Preoperative Atrial Fibrillation Research Articles

Pericardiectomy using ultrasonic scalpel in patients with constrictive pericarditis.

Pericardiectomy using ultrasonic scalpel is the effective operative treatment of chronic pericarditis. However, no consecutive case series of radical pericardiectomy using ultrasonic scalpel has been reported. We retrospectively reviewed the records of 10 patients who underwent radical pericardiectomy using ultrasonic scalpel between April 2015 and March 2024. Preoperative and postoperative variables were reviewed. The median age was 65 years, and three patients were female. Three patients had preoperative atrial fibrillation. Forty % of patients were in NYHA class 3-4. Three patients underwent urgent surgery. Ultrasonic scalpel was used for dissection and resection of thickened parietal pericardium and visceral pericardium around the heart except in the area of the posterior left atrium in all patients. Three patients underwent the off-pump technique. Coronary artery bypass grafting and tricuspid valve annuloplasty were performed concomitantly in 3 and 1 patients, respectively. Operative mortality was zero. Mediastinitis and acute kidney injury were observed in one patient each. One patient died of stroke during follow-up. The other patients were in NYHA class I. Radical pericardiectomy is essential in patients with constrictive pericarditis. Ultrasonic scalpel is a useful tool to perform radical resection of pericardium.

Left atrial strain and risk of atrial fibrillation post-aortic valve replacement surgery

Abstract Background Post-operative atrial fibrillation (POAF) occurs in approximately 30% of patients following aortic valve replacement (AVR) surgery. Left atrial dilatation has been proposed as a predictor of POAF. However, very little is known about the predictive value of left atrial strain analysis, which is a surrogate of left atrial mechanical function. This study evaluates the strength of association between left atrial function, assessed using strain echocardiography, and the occurrence of POAF after AVR. Methods and materials Perioperative data was collected retrospectively for patients undergoing surgical aortic valve replacement (n=100) who had appropriate pre-operative echocardiographic characterization, including echocardiography measures of LA strain (Fig. 1). Patients with pre-operative AF (n=3) were excluded. Patients were categorised according to the development of POAF. Results 28 (29%) of 97 patients developed POAF. Initial univariate analysis suggested an association between POAF and increased age, larger LA and LV volumes, diastolic dysfunction, mitral valve E and A values, and lower LA and LV strain. Univariate analysis suggested post-operative associations between POAF and longer durations of intubation, longer durations of noradrenaline requirement, and longer stays in ICU and hospital. Multivariate analysis demonstrated that lower pre-operative left atrial reservoir function had a very strong independent association (mean 12.0% vs 41.5%, odds ratio 0.007, 95% CI 0.0001-0.33, p=0.01) with POAF. Longer post-operative duration of intubation also had a strong association (mean 10hr vs 8hr, odds ratio 67.5, 95% CI 1.1-41.5, p=0.04) with POAF. Conclusion Left atrial reservoir function, a surrogate of left atrial compliance, has a strong independent association with POAF post-AVR. This suggests that patients with underlying mechanical atrial dysfunction are at increased risk of developing POAF. This study supports the inclusion of left atrial reservoir function in any predictive tool for POAF post-AVR. The longer duration of post-operative intubation in the AF group supports the negative impact of POAF. Figure 1. Example of speckle tracking analysis and strain measurements during the three phases of left atrial (LA) cycle using R-R ECG gating with the zero-baseline strain reference. Reservoir strain (yellow line) is the peak strain before mitral valve opening (positive value). Conduit strain (red line) is calculated as difference of the strain value at the onset of atrial contraction minus the peak strain value (negative value). Contraction strain is calculated as difference of the strain value at baseline (0) minus the strain value at onset of atrial contraction (negative value).

Prevalence and risk factors for hospital-acquired pneumonia after on-pump cardiac surgery

Aim. To study the prevalence and risk factors (RF) for hospital-acquired pneumonia (HAP) after on-pump cardiac surgery in a modern cohort of patients.Material and methods. This retrospective analysis of the medical records of cardiovascular surgery patients, operated on in the period from January 1, 2022 to December 31, 2022. The study consistently included 417 patients who underwent on-pump cardiac surgery. The incidence and timing of HAP development were assessed. The influence of the main demographic, clinical, and perioperative factors on HAP risk was studied.Results. The pneumonia prevalence per year was 27,6%, including after the Frozen Elephant Trunk (FET) procedure — 32%, after coronary artery bypass grafting (CABG) — 29,5%, after combined CABG and heart valve surgery — 26,2%, after isolated valve surgery — 25,9%, after thoracic aortic hemiarch replacement — 19,5%. Pneumonia developed on the 4,6±2,9 day after surgery. The risk of pneumonia increased with atrial fibrillation (AF) before surgery (odds ratio (OR) 3,17; 95% confidence interval (CI): 1,67; 6,02, p=0,0002), on-pump duration (OR 1,01; 95% CI: 1,00; 1,01; p=0,0006), aortic cross-clamping (OR 1,01; 95% CI: 1,00; 1,01; p=0,0002) and mechanical ventilation (OR 1,03; 95% CI: 1,01; 1,05; p=0,005). Pneumonia predictors were on-pump duration ≥96 min (sensitivity 67,7%, specificity 64,6%, AUC=0,681, p=0,0006) and mechanical ventilation ≥14 h (sensitivity 63,1%, specificity 69,3%, AUC=0,641, p=0,005), as well as preoperative AF (sensitivity 61%, specificity 75%, p=0,0002).Conclusion. Preoperative AF, on-pump duration ≥96 min and mechanical ventilation ≥14 h serve as categorical and quantitative predictors of postoperative HAP in a modern cohort of patients.

Predictors for length of stay after surgical aortic valve replacement.

Aortic valve replacement improves and prolongs lives of patients with aortic valve disease, but requires significant healthcare resources, which are mainly determined by the length of associated hospital stays. Therefore, this study aims to identify risk factors for extended length of stay after surgical aortic valve replacement. Between 2018 and 2023, 458 consecutive patients underwent isolated surgical aortic valve replacement at our center and were included in our analysis. To identify independent predictors for hospital and intensive care unit stay, multivariable linear regression analysis using backward elimination process was performed. Upon multivariable linear regression, endocarditis [regression coefficient (β) 2.98; 95% confidence interval (CI) 1.51, 4.45; p<0.001)] and prior aortic valve surgery (β 1.72; 95% CI 0.18, 3.26; p=0.029) were associated with prolonged hospital stay. Prior aortic valve surgery was associated with prolonged intensive care unit stay (β 0.99; 95% CI 0.39, 1.59; p=0.001) as well as chronic obstructive pulmonary disease (β 1.61; 95% CI 0.66, 2.55; p=0.001), smaller prosthetic valve sizes (β -0.18; 95% CI -0.30, -0.06; p=0.003), preoperative atrial fibrillation (β 1.06; 95% CI 0.32, 1.79; p=0.005), and reduced left ventricular ejection fraction (β -0.03; 95% CI -0.05, -0.01; p=0.006). Pending further validation, structured programs aiming to accelerate intensive care unit and hospital discharge after surgical aortic valve replacement should focus on patients with prior cardiac surgery, atrial fibrillation, and chronic obstructive pulmonary disease. Surgeons should aim to implant large-diameter valves. Furthermore, the identified predictors should be used to discuss surgical versus transcatheter procedures in the interdisciplinary heart team.

Preoperative atrial fibrillation in patients undergoing cardiac surgery: Gender versus other factors. Authors' reply.

Preoperative atrial fibrillation in patients undergoing cardiac surgery: Gender versus other factors. Authors' reply.

Preoperative atrial fibrillation in patients undergoing cardiac surgery: Gender versus other factors.

Preoperative atrial fibrillation in patients undergoing cardiac surgery: Gender versus other factors.

Prophylactic Left Atrial Appendage Ligation During CABG: A Propensity Score-Matched Analysis

To evaluate short-term outcomes and statewide practice patterns of prophylactic left atrial appendage ligation (P-LAAL) in coronary artery bypass grafting (CABG) patients without pre-operative atrial fibrillation (AF). Adult patients who underwent an on-pump CABG (2017 - 2023) within a regional collaborative were identified. Patients with a history of AF, previous cardiac surgery, or non-device based LAAL were excluded. Patients were stratified by LAAL status and were propensity score matched. Univariable analysis was used to compare short-term clinical outcomes. Of 16,547 patients examined, 442 underwent P-LAAL. The propensity score matched cohort (439 P-LAAL, 439 No P-LAAL) was compared and had no significant differences in pre-operative CHA2DS2-VASc scores or operative variables. The P-LAAL group had longer cross clamp time (82 vs 76 minutes, p=0.001), ICU hours (72 vs 66, p=0.001), length of stay (6.0 vs 6.0 days, p=0.010), increased post-operative AF (35% vs 24%, p<0.001), and more discharge on anticoagulation (17% vs 8.2%, p<0.001). There were no significant differences in post-operative stroke (1.1% vs 2.1%, p=0.423), readmission (13% vs 9.6%, p=0.118), operative mortality (2.5% vs 1.6%, p=0.480), or readmission for thrombotic or bleeding complications (0.7% vs 1.1%, p=0.724). Hospitalization costs were significantly higher for P-LAAL patients ($43,478 vs $40,645, p<0.001). The rate of P-LAAL during CABG increased from 1.61% (2017) to 5.65% (2023) (p<0.001). Despite higher rates of post-operative AF, discharge on anticoagulation, and hospitalization costs in patients undergoing P-LAAL during CABG, there was no difference in short-term clinical endpoints including stroke and operative mortality.

Perioperative and mid-term outcomes of mitral valve surgery with and without concomitant surgical ablation for atrial fibrillation: a retrospective analysis.

We retrospectively analysed perioperative and mid-term outcomes for patients undergoing mitral valve surgery with and without atrial fibrillation. Patients who underwent mitral valve surgery between January 2018 and February 2023 were included and categorized into 3 groups: 'No AF' (no documented atrial fibrillation), 'AF no SA' (atrial fibrillation without surgical ablation) and 'AF and SA' (atrial fibrillation with concomitant surgical ablation). Groups were compared for perioperative and mid-term outcomes, including mortality, stroke, bleeding and pacemaker implantation. A P-value <0.05 was considered statistically significant. Of the 400 patients included, preoperative atrial fibrillation was present in 43%. Mean follow-up was 1.8 (standard deviation: 1.1) years. The patients who underwent surgical ablation for atrial fibrillation exhibited similar overall outcomes compared to patients without preoperative atrial fibrillation. Patients with untreated atrial fibrillation showed higher mortality ('No AF': 2.2% versus 'AF no SA': 8.3% versus 'AF and SA': 3.2%; P-value 0.027) and increased postoperative pacemaker implantation rates ('No AF': 5.7% versus 'AF no SA': 15.6% versus 'AF and SA': 7.9%, P-value: 0.011). In a composite analysis of adverse events (Mortality, Bleeding, Stroke), the highest incidence was observed in patients with untreated atrial fibrillation, while patients with treated atrial fibrillation had similar outcomes as those without preoperative documented atrial fibrillation ('No AF': 9.6% versus 'AF no SA': 20.2% versus 'AF and SA' 3: 9.5%, P-value: 0.018). Concomitant surgical ablation should be considered in mitral valve surgery for atrial fibrillation, as it leads to similar mid-term outcomes compared to patients without preoperative documented atrial fibrillation.

Surgical treatment of atrial fibrillation in elderly patients undergoing high risk cardiac surgery

BackgroundEvaluating outcomes of concurrent Cox-Maze procedures in elderly patients undergoing high-risk cardiac surgery.MehodsWe retrospectively identified patients aged over 70 years with Atrial Fibrillation (AF) from 2011 to 2017 who had two or more other cardiac procedures. They were subdivided into two groups: 1. Cox-Maze IV AF ablation. 2. No-Surgical AF treatment. A propensity match score was used to generate a homogeneous cohort and to eliminate confounding variables. Heart rhythm was assessed from Holter reports or 12-lead ECG. Follow-up data was collected through telephone consultations and medical records.ResultsThere were 239 patients. Median follow up was 61 months. 70 patients had Cox-Maze IV procedures (29.3%). Demographic, intra- and post-operative outcomes were similar between groups although duration of pre-operative AF was shorter in Cox-Maze group (p = 0.001). There was no significant 30-day mortality difference in propensity matched cohorts (n = 84. P = 0.078). Sinus rhythm at annual and latest follow-up was 84.9% and 80.0% respectively in Maze group – 160 patients (66.9%) were alive at long-term follow-up with good survival outcomes in Cox Maze group. There was a high proportion of patients in NYHA 1 status in Cox-Maze group. No differences observed in freedom from stroke (p = 0.80) or permanent pacemaker (p = 0.33) between the groups.ConclusionsSurgical ablation is beneficial in elderly patients undergoing high-risk surgery - promoting excellent long-term freedom from AF and symptomatic / prognostic benefits, without added risk. Therefore, surgical risk should not be reason to deny benefits of concomitant AF-ablation.Clinical trial registrationNot required.

Concomitant Surgical Ablation in Paroxysmal vs Persistent Atrial Fibrillation During Mitral Surgery

Despite prospective randomized evidence supporting concomitant treatment of atrial fibrillation (AF) during mitral valve (MV) surgery, variation in surgical management of AF remains. We assessed longitudinal outcomes after surgical treatment of persistent or paroxysmal AF during MV surgery in Medicare beneficiaries. All Medicare beneficiaries with a diagnosis of AF undergoing MV surgery (2018-2020) were evaluated. Patients were stratified by no AF treatment, left atrial appendage obliteration (LAAO) alone, or surgical ablation and LAAO (SA+LAAO). Doubly robust risk adjustment and subgroup analysis by persistent or paroxysmal AF were performed. A total of 7517 patients with preoperative AF underwent MV surgery (32.1% no AF treatment, 23.1% LAAO alone, 44.7% SA+LAAO). After doubly robust risk adjustment, AF treatment with SA+LAAO or LAAO alone were associated with lower 3-year readmission for stroke or bleeding. However, SA+LAAO was associated with reduced 3-year mortality and readmission for AF or heart failure compared with no AF treatment or LAAO alone. Compared with no AF treatment or LAAO alone, SA+LAAO was associated with lower composite end point of stroke (hazard ratio, 0.75) or death (hazard ratio, 0.83) at 3 years. Subgroup analysis identified similar longitudinal benefits of SA+LAAO in patients with persistent or paroxysmal AF. In Medicare beneficiaries with AF undergoing MV surgery, SA+LAAO was associated with improved longitudinal outcomes compared with LAAO alone or no AF treatment in patients with paroxysmal or persistent AF. These contemporary real-world data further clarify the benefit of SA+LAAO during MV surgery across all types of AF.

Impact of Persistent Versus Paroxysmal Preoperative Atrial Fibrillation on In-Hospital, One-Year, and Late Clinical Outcomes Following Transcatheter Aortic Valve Implantation

Previous reports on the impact of preexisting atrial fibrillation (AF) on clinical outcomes after transcatheter aortic valve implantation (TAVI) have presented limited data on the relative impact of paroxysmal versus persistent AF subtypes. We compared in-hospital, 1-year, and late clinical outcomes in 1,098 patients who underwent TAVI with preoperative AF (556 paroxysmal, 542 persistent) versus 1,787 patients without AF. The propensity-matched cohorts with AF (n = 643) and without AF (n = 686) did not differ with respect to baseline clinical characteristics, operative technique, or in-hospital TAVI complications. At 1-year, patients with AF had higher all-cause mortality (9.0% vs 6.1%, p = 0.046) and readmission rates (13.1 vs 8.8%, p = 0.014), with lower Kansas City cardiomyopathy questionnaire scores (77.8 ± 21.8 vs 84.3 ± 17.1, p <0.001). Echocardiographic follow-up (mean time 455 ± 285 days) demonstrated no significant intergroup differences in hemodynamic findings other than a progressive increase in left atrial volume index in patient subgroups (without AF: 37.4 ± 14.7 ml/m2 vs paroxysmal AF: 46.4 ± 21.4 ml/m2 vs persistent AF: 60.5 ± 26.3 ml/m2, p <0.001). On late follow-up (mean time 49.0 [45.1 to 52.9] months), patients with persistent AF had worse all-cause mortality than patients without AF (hazard ratio 1.55, 95% confidence interval 1.17 to 2.06, p = 0.003), with no significant survival differences between the paroxysmal AF and without AF subgroups. In conclusion, patients with preexisting AF and patients without AF who underwent TAVI had similar in-hospital outcomes but worse 1-year mortality, hospital readmission, and quality of life outcomes. Compared with patients without AF, patients with persistent but not paroxysmal preexisting AF have higher late all-cause mortality at a mean follow-up of 49 months. Patients with persistent AF have higher levels of left atrial volume index than patients with paroxysmal AF and patients without AF on intermediate echocardiographic follow-up.

Association of Postoperative Serum Lactate Levels with Acute Kidney Injury in Mexican Patients Undergoing Cardiac Surgery.

Acute kidney injury (AKI) is a highly prevalent and a critical complication of cardiac surgery (CS). Serum lactate (sLac) levels have consistently shown an association with morbimortality after CS. We performed a cross-sectional study including 264 adult patients that had a cardiac surgery between January and December 2020. Logistic regression analysis was performed to determine factors associated with AKI development. We measured the postoperative levels of sLac for all participants immediately after CS (T0) and at 4 h (T4) after the surgical intervention. A linear regression model was used to identify the factors influencing both sLac metrics. We identified four risk predictors of AKI; one was preoperative (atrial fibrillation), one intraoperative (cardiopulmonary bypass time), and two were postoperative (length of hospital stay and postoperative sLac). T0 and T4 sLac levels were higher among CS-AKI patients than in Non-CS-AKI patients. Postoperative sLac levels were significant independent predictors of CSA-AKI, and sLac levels are influenced by length of hospital stay, the number of transfused packed red blood cells, and the use of furosemide in CS-AKI patients. These findings may facilitate the earlier identification of patients susceptible to AKI after CS.

Effect of myocardial bridging on preoperative atrial fibrillation and survival in patients with obstructive hypertrophic cardiomyopathy

Effect of myocardial bridging on preoperative atrial fibrillation and survival in patients with obstructive hypertrophic cardiomyopathy

Increased circulating BMP10 levels are associated with late postoperative atrial fibrillation after cardiac surgery and left atrial endomysial fibrosis

Abstract Background Serum bone morphogenetic protein 10 (BMP10) levels are a marker for history of atrial fibrillation (AF) and for major adverse cardiovascular events in AF-patients, including stroke, recurrence after catheter ablation, and mortality. The predictive value of BMP10 in patients undergoing cardiac surgery and association with morphological properties of atrial tissue are unknown. Objective To study the correlation between BMP10 levels and pre-operative clinical traits, occurrence of early and late postoperative atrial fibrillation (POAF), and atrial fibrosis in patients undergoing cardiac surgery. Methods Patients with and without preoperative AF history undergoing first cardiac surgery were included (RACE V, n=147). Pre-operative blood biomarkers were analyzed, left (n=114) and right (n=125) atrial appendage biopsies were histologically assessed following WGA-staining, and post-operative rhythm was monitored continuously with implantable loop recorders (n=134, 2.5yrs). Results Multiple logistic regression indicated that BMP10 accurately predicts a history of persistent AF (OR=1.24, 95%CI: 1.10-1.40, p=4.32e-4), similar to NT-pro-BNP. BMP10 levels were associated with increased late-POAF90 occurrence after adjusting for age, sex, AF history, and early-POAF occurrence (HR=1.07 [per 0.1ng/ml increase], 95%CI: 1.00-1.14, p=0.04). Left atrial endomysial fibrosis (St.β=0.22, p=0.04), but not overall fibrosis (St. β= , p=), was associated with circulating BMP10, after adjusting for age, sex, AF history, reduced LVF, and valvular surgery indication. Conclusion Increased BMP10 levels were associated with persistent AF-history, increased late-POAF incidence, and LAA endomysial fibrosis in a diverse population of patients undergoing cardiac surgery.

Circadian occurence patterns of atrial fibrillation after cardiac surgery during 2.5 years of continuous rhythm monitoring

Abstract Background Atrial fibrillation (AF) is a common complication after cardiac surgery, and current theories suggest that the autonomic nervous system plays a major role in the development of early postoperative AF (early-POAF).(1) However, its role in late recurrences is still unknown. Previous studies in non-surgical patients have revealed distinct preferential patterns of AF occurrence, such as adrenergic/daytime AF or nocturnal AF.(2, 3) Nevertheless, circadian onset patterns for POAF have never been studied before. Purpose To establish the circadian occurrence patterns of POAF after cardiac surgery during 2.5 years of continuous rhythm monitoring. Methods Patients with and without a history of AF undergoing cardiac surgery were included. Continuous rhythm monitoring was performed over a period of 2.5 years. POAF was defined as an AF episode lasting 2 minutes or longer, detected by the ILR algorithm, and all episodes were manually checked by the investigators. Circadian distribution of AF episode onset was presented in circadian plots for the early postoperative phase (first 90 days) and late postoperative phase (after the first 90 days). Additionally, comparisons for circadian occurrence patterns were made between early and late POAF, after dividing the daytime period into four equal time intervals (night = 12 a.m. to 5.59 a.m., morning = 6 a.m. to 11.59 a.m., afternoon = 12 p.m. to 5.59 p.m., evening = 6 p.m. to 11.59 p.m.), both in patients with and without a preoperative AF history. Results The study population consisted of 98 patients (71 without a preoperative AF history and 27 with a preoperative AF history), of which 53 developed POAF (29 without a preoperative AF history and 24 with a preoperative AF history), resulting in a total of 3607 confirmed AF episodes (Figure 1). Early-POAF occurred in 46 patients, while late-POAF occurred in 36 patients. In both patients with and without AF history, the majority of early-POAF episodes occurred between 12 a.m. and 12 p.m. (59.2% and 55.9%, respectively) (Figure 2). In patients without AF history, late-POAF occurred predominantly in the evening (26.7%), particularly episodes lasting between 10 and 360 minutes, and in the afternoon (32.3%), with a greater number of episodes lasting &amp;lt;10 minutes (Figure 2). Patients with AF history experienced most late-POAF episodes at night (26.4%) and during the morning (33.1%), with a peak of short episodes (&amp;lt;10 minutes) in the morning (Figure 2). The circadian distribution was significantly different between early- and late-POAF for both patients with and without AF history (p&amp;lt;0.001 and p&amp;lt;0.001, respectively). Conclusion In patients without a preoperative AF history, early-POAF showed a more heterogeneous circadian occurrence pattern compared to late-POAF, which occurred mostly in the evening and afternoon. In patients with a preoperative AF history, POAF initiated mostly during the night and in the morning.Figure 1Figure 2

Postoperative atrial fibrillation burden and progression patterns after cardiac surgery during 2.5 years of continuous rhythm monitoring

Abstract Background Early postoperative atrial fibrillation (POAF) is a frequent complication after cardiac surgery, with an incidence of up to 50%.(1, 2) The clinical presentation of early-POAF, however, might be highly diverse, showing great individual differences in symptoms, as well as POAF-specific characteristics such as the number of episodes, duration of episodes, and the percentage of time spent in POAF (POAF-burden). It is currently unknown how these early-POAF characteristics, particularly POAF-burden, are related to the risk of developing late-POAF recurrences. Purpose To establish the association between early-POAF characteristics, in particular POAF-burden, and late-POAF occurrence and burden. Methods Patients with and without a history of AF undergoing cardiac surgery were included. Preoperatively, all patients underwent echocardiography, electrocardiography, and blood biomarker analysis. Intraoperatively, all patients received an implantable loop recorder for a period of 2.5 years. POAF was defined as an AF episode lasting at least 2 minutes, detected by the ILR algorithm, and all episodes were manually checked by the investigators. POAF-burden was calculated as the percentage of time in AF for different time intervals (early: 0-3 months, late: 3-30 months). Classification of burden was performed based on cut-off values for tertiles. Also, associations between early-POAF characteristics, such as episode duration, and the incidence of late-POAF were analyzed. Results The study population consisted of 98 patients undergoing cardiac surgery (71 without preoperative AF history and 27 with preoperative AF history), out of which 53 developed POAF. Early-POAF occurred in 46 patients, and late-POAF in 36 patients. Early-POAF was associated with an increased occurrence of late POAF after adjusting for age, sex, PAF-history, and persistent AF-history (adjusted hazard ratio [aHR] = 4.62, 95% CI: 1.93-11.05, p&amp;lt;0.001) (Figure 1A). Multiple regression analysis, adjusted for age, sex, PAF-history, and persistent AF-history, revealed a gradual increase in late-POAF hazard between the early-POAF burden tertiles compared to patients without early-POAF (p&amp;lt;0.001) (Figure 1B). Similarly, the longest individual early-POAF episode and the number of early-POAF episodes were both associated with an increased late-POAF hazard (p&amp;lt;0.001 and p&amp;lt;0.001, respectively) (Figure 1C-D). The highest POAF-burden was observed in the early postoperative phase, with a significant reduction in the late phase (p=0.007) (Figure 2A). Overall, 84 patients had no late-POAF or a reduction in POAF burden, while 14 patients showed an increase in POAF-burden compared to the early postoperative phase (Figure 2B). Conclusion Early-POAF characteristics, such as POAF-burden, are strongly associated with an increased occurrence of late-POAF. The highest POAF-burden is present in the early postoperative phase, and only a minority of patients experience an increase in late-POAF burden.Figure 1Figure 2

The left atrial appendage closure by surgery 2 trial: statistical analysis plan for a randomized multicenter trial exploring if the closure of the left atrial appendage during open-heart surgery reduces stroke irrespective of patients’ stroke risk and preoperative atrial fibrillation status

BackgroundSurgical left atrial appendage (LAA) closure concomitant to open-heart surgery prevents thromboembolism in high-risk patients. Nevertheless, high-level evidence does not exist for LAA closure performed in patients with any CHA2DS2-VASc score and preoperative atrial fibrillation or flutter (AF) status—the current trial attempts to provide such evidence.MethodsThe study is designed as a randomized, open-label, blinded outcome assessor, multicenter trial of adult patients undergoing first-time elective open-heart surgery. Patients with and without AF and any CHA2DS2-VASc score will be enrolled. The primary exclusion criteria are planned LAA closure, planned AF ablation, or ongoing endocarditis. Before randomization, a three-step stratification process will sort patients by site, surgery type, and preoperative or expected oral anticoagulation treatment. Patients will undergo balanced randomization (1:1) to LAA closure on top of the planned cardiac surgery or standard care. Block sizes vary from 8 to 16. Neurologists blinded to randomization will adjudicate the primary outcome of stroke, including transient ischemic attack (TIA). The secondary outcomes include a composite outcome of stroke, including TIA, and silent cerebral infarcts, an outcome of ischemic stroke, including TIA, and a composite outcome of stroke and all-cause mortality. LAA closure is expected to provide a 60% relative risk reduction. In total, 1500 patients will be randomized and followed for 2 years.DiscussionThe trial is expected to help form future guidelines within surgical LAA closure. This statistical analysis plan ensures transparency of analyses and limits potential reporting biases.Trial registrationClinicaltrials.gov, NCT03724318. Registered 26 October 2018, https://clinicaltrials.gov/study/NCT03724318.Protocol versionhttps://doi.org/10.1016/j.ahj.2023.06.003.

Isolated Tricuspid Valve Surgery for Functional Tricuspid Regurgitation.

Severe tricuspid regurgitation (TR) adversely affects long-term survival; however, isolated tricuspid valve (TV) surgery has been rarely performed due to high operative mortality. In addition, the previous literature included heterogeneous TR etiologies. Therefore, we aimed to elucidate early and long-term outcomes of isolated TV surgery for functional TR. An electronic search was performed to identify all relevant studies. Baseline characteristics, perioperative variables, and clinical outcomes were extracted and pooled for meta-analysis. This meta-analysis included seven studies. Pooled analyses showed that 68% (35, 89) of patients had preoperative atrial fibrillation or flutter, and 58% (11, 94) had a history of left-sided valve surgery. Seventy-three percent (65, 80) of patients had at least one physical exam finding of right-sided heart failure, and 57% (44, 69) were in New York Heart Association class III or IV. TV replacement was more common than repair. In TV replacement, bioprosthetic valve (39%, 13, 74) was more common than mechanical prosthesis (22%, 18, 26). The early mortality rate was 7%. Twenty percent of patients required a permanent pacemaker postoperatively. The overall 1- and 5-year survival rates were 84.5 and 69.1%, respectively. More than half of the patients who underwent isolated TV surgery for functional TR had undergone left-sided valve surgery and had significant heart failure symptoms at the time of surgery. Further studies on the surgical indication for concomitant TV surgery at the time of left-sided valve surgery and the appropriate timing of surgery for isolated functional TR are needed to improve survival.

Therapeutic strategy for totally thoracoscopic repeat mitral valve surgery under moderate hypothermia-induced ventricular fibrillation

Objective: To examine the therapeutic strategy and its impacting factors by analyzing the perioperative outcomes of total thoracoscopic repeat mitral valve surgery under moderate hypothermia-induced ventricular fibrillation with cardiopulmonary bypass. Methods: This study is a retrospective case series. Totally 63 patients who underwent repeat mitral valve surgery by the same surgeon from January 2021 to December 2023 in Department of Cardiovascular Surgery, the First Medical Center of People's Liberation Army General Hospital were retrospectively enrolled. There were 28 males and 35 females with an age of (58.3±15.9) years (range: 13 to 84 years). Surgery was performed using a totally thoracoscopic approach under moderate hypothermia-induced ventricular fibrillation. Mitral valvuloplasty was completed in 32 cases and mitral valve replacement in 31 cases. Preoperative baseline data and perioperative outcomes of the patients were collected and Logistic regression was used to analyze independent influencing factors of premature ventricular contractions in the early postoperative period. Results: The intraoperative cardiopulmonary bypass time was (191.5±50.9) minutes (range: 95 to 286 minutes), and the hypothermic ventricular fibrillation time was (99.0±39.8) minutes (range: 34 to 203 minutes). The anal temperature before the start of cardiopulmonary bypass was (36.3±0.5) ℃ (range: 35.2 to 38.0 ℃), the lowest intraoperative anal temperature was (27.3±1.3) ℃(range: 23.7 to 30.1 ℃), and the anal temperature at the time of the cessation of cardiopulmonary bypass was (36.3±0.4) ℃ (range: 35.2 to 37.0 ℃), and excessive rewarming was observed in 33 cases. Six cases applied the artificial heart assist device. Seventeen cases developed premature ventricular contractions in the early postoperative period. Two cases developed neurologic complications. Five cases developed respiratory complications. One case developed urological systemic complications. Six cases were mechanically ventilated for more than 3 days, and the duration of ICU stay in 16 cases was more than 3 days and the postoperative discharge time of (M(IQR)) 8.0 (3.5) days (range: 3 to 26 days). Two cases died or were discharged voluntarily. Logistic regression results showed that persistent preoperative atrial fibrillation (OR=11.424, 95%CI: 1.477 to 144.564, P=0.033) and excessive rewarming (OR=15.249, 95%CI: 1.357 to 279.571, P=0.038) were independent risk factors for the appearance of premature ventricular contractions in the early postoperative period. Conclusions: The technique of total thoracoscopic surgery under induced moderate hypothermic ventricular fibrillation with cardiopulmonary bypass could be applied to repeated mitral valve surgeries with less trauma and faster recovery. Persistent preoperative atrial fibrillation and excessive rewarming are independent risk factors for the occurrence of premature ventricular contractions in the early postoperative period.

Evaluation of sex differences in the receipt of concomitant atrial fibrillation procedures during nonmitral cardiac surgery

Women are less likely to receive guideline-recommended cardiovascular care, but evaluation of sex-based disparities in cardiac surgical procedures is limited. Receipt of concomitant atrial fibrillation (AF) procedures during nonmitral cardiac surgery was compared by sex for patients with preoperative AF. Patients with preoperative AF undergoing coronary artery bypass grafting and/or aortic valve replacement at any of the 33 hospitals in Michigan from 2014 to 2022 were included. Patients with prior cardiac surgery, transcatheter AF procedure, or emergency/salvage status were excluded. Hierarchical logistic regression identified predictors of concomitant AF procedures, account for hospital and surgeon as random effects. Of 5460 patients with preoperative AF undergoing nonmitral cardiac surgery, 24% (n=1291) were women with a mean age of 71years. Women were more likely to have paroxysmal (vs persistent) AF than men (80% vs 72%; P<.001) and had a higher mean predicted risk of mortality (5% vs 3%; P<.001). The unadjusted rate of concomitant AF procedure was 59% for women and 67% for men (P<.001). After risk adjustment, women had 26% lower adjusted odds of concomitant AF procedure than men (adjusted odds ratio, 0.74; 95% CI, 0.64-0.86; P<.001). Female sex was the risk factor associated with the lowest odds of concomitant AF procedure. Women are less likely to receive guideline recommended concomitant AF procedure during nonmitral surgery. Identification of barriers to concomitant AF procedure in women may improve treatment of AF.