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Journal and News Scan
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its prevalence is ∼1–2% of the general population, but higher with increasing age and in patients with concomitant heart disease. The Cox-maze III procedure was a groundbreaking development and remains the surgical intervention with the highest cure rate, but due to its technical difficulty alternative techniques have been developed to create the lesions sets. The field is fast moving and there are now multiple energy sources, multiple potential lesion sets and even multiple guidelines addressing the issues surrounding the surgical treatment of AF both for patients undergoing this concomitantly with other cardiac surgical procedures and also as stand-alone procedures either via sternotomy or via videothoracoscopic techniques. The aim of this document is to bring together all major guidelines in this area into one resource for clinicians interested in surgery for AF. Where we felt that guidance was lacking, we also reviewed the evidence and provided summaries in those areas. We conclude that AF surgery is an effective intervention for patients with all types of AF undergoing concomitant cardiac surgery to reduce the incidence of AF, as demonstrated in multiple randomized studies. There is some evidence that this translates into reduced stroke risk, reduced heart failure risk and longer survival. In addition, symptomatic patients with AF may be considered for surgery after failed catheter intervention or even as an alternative to catheter intervention where either catheter ablation is contraindicated or by patient choice.
Seventy-five patients with acute type A aortic dissection with coronary artery dissection were analyzed. Preoperative cardiopulmonary arrest and myocardial ischemia were associated with poor survival outcome whereas early revascularization resulted in a lower frequency of low cardiac output syndrome.
Forty-six patients with acute type A aortic dissection underwent valve-sparing root repair with replacement of all pathological sinuses of Valsalva. The actuarial survival rate at 8 years was 85.5 ± 5.6% with no valve-related events and no reoperation on the proximal aorta/aortic valve during the follow-up
About 3% of 458 TAVI patients required emergent conversion to open surgery with a 30-day mortality of 38.5% in a monocenter analysis. The importance of a interdisciplinary surgical and interventional safety net is emphasized.
A 41 minute presentation on some of the techniques used to address MAC (mitral annular calcification) is followed by an operative video demonstrating several of the techniques. Techniques include mechanical debridement, CUSA debridement, supra-annular MVR, and infra-annular MVR.
uay J et al. – The study aims to determine major adverse outcomes, including the risk of mediastinal reexploration, death, stroke and myocardial infarction, associated with continuing antiplatelet therapy in patients undergoing surgery with cardiopulmonary bypass. Continuing antiplatelet therapy for patients undergoing surgery with cardiopulmonary bypass (CPB) is associated with a low risk for reexploration.
Methods A meta–analysis of parallel randomized, controlled trials published in English. Patients undergoing surgery with cardiopulmonary bypass (CPB). Continuing antiplatelet therapy versus stopping antiplatelet therapy before the surgery. A search was conducted in PubMed, EMBASE, MEDLINE(R), and the Cochrane Central Register of Controlled Trials. Twelve studies were retained for analysis.
Results Continuing antiplatelet drugs for CPB increases the rate of reexploration by a standardized mean difference (SMD) 0.22, 95% confidence interval (CI) 0.06, 0.39; I–square 0%; p value 0.01; classical fail–safe number 5. The number needed to harm (NNTH) is 87 (95% CI 390, 44). There was no statistical difference for death at 30days and 1year, myocardial infarction at 30days, and stroke at 30days. Continuing antiplatelet drugs increases blood loss, SMD 0.27 (95% CI 0.09, 0.45), I–square 73.1%; p=0.003.
Dr Ranucci and collegues have analysed data collected about bleeding and transfusion in over 16,000 patients over a 12 year period. Where major bleeding (>900 ml in 12 hrs) occurred, mortality was increased. Other factors associated with mortality included red cell transfusion and preoperative anemia. This is further evidence of the harmful effects of bleeding and its consequences. It supports close attention being paid to factors that can reduce bleeding - stopping drugs associated with bleeding, and use of protocols to determine and manage excessive blood loss and reduce exposure to blood products.
Prediction of N2 nodal involvement by NSCLC would be valuable in identifying patients who are appropriate for invasive staging. This study modeled pathologic N2 disease in a cohort of N2 negative patients based on clinical staging. 10% were pathologic N2 largely based on findings at the time of lung resection. The only predictor of pathologic N2 on multivariate analysis was the presence of N1 disease on PET.
Yang JH et al. – Limited data are available on comparing the clinical outcomes of coronary artery bypass grafting (CABG) and drug–eluting stent (DES) implantation in patients with reduced left ventricular systolic function in the DES era. DES implantation provides comparable long–term clinical outcomes, except for repeat revascularization, to CABG in patients with coronary artery disease and chronic left ventricular systolic dysfunction.
From January 2003 to December 2010, 953 patients with reduced left ventricular systolic function, defined as a left ventricular ejection fraction <50%, who had undergone percutaneous coronary intervention with DESs (n = 402) or CABG (n = 551) were enrolled in a retrospective, observational registry.
After propensity score matching, the long-term cumulative rate of death was not significantly different between the 2 groups (DES vs CABG 21.3% vs 19.1%; adjusted hazard ratio 1.23, 95% confidence interval 0.57 to 2.66, p = 0.603). However, the rate of major adverse cardiac and cerebrovascular events (35.5% vs 24.1%, adjusted hazard ratio 1.69, 95% confidence interval 1.04 to 2.77, p = 0.036) was higher in the DES group than the CABG group. This was driven by the higher incidence of repeat revascularization in the DES group (11.3% vs 4.3%, adjusted hazard ratio 3.65, 95% confidence interval 1.01 to 10.37, p = 0.018). In conclusion, DES implantation provides comparable long-term clinical outcomes, except for repeat revascularization, to CABG in patients with coronary artery disease and chronic left ventricular systolic dysfunction.
In this retrospective study the authors compare the outcomes between early surgery and watchful waiting in a large group of patients with mitral regurgitation due to flail mitral leaflets and without class I indication for surgery. Those patients who underwent early surgery had lower long term mortality and heart failure risk. There were no differences in the short term outcomes.