasons. In this case report, a patient with MVSA and severe AS was treated with AVR with the sutureless Perceval bioprosthesis. After implantation, no paravalvular leakage was detected in echocardiography, and no other postoperative complications were observed. Postoperative electrocardiography-gated computed tomography revealed no contrast enhancement for MVSA. The MVSA was closed by the Perceval bioprosthetic valve. Thus, patients with simultaneous MVSA and AS may be effectively treated with AVR using a Perceval bioprosthesis.

Modified Implant Technique of Perceval Sutureless Valve in Congenital Type 0 Bicuspid Valve Stenosis.

The Perceval sutureless valve has gained in popularity for treating degenerative aortic valve stenosis but not for congenital type 0 bicuspid aortic valve owing to anatomic challenges. We modified implant techniques following the four principles of ECHO-an acronym for elasticity, circularity, height, and orientation-to prevent paravalvular leakage and malposition.

Comparison of serum troponin I and plasma lactate concentrations in arrested versus beating-heart aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: The study aim was to monitor serum troponin and plasma lactate concentrations in conventional aortic valve replacement compared to a beating-heart technique, perfused via the coronary sinus. METHODS: In this prospective, non-randomized study, which was conducted between 2003 and 2009, a total of 35 patients was allocated to two groups, based on the method of myocardial protection. The groups did not differ significantly in terms of preoperative parameters. Levels of lactate were measured in all 35 patients, and of troponin I in 20 patients, in consecutive samples during and after surgery. RESULTS: There was no in-hospital mortality and no serious complications among patients. The cardiopulmonary bypass and aortic cross-clamp times were each significantly shorter and lactate and troponin I concentrations higher, in the beating-heart group. No perioperative myocardial infarction was observed. CONCLUSION: Although good clinical results were observed in patients operated when using the beating-heart technique with retrograde coronary sinus perfusion, postoperative serum levels of troponin I were higher than in patients operated on using a conventional technique. Although troponin I is considered a prognostic factor for postoperative mortality, this parameter applies only to selected patients rather than for widespread use.

Ex vivo study of altered mitral apparatus geometry in functional mitral regurgitation.

BACKGROUND: Functional mitral regurgitation (FMR) in patients with ischemic or nonischemic cardiomyopathy has been related to several overlapping factors. In vivo, these factors are very difficult to study independently of dynamic processes, such as ventricular wall motion or annular contraction. We developed an ex vivo left ventricular model that allows independent variations of annular size, papillary muscle (PM) position, and transvalvular pressure. We tested the hypothesis that FMR is a consequence of an altered balance of the tethering and coapting forces acting on leaflets. METHODS: Measurements were made on 4 excised porcine valves under physiological pressures and flows. Testing was done by systematically varying annular size and PM position. We evaluated 3 annulus sizes (normal, 15% dilation, and 25% symmetric dilation) by sequentially displacing PMs in lateral, posterolateral, and apicoposterolateral positions. RESULTS: Our results show that annular dilation is a major determinant of mitral regurgitation. Displacement of PMs also affects the regurgitant flow, but to a much lesser degree. Apical and posterolateral PM displacement increases regurgitant flow to a higher degree than isolated lateral or posterolateral displacement. Increased transvalvular pressure decreases regurgitant flow for any given geometric configuration of the mitral valve (MV). CONCLUSION: Clinically observed pathologic configurations of the MV can be accurately reproduced ex vivo by altering the tethering and coapting forces acting on mitral leaflets. Our results support the mechanism of mitral regurgitation in which increased tethering forces and decreased coapting forces acting on the leaflets create the regurgitant orifice.

Early extubation and fast-track anesthetic technique for endoscopic cardiac surgery.

OBJECTIVE: In this retrospective study, we evaluated the "fast-track" recovery protocol for endoscopic Port Access (PA) (Edwards Lifesciences) heart procedures. We also determined which factors and variables are important for the success of immediate extubation at the end of the operation while the patient is still in the operating room (OR). METHODS: In the study, we included 104 patients scheduled for PA heart surgery under cardioplegic arrest. All patients were marked before surgery for the fast-track recovery protocol. If the patients fulfilled the extubation criteria within 10 to 15 minutes after the end of operation, they were extubated in the OR (OR group); the others were transferred to the intensive care unit (ICU) (ICU group) and extubated later. The 2 groups were compared with respect to preoperative and intraoperative variables that could influence early extubation, postoperative complications, duration of ICU stay, and hospital stay. RESULTS: Seventy-eight patients (75%) were extubated in the OR. The patients from the OR group had significantly lower EuroSCOREs than the patients from the ICU group (P = .025). The variables of vital capacity (P = .001) and forced expiratory volume in the first second (FEV1) (P < .001) were significantly higher preoperatively in the OR group than in the ICU group. There were no significant differences between the groups with respect to intraoperative characteristics. Postoperative complications were fewer in the OR group. The mean duration of ICU stay was significantly shorter in the OR group than in the ICU group (P < .001). CONCLUSIONS: Immediate extubation in the OR after endoscopic cardiac procedures is safe and possible for the majority of patients. The preoperative patient characteristics of Euro-SCORE, vital capacity, and FEV1 influence the success of ontable extubation.

The analgesic efficacy of local anesthetics for the incisional administration following port access heart surgery: bupivacaine versus ropivacaine.

BACKGROUND: To avoid large dose opioids, the authors investigated an alternative method for postoperative pain relief after Port Access cardiac surgery. METHODS: Out of 104 patients who underwent Port Access heart surgery, 78 patients who were extubated in the operating room were enrolled in the retrospective study. The standardized fast track cardiac anesthesia was used for all patients, and the catheter was placed in the surgical wound at the end of the operation. Analgesia was started with a bolus of bupivacaine (B group) or ropivacaine (R group) through the catheter and followed by continuous infusion of local anesthetic. The variables recorded were visual analogue scale (VAS) at extubation and during the first 24 hours, additional requirements of local anesthetic (LA), and opioid analgetic. Possible complications that could be connected with the catheter in the wound or with the administration of LA were recorded as well. RESULTS: There was no statistical difference between the R and B groups in mean pain score at extubation and in the first 24 hours. The groups were also comparable concerning the need for bolus application of the LA and opioid analgetic. The microbiological analysis of 9 randomly chosen catheter tips from both groups was sterile. CONCLUSION: Both local anesthetics, ropivacaine and bupivacaine, are equally effective for pain relief after Port Access cardiac surgery. The catheter in surgical incision and application of LA through it does not increase the risk for wound infection and does not interfere with wound healing.

Coronary artery bypass grafting with and without concomitant epicardial cardiac resynchronization therapy in patients with ischemic cardiomyopathy: a randomized study.

BACKGROUND: Epicardial implantation of a cardiac resynchronization therapy (CRT) system during coronary artery bypass grafting (CABG) may be an additional treatment method for improving left ventricle (LV) systolic function and dyssynchrony in patients with ischemic heart failure. OBJECTIVE: The objective was to compare the long-term results in patients with severe ischemic heart failure who underwent CABG alone or CABG combined with concomitant epicardial implantation of a CRT system. METHODS: One hundred sixty-four consecutive patients with severe ischemic heart failure and LV dyssynchrony were enrolled into 2 groups: CABG alone (n = 80) and epicardial CRT implantation during CABG (CABG + CRT) (n = 84). This prospective, randomized, and single-blind study was designed to compare clinical and echocardiography data after 6, 12, and 18 months of follow-up. RESULTS: In the CABG group, LV systolic function, dyssynchrony signs, and quality of life did not change postoperatively, compared with preoperative data. In contrast, these parameters significantly improved in the CABG + CRT group. The 2 treatment groups did not differ with respect to postoperative improvement in Canadian Cardiovascular Society class (P = .68). The improvement in the New York Heart Association functional class was much more pronounced in the CABG + CRT group than in the CABG group (P = .029). In the CABG group, 21 patients (26.2%) had died by the 18-month follow-up, compared with 9 patients (10.7%) in the CABG + CRT group (P = .012, log-rank test). CONCLUSION: Epicardial implantation of a CRT system concomitantly with CABG facilitates the early postoperative period, improves LV systolic function, improves the quality of life, and decreases LV dyssynchrony. Moreover, mortality in the CABG + CRT group was significantly lower than in the CABG group.

The convergent procedure: a multidisciplinary atrial fibrillation treatment.

BACKGROUND: Persistent atrial fibrillation (AF) and long-standing persistent AF (LSPAF) are difficult to treat. Epicardial surgical and percutaneous catheter ablations have lower success rates in these patients. The convergent procedure, an endoscopic transdiaphragmatic ablation procedure with conventional percutaneous endocardial ablation, is examined. METHODS: Twenty-eight patients with persistent AF or LSPAF underwent the convergent procedure. All underwent combined surgical epicardial radiofrequency ablation and electrophysiological transseptal endocardial ablation to electrically isolate the 4 pulmonary veins, to exclude the posterior left atrium, to ablate the coronary sinus, and to confirm block at the cavotricuspid isthmus. Follow-up was with 24-hour Holter monitoring at 3 months, and 24-hour or 7-day monitoring at 6 and 12 months. RESULTS: The mean duration of the procedure was 187 minutes (102 surgical ablation minutes; 85 endocardial ablation minutes). The mean total fluoroscopy time was 35.1 minutes. Two patients developed symptomatic pericardial effusions requiring percutaneous drainage, and 1 patient has demonstrated phrenic nerve paresis. There were no deaths. At 3 months, 87% were in sinus rhythm, and 43% were free of AF and antiarrhythmic medications (AADs). At 6 months, 76% were free from AF and AADs. CONCLUSION: The convergent procedure effectively combines surgical and electrophysiological AF expertise to provide a viable treatment option to patients with persistent AF or LSPAF. Long-term follow-up is under way.

Cardiac effects of postconditioning depend critically on the duration of reperfusion and reocclusion episodes.

OBJECTIVE: The objective of the present study was to evaluate the effects of ischemic postconditioning on left ventricular function in isolated rat hearts. METHODS: The hearts of 24 Wistar rats were were isolated, perfused immediately, and distributed into 3 groups: GI, control (n = 8); GII, three 10-second cycles of postconditioning (n = 8); and GIII, three 30-second cycles of postconditioning (n = 8). After a 15-minute stabilization period, all hearts underwent 20 minutes of global ischemia following 20 minutes of reperfusion. At times t0 (control), t5, t10, t15, and t20 (0, 5, 10, 15, and 20 minutes of reperfusion, respectively), we recorded the heart rate, coronary flow, systolic pressure, +(dP/dt)max (maximum speed of increase in the left ventricular pressure), and -(dP/dt)max (maximum speed of decrease in the left ventricular pressure). Data were analyzed by a 1-way analysis of variance, followed by the Tukey test; a P value <.05 was considered statistically significant. RESULTS: There were no significant differences among the analyzed groups with respect to heart rate, coronary flow, systolic pressure, and -(dP/dt)max (P > .05); however, statistically significant differences in +(dP/dt)max between GII and GI and between GII and GIII occurred at t20 (GI, 1409.0 +/- 415.1 mm Hg/s; GII, 1917.3 +/- 403.0 mm Hg/s; GIII, 1344.8 +/- 355.8 mm Hg/s) (GII versus GI, P = .04; GII versus GIII, P = .02). CONCLUSION: Ischemic postconditioning with three 10-second cycles of reperfusion/reocclusion was demonstrated effective for preserving +(dP/dt)max in isolated rat hearts that underwent 20 minutes of ischemia following 20 minutes of reperfusion.