Preoperative Left Atrial Volume Index Research Articles

Robotic-enhanced hybrid ablation for persistent and long-standing atrial fibrillation: Early assessment of feasibility, safety, and efficacy

ObjectivesTo assess feasibility, safety, and early efficacy of robotic-enhanced epicardial ablation (RE-EA) as first stage of a hybrid approach to patients with persistent (PsAF) and long-standing atrial fibrillation (LSAF). MethodsSingle-center, retrospective analysis of patients with documented PsAF and LSAF who underwent RE-EA followed by catheter-guided endocardial ablation. Postoperatively, patients were monitored for major adverse events and underwent rhythm follow-up at 3 and 12 months. ResultsBetween January 2021 and June 2023, we performed RE-EA in 64 patients (73.5% male, CHA2DS2-VASc 2.7 ± 1.6, BMI 34.1 ± 6.3 kg/m2). Mean AF preoperative duration and left atrial volume index were, respectively, 85 months and 47.5 mL/m2. Through the robotic approach, the intended lesion set was completed in all patients without cardiopulmonary bypass support, conversion to thoracotomy/sternotomy, blood transfusions, or perioperative mortality. The average LOS was 1.7 days, with only 1 patient requiring intensive care unit admission and >65% of patients discharged within 24 hours. At follow-up, 2 (3.1%) patients experienced new left pleural effusion or hemidiaphragm paralysis requiring treatment. There were no readmissions related to AF, stroke, thromboembolic events, or deaths. The mean interval between the epicardial and endocardial stages of the procedure was 5.9 months. Rhythm follow-up showed AF resolution in 73.4% and 71.9% of patients at 3 and 12 months, respectively. ConclusionsRE-EA is a feasible and safe, first-stage approach for the treatment of patients with PsAF and LSAF. It improves exposure of the intended targets, favors short hospital stay, and facilitates return to activity with satisfactory AF treatment in the short term.

Racial Disparities in Atrial Fibrillation After Coronary Artery Bypass: Impact of Left Atrial Volume

BackgroundPrior studies have demonstrated a lower prevalence of postoperative atrial fibrillation (POAF) in Black, Hispanic, Asian, and Native American patients compared with White cohorts after coronary artery bypass grafting. We hypothesized that preoperative differences in left atrial size may explain this disparity. MethodsWe assessed the incidence of new POAF in 1218 patients (215 minority patients and 1003 White patients) undergoing isolated, first-time coronary artery bypass grafting from January 2017 through September 2022. Preoperative left atrial volume index (LAVi) was assessed by transthoracic echocardiography. ResultsMinority patients were younger and more likely to be female, with more comorbidities, including diabetes, prior stroke, and dialysis. There was no difference in postoperative mortality, stroke, renal failure, or reoperation for bleeding between minority and White patients. Whereas minority patients had higher blood product use and longer intensive care unit and postoperative lengths of stay, they experienced a lower incidence of new POAF (19.5% [42/215] vs 29.5% [292/1003]; P = 0.02). Mean LAVi was similar between minority and White patients (30.3 ± 12.6 mL/m2 vs 29.9 ± 10.1 mL/m2; P = .64). However, for White patients, LAVi was higher for patients with POAF than for patients without POAF (31.3 ± 10.9 mL/m2 vs 29.3 ± 9.7 mL/m2; P = .007), whereas for minority patients, LAVi was similar for patients with and without POAF (30.7 ± 26.0 mL/m2 vs 30.3 ± 11.7 mL/m2; P = .84). ConclusionsDespite more comorbidities, higher transfusion rates, and longer length of stay, minority patients had a significantly lower incidence of POAF compared with White patients but no difference in preoperative LAVi. Larger LAVi may be predictive of POAF in White patients but not in minority patients.

Preoperative left atrial volume index may be associated with postoperative atrial fibrillation in non-cardiac surgery.

Postoperative atrial fibrillation (POAF) is related to mortality after non-cardiac surgery. Left atrial volume index (LAVI) is known to be associated with prognosis and development of atrial fibrillation, but it has not been fully investigated in patients undergoing non-cardiac surgery. A total of 203,787 consecutive adult patients underwent non-cardiac surgery at our institution between January 2011 and June 2019. After identifying those with available LAVI estimated during preoperative echocardiography, we divided them into those with LAVI higher and lower than 34 mL/m2. The primary outcome was incidence of POAF. A total of 83,097 patients were enrolled in this study. The study patients were divided into the low (57,838 [69.6%]) and high (25,259 [30.4%]) LAVI groups. After an adjustment, higher LAVI was associated with increased incidence of POAF (5.1% vs. 8.1%; odds ratio [OR], 1.33; 95% confidence interval [CI], 1.25-1.41; p < 0.001). In 24,549 pairs of propensity-score-matched population, the result was similar (6.2% vs. 7.9%; OR, 1.30; 95% CI, 1.21-1.39; p < 0.001). The estimated threshold of LAVI associated with POAF was 36.4 mL/m2 with an area under the curve of 0.571. Subgroup analysis in non-thoracic and thoracic surgery showed that the association between preoperative LAVI and POAF significantly interacted with diastolic dysfunction (p for interaction < 0.001), and the observed association was valid in patients without diastolic dysfunction. Preoperative LAVI was shown to be associated with POAF in non-cardiac surgery. Our result needs verification in further studies.

Left Atrial Remodeling after Mitral Valve Repair for Primary Mitral Regurgitation: Evolution over Time and Prognostic Significance.

Left atrial (LA) dilatation is associated with worse outcomes in primary mitral regurgitation (MR). However, the effects of mitral valve repair on LA size and its prognostic implications are not well known. In the current study, LA volume index (LAVi) and LA reservoir strain (LASr) were evaluated immediately before and after surgery, and during long-term follow-up in 226 patients undergoing mitral valve repair for primary MR (age 62 ± 13 years, 66% male). Mean LAVi was reduced significantly after surgery and at long-term follow-up (from 56 ± 28 to 38 ± 21 to 32 ± 17 mL/m2; p < 0.001). LASr reduced significantly after surgery but increased again during the long-term (from 23.6 ± 9.4 to 11.5 ± 5.0 to 17.3 ± 7.5%; p < 0.001). Age, pre-operative LAVi, MR severity, and postoperative transmitral pressure gradient were associated with LA reverse remodeling by the long-term check-up. During a median follow-up of 72 (40–114) months, 43 (19%) patients died. Patients with LAVi ≥ 42 mL/m2 at long-term follow-up showed significant higher mortality rates compared to patients with LAVI < 42 mL/m2 (p < 0.001), even after adjusting for clinical covariates. In conclusion, significant LA reverse remodeling was observed both immediately and at long-term follow-up after mitral valve repair. LA dilatation at long term follow-up after surgery was still associated with all-cause mortality.

Patient-Reported Atrial Fibrillation After Septal Myectomy for Hypertrophic Cardiomyopathy

BackgroundPatient-reported outcomes are important metrics of medical and surgical care. In this study, we investigated the prevalence and risk factors of patient-reported postdischarge atrial fibrillation (AF) after septal myectomy for obstructive hypertrophic cardiomyopathy. MethodsPatients undergoing transaortic septal myectomy from August 2001 to January 2017 were contacted regarding postdischarge AF through questionnaire-based surveys sent at 3, 5, and 10 years post procedure. For each patient, the most recent survey response was analyzed. ResultsAmong 949 patients, 248 (26.1%) last responded at 3 years post procedure, 353 (37.2%) at 5 years, and 348 (36.7%) at 10 years. The overall incidence of patient-reported postdischarge AF was 34.4% (n = 326), and at 3, 5, and 10 years, the incidences were 22.2%, 34.8%, and 42.5% (P < .001). After multivariable adjustment, history of preoperative AF (odds ratio [OR] 5.566, P < .001), early postoperative AF within the first 30 days (OR 2.211, P < .001), preoperative left atrial volume index (OR 1.014, P = .005), postoperative right ventricular systolic pressure (OR 1.021, P = .013), postoperative moderate or greater mitral valve regurgitation (OR 1.893, P = .022), and preoperative septal thickness (OR 1.043, P = .036) were independently associated with patient-reported postdischarge AF. ConclusionsThe incidence of patient-reported postdischarge AF increases with increasing length of follow-up after septal myectomy. We identified several risk factors for late postdischarge AF that were associated with chronicity of left ventricular outflow tract obstruction, and earlier intervention may mitigate late atrial arrhythmias.

Left atrial remodeling after mitral valve repair for primary mitral regurgitation: evolution over time and prognostic significance

Abstract Background Although preoperative left atrial (LA) dilation is a well-known predictor of adverse cardiovascular events in patients with severe, primary mitral regurgitation (MR), little is known about LA reverse remodeling after mitral valve (MV) surgery and its prognostic value. Purpose This study sought to systematically investigate the changes in LA volume in patients undergoing MV repair for severe, primary MR and the association between LA volume after surgery and long-term outcome. Methods In patients undergoing MV repair for severe, primary MR, echocardiography was evaluated at three different time points: pre-operatively, immediate postoperatively (5 [4–6] days) and within 1–3 years (19 [14–24] months) follow-up. Outcome was all-cause mortality happening after the third echocardiographic evaluation. Results A total of 226 patients (mean age 62±13 years, 66% male) were included. Mean pre-operative LA volume index (LAVi) was 56±28 ml/m2 and significantly decreased immediately after surgery (to 38±21 ml/m2; p&amp;lt;0.001) as well as at long-term follow-up (to 32±17 ml/m2; p&amp;lt;0.001). Significant correlations were found between reduction in LAVi at long-term follow-up and age (R=−0.139; p=0.037), pre-operative left ventricular end-diastolic volume index (R=0.199; p=0.003), preoperative LAVi (R=0.498; p&amp;lt;0.001), preoperative effective regurgitant orifice area (R=0.205; p=0.004), preoperative regurgitant volume (R=0.222; p=0.002) and postoperative transmitral mean pressure gradient at long-term follow-up (R=−0.150; p=0.026). Patients were subsequently divided into 3 groups: patients with a preoperative LAVi &amp;lt;42 ml/m2 (n=68), based on the definition of moderately dilated LA; patients with a LAVi 42–59 ml/m2 (n=88) and patients with a LAVi ≥60 ml/m2 (n=70), based on the current class IIaC indication for intervention in primary MR. Although patients with a LAVi ≥60 ml/m2 at baseline showed the most pronounced reduction in LAVi, their values of LAVi at long-term follow-up remained above the range of normality (figure 1). During a median follow-up of 72 (40–114) months, 43 (19.0%) patients died. Patients who had a LAVi ≥42 ml/m2 at long-term follow-up (3rd echocardiographic evaluation) showed significantly higher mortality rates as compared to patients with a LAVi &amp;lt;42 ml/m2 (p&amp;lt;0.001) (figure 2). Multivariable Cox regression analysis showed that, after adjusting for age, sex and coronary artery disease, postoperative LAVi ≥42ml/m2 at long-term follow-up remained independently associated with all-cause mortality (HR 2.494; CI 1.292 to 4.815; p=0.006). Conclusions In patients with severe primary MR, LA reverse remodeling occurs immediately after MV repair, with a further reduction in LAVi during follow-up. Patients in whom LAVi does not remodel to normal values present worse long-term prognosis as compared to patients who achieve normal LAVi values. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): ESC Training Grant (Appehab724.011664741). Changes in LA volume over timeKM curve for all-cause mortality

W36. INTEGRATING FUNCTIONAL NEUROIMAGING AND SERUM PROTEINS CAN IMPROVE THE DIAGNOSTIC ACCURACY OF MAJOR DEPRESSIVE DISORDER: A PILOT STUDY

The ability of perioperative fluid management to prevent postoperative recurrence of atrial tachyarrhythmia remains controversial. The aim of the present study was to assess if intraoperative net fluid balance was associated with atrial tachyarrhythmia recurrence after the Cryo-Maze procedure.An observational cohort study.A tertiary care hospital from April 2007 to May 2019.Four hundred forty-four patients undergoing the Cryo-Maze procedure in conjunction with other cardiac surgeries.The Cryo-Maze procedure in conjunction with other cardiac surgeries.The main outcome was early atrial tachyarrhythmia recurrence, consisting of atrial fibrillation, atrial flutter, or atrial tachycardia, within the first three months after surgery. Complete follow-up was achieved in 443 patients (99.8%), of them 127 (28.6%) developed early atrial tachyarrhythmia recurrence. The median intraoperative net fluid balance was 1,627 mL (interquartile range, −215 to 3,557 mL). Multivariate logistic regression showed that intraoperative net fluid balance (p = 0.001), preoperative AF duration (adjusted odds ratio, 1.40; 95% CI, 1.17-1.68; p < 0.001) and left atrial volume index (aOR, 1.61; 95% CI, 1.06-2.45; p = 0.025) were independent predictors of early atrial tachyarrhythmia recurrence. The adjusted log odds were lowest (–1.52) when net fluid balance was 1,557 mL.There is a significant U-shaped association between intraoperative net fluid balance and early atrial tachyarrhythmia recurrence among patients undergoing the Cryo-Maze procedure.

U-Shaped Association Between Intraoperative Net Fluid Balance and Risk of Postoperative Recurrent Atrial Tachyarrhythmia Among Patients Undergoing the Cryo-Maze Procedure: An Observational Study

The ability of perioperative fluid management to prevent postoperative recurrence of atrial tachyarrhythmia remains controversial. The aim of the present study was to assess if intraoperative net fluid balance was associated with atrial tachyarrhythmia recurrence after the Cryo-Maze procedure. An observational cohort study. A tertiary care hospital from April 2007 to May 2019. Four hundred forty-four patients undergoing the Cryo-Maze procedure in conjunction with other cardiac surgeries. The Cryo-Maze procedure in conjunction with other cardiac surgeries. The main outcome was early atrial tachyarrhythmia recurrence, consisting of atrial fibrillation, atrial flutter, or atrial tachycardia, within the first three months after surgery. Complete follow-up was achieved in 443 patients (99.8%), of them 127 (28.6%) developed early atrial tachyarrhythmia recurrence. The median intraoperative net fluid balance was 1,627 mL (interquartile range, -215 to 3,557 mL). Multivariate logistic regression showed that intraoperative net fluid balance (p = 0.001), preoperative AF duration (adjusted odds ratio, 1.40; 95% CI, 1.17-1.68; p < 0.001) and left atrial volume index (aOR, 1.61; 95% CI, 1.06-2.45; p = 0.025) were independent predictors of early atrial tachyarrhythmia recurrence. The adjusted log odds were lowest (-1.52) when net fluid balance was 1,557 mL. There is a significant U-shaped association between intraoperative net fluid balance and early atrial tachyarrhythmia recurrence among patients undergoing the Cryo-Maze procedure.

Isolated left atrial cryoablation of atrial fibrillation in conventional mitral valve surgery.

Recent trends of surgery for atrial fibrillation (AF) are towards more safe and effective energy sources, as well as to simplified sets of atrial lesions. One hundred eighteen (mean age, 67.4±9.2years) selected patients with paroxysmal/persistent AF and mitral valve (MV) disease underwent cryoablation of AF combined with conventional (not via mini-thoracotomy) MV surgery; the lesion set was limited to only the left atrium. Multivariable analyses identified predictors of cardiac rhythm at hospital discharge and follow-up. There were 7 (5.9%) hospital deaths; 33 (28%) patients were discharged on AF. Higher values of preoperative left atrial volume index (odds ratio [OR]=1.07, 95% confidence interval [95%CI]: 1.01-1.13) and mixed etiology of MV disease (OR=4.19, 95%CI: 1.23-14.2) were predictors of hospital discharge on AF. Seventy-four (66.7%) patients were on stable sinus rhythm at follow-up (median period, 6.6years); the 1, 5, and 10-year nonparametric estimates of adjusted freedom from AF were 98.1%, 89.2% and 45.6%, respectively. Higher values of preoperative systolic pulmonary artery pressure (hazard ratio [HR]=HR=1.04, 95%CI: 1.01-1.08) and AF at hospital discharge (HR=4.14, 95%CI: 1.50-11.4) were predictors of AF at follow-up. During conventional MV surgery, a cryo-lesion set limited to only the left atrium may give good, immediate and long-term results. Left atrial dilation and mixed etiology of MV disease were predictors of hospital discharge on AF. Preoperative pulmonary hypertension and AF at discharge combined with an increased risk of AF at follow-up.

Preoperative left atrial strain abnormalities are associated with the development of postoperative atrial fibrillation following isolated coronary artery bypass surgery

ObjectivePostoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG). Currently, there is no reliable way to determine preoperatively which patients will develop POAF following CABG. The aim of this study was to determine whether preoperative left atrial (LA) strain analysis might identify patients destined to develop POAF following CABG. MethodsFrom 2016 to 2018, 211 patients who had a preoperative left ventricular ejection fraction >50% and adequate preoperative, predischarge, and follow-up echo images for interpretation underwent isolated CABG surgery. Postoperatively, patients had continuous rhythm monitoring until hospital discharge. Retrospective speckle-tracking analysis of preoperative echocardiograms was performed to calculate preoperative left ventricular global longitudinal strain and LA compliance and contraction strains in 92 matched patients. Multivariate logistic regression and Cox proportional hazards models were used to determine the predictors of POAF after CABG. ResultsPOAF occurred in 50 patients (24%). They were older, had longer intensive care unit and hospital stays, and a slightly greater 30-day mortality (P = .07). Preoperative LA volume index was larger in the patients with POAF but still “normal” as defined by current guidelines. However, preoperative LA compliance and contraction strains were significantly lower in patients who developed POAF after CABG. ConclusionsDecreased preoperative LA strain measurements, especially LA-fractional area change, LA-emptying fraction, and LA-reservoir strain, taken jointly, are more specific and sensitive than other preoperative parameters in identifying patients who will develop POAF following CABG. The ability to identify patients preoperatively who are destined to develop POAF following CABG provides a basis for limiting POAF prophylactic therapy to only those patients undergoing CABG who are most likely to benefit from it rather than to all patients undergoing CABG.

Timing of Valve Repair for Asymptomatic Mitral Regurgitation and Preserved Left Ventricular Function

According to current guidelines, mitral valve repair is reasonable in asymptomatic patients with severe degenerative mitral regurgitation and preserved left ventricular (LV) function. However, the surgical timing is challenging. This study aims to identify risk factors and delineate a quantitative threshold for predicting postoperative outcomes. In all, 623 asymptomatic degenerative mitral regurgitation patients with left ventricular ejection fraction (LVEF) 60% or greater and LV end-systolic diameter less than 40 mm who underwent mitral valve repair were retrospectively reviewed. Logistic regression analysis and receiver-operating characteristics curves were used to analyze predictors for early postoperative LV dysfunction (LVEF less than 50%), and mid to long-term outcomes were analyzed by Kaplan-Meier analysis. The postoperative inhospital mortality was 0.96%. Survival at 1, 3, 5, and 10 years was 98.8%, 97.7%, 94.5%, and 90.4%, respectively; and freedom from moderate or severe mitral regurgitation at 1, 3, 5, and 10 years was 98.6%, 95%, 92.4%, and 83.6%, respectively. Logistic regression analysis indicated that early postoperative LV dysfunction was associated with preoperative LVEF (hazard ratio 0.933; 95% confidence interval, 0.891 to 0.977; P= .003) and left atrial volume index (hazard ratio 1.212; 95% confidence interval, 1.106 to 1.329; P < .001). Receiver-operating characteristics curve analysis identified preoperative LVEF 65% (area under the curve 0.765; P < .001) and left atrial volume index 53 mL/m2 (area under the curve 0.733; P < .001) as the best cutoff values for predicting early postoperative LV dysfunction. Furthermore, midterm to long-term survival was significantly lower among patients with early postoperative LV dysfunction than among patients with normal LV function (hazard ratio 3.19; 95% confidence interval, 1.41 to 7.23; P= .005). Preoperative LVEF and left atrial volume index were the predictors for early postoperative LV dysfunction, which further lead to poor long-term survival after mitral valve repair in asymptomatic degenerative mitral regurgitation patients with preserved LV function. Surgery intervention should be encouraged before onset of LVEF less than 65% or left atrial volume index 53 mL/m2 or more.

Higher preoperative left atrial volume index predicts lack of mitral regurgitation improvement after transcatheter aortic valve replacement.

Moderate-to-severe mitral regurgitation is present in 20-35% of patients undergoing transcatheter aortic valve replacement (TAVR) and the current literature lacks simple echocardiographic parameters, which can predict post-TAVR changes in mitral regurgitation. The aim of this study is to investigate the echocardiographic predictors of improvement or worsening of mitral regurgitation in patients undergoing TAVR with moderate-to-severe mitral regurgitation. This retrospective study included 113 patients who underwent TAVR with preoperative mitral regurgitation grade at least 2. Patients with concomitant coronary artery disease requiring treatment were excluded. Mitral regurgitation was related to the annular dilatation or tethering mechanism in all patients. Preoperative and postoperative echocardiographies were compared in terms of mitral regurgitation and other commonly measured parameters. After TAVR, a reduction in mitral regurgitation was observed in 62.8% of cases. On the basis of the difference between postoperative and preoperative echocardiograms, 71 patients had improved mitral regurgitation, whereas 42 patients had stable or worsened mitral regurgitation. After analyzing preoperative echocardiographic parameters with regard to this group difference, left atrial volume index (LAVI) was the only variable that was different between groups (33.4 ± 4.8 ml/m in improved mitral regurgitation vs. 39.8 ± 3.0 ml/m in not improved mitral regurgitation, P < 0.001). In a multivariable logistic regression model, a LAVI increase was associated with lack of an acute reduction in mitral regurgitation (odds ratio = 1.41, P < 0.001) after adjustment for age and preoperative serum creatinine. Higher preoperative LAVI is a determinant predictor of lack of an acute reduction in mitral regurgitation after TAVR, and LAVI could be used as a stratifying tool to tailor the treatment strategy and the timing of the procedures. However, validation of these results and long-term outcomes are warranted to support those conclusions.

Preoperative left atrial volume index is associated with postoperative outcomes in mitral valve repair for chronic mitral regurgitation

ObjectiveTo assess determinants of left atrial reverse remodeling after mitral valve repair and to evaluate the impact of preoperative left atrial volume on postoperative outcomes. MethodsWe reviewed the records of 720 patients who underwent mitral valve repair from September 2008 to July 2015 and had preoperative measurement of left atrial volume index. We analyzed the association of preoperative left atrial volume index on early and late outcomes, and determined which baseline characteristics are associated with left atrial reverse remodeling, as measured by changes in left atrial volume index in 512 patients who had at least 1 postoperative measurement. ResultsThe median (interquartile range) preoperative left atrial volume index was 54.0 (44.0-66.0) mL/m2. Preoperative left atrial volume index, age, body mass index, and atrial fibrillation were independently associated with the degree of left atrial reverse remodeling over the follow-up period. Reverse remodeling was greatest in patients with higher baseline left atrial volume index (P < .001), but less reverse remodeling was observed in patients with advanced age (P < .001), preoperative atrial fibrillation (P < .001), and extreme values of body mass index (P = .004), although these effects were moderately attenuated when limiting the analysis to 6-month follow-up. Secondary analysis demonstrated marginally significant effects of preoperative left atrial volume index on risks of early postoperative atrial fibrillation (P = .030) and late mortality (P = .077) after adjusting for age and sex. ConclusionsIn patients with degenerative mitral valve regurgitation who had mitral valve repair, preoperative left atrial volume index was associated with extent of left atrial reverse remodeling, risk of early postoperative atrial fibrillation, and late mortality. The majority of reverse remodeling occurs within the first month after operation and is greatest in younger patients.

Mid-term results of valve repairs for atrial functional mitral and tricuspid regurgitations.

This study aimed to determine the mid-term outcomes of surgical valve repairs for atrial functional mitral regurgitation and tricuspid regurgitation in patients with atrial fibrillation. From October 2008 to August 2016, we performed mitral and tricuspid valve repairs in 45 patients with permanent atrial fibrillation, chronic heart failure, preserved left ventricular ejection fraction, and at least moderate functional mitral regurgitation and mild functional tricuspid regurgitation. The follow-up period ranged from 56 to 3283days (2-109months; median 932days). All patients underwent both mitral and tricuspid annuloplasty. Mitral regurgitation and tricuspid regurgitation improved from 2.6 ± 0.6 (0-3) and 2.0 ± 0.7 (0-3) preoperatively to 0.4 ± 0.3 (0-3) and 0.8 ± 0.5 (0-3) at the most recent echocardiography (p < 0.0001 and p < 0.0001), respectively. Further, the New York Heart Association functional class dramatically improved from 2.8 ± 0.7 to 1.5 ± 0.7 (p < 0.0001). Postoperative cardiovascular events occurred in 10 patients, including 3 with re-admissions for heart failure. The event-free rates were 93%, 87%, and 52% at 1, 3, and 5years after surgery, respectively. The preoperative left atrial volume index was the independent predictor of postoperative cardiovascular events. Our results suggest that mitral and tricuspid valve repairs lead to reductions in regurgitations and heart failure symptoms in patients with atrial functional mitral and tricuspid regurgitations. The preoperative left atrial size should be recognized as an important risk factor of postoperative cardiovascular events.

Long-term results of monopolar versus bipolar radiofrequency ablation procedure for atrial fibrillation.

In this study, we aimed to evaluate the long-term outcomes of monopolar or bipolar radiofrequency ablation concomitant to mitral valve surgery in patients with atrial fibrillation. We retrospectively evaluated a total of 167 patients (67 males, 100 females; mean age 56.8±6.9 years; range, 48 to 65 years) with atrial fibrillation who underwent monopolar or bipolar radiofrequency ablation concomitant to mitral valve surgery between September 2001 and January 2015. The patients were divided into two groups according to the procedure applied as those undergoing monopolar ablation (group 1, n=68) and those undergoing bipolar ablation (group 2, n=99). All patients were followed by electrocardiogram and 24-h Holter monitoring. Echocardiography was performed before discharge, at three and 12 months postoperatively, and annually thereafter. Left atrial volume index, left atrial diameter, and left ventricular ejection fraction were recorded. There was no significant correlation between the procedure applied and hypertension, hyperlipidemia, diabetes mellitus, chronic obstructive pulmonary disease, history of the cerebrovascular events (p>0.05). The mean preoperative left atrial diameter decreased from 5.3±0.5 cm to 4.9±0.5 cm postoperatively in all patients (p=0.0001). The mean preoperative left atrial volume index decreased from 53.8±0.4 mL/m2 t o 43.7±6.2 m L/m2 i n t he postoperative period (p=0.0001). During follow-up, 61.8% (n=42) of the patients in group 1 and 62.6% (n=62) of the patients in group 2 remained in sinus rhythm. One patient (1.5%) in group 1 and two patients (2.0%) in group 2 developed early postoperative cerebrovascular accident. Monopolar and bipolar ablation methods are safe and effective methods to ensure long-term sinus rhythm. Both procedures do not increase the morbidity risk with very low thromboembolic complication rates.

Postoperative atrial fibrillation after aortic valve replacement is a risk factor for long-term atrial fibrillation.

Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery. However, knowledge on the rate of long-term atrial fibrillation (LTAF) after POAF remains unclear. We investigated predictors of POAF in patients with aortic stenosis undergoing surgical aortic valve replacement, and assessed the rate of LTAF during follow-up. We prospectively included 96 adult patients with severe aortic stenosis undergoing surgical aortic valve replacement. Patients with previous atrial fibrillation (AF) were excluded. Patients underwent echocardiography, cardiac computed tomography and magnetic resonance imaging immediately prior to surgery. Surgical aortic clamp time and postoperative C-reactive protein (CRP) were documented. POAF was defined as AF recorded within 7 days of surgery. Through chart review, patients were followed up for documented episodes of LTAF occurring more than 7 days after surgery. POAF occurred in 51 patients (53%). It was associated with larger preoperative echocardiographic left atrial volume index (44 ± 12 vs 37 ± 8 ml/m2, P = 0.004), longer aortic clamp time [80 (70-102) vs 72 (62-65) min, P = 0.04] and higher CRP on first postoperative day [80 (64-87) vs 65 (44-83) mg/l, P = 0.001]. Multivariable logistic regression revealed that left atrial volume index [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.02-1.13; P = 0.005] and postoperative CRP (OR 1.03, 95% CI 1.01-1.05; P = 0.006) were the only independent predictors of POAF. During 695 days (25th-75th percentile: 498-859 days) of follow-up, LTAF occurred in 11 patients of whom 10 were in the POAF group (hazard ratio 9.4, 95% CI 1.2-74; P = 0.03). POAF is predicted by left atrial volume index and postoperative CRP. Patients with POAF have a 9-fold increase risk of developing symptomatic LTAF during follow-up. ClinicalTrials.gov (NCT02316587).

Preoperative Echocardiographic Indices of Diastolic Dysfunction and Brain Natriuretic Peptide in Predicting Postoperative Atrial Fibrillation After Noncardiac Surgery.

We have shown previously that either echocardiographic indices of diastolic dysfunction or increased preoperative brain natriuretic peptide (BNP) predict postoperative atrial fibrillation (POAF). Because these 2 predictors of POAF have not been evaluated together, our goal was to further elucidate their concurrent role in patients undergoing noncardiac thoracic surgery. We retrospectively identified 191 patients who had a preoperative transthoracic echocardiogram and serum BNP level collected as part of routine care before major lung or esophageal resection. Clinical and echocardiographic data were compared between patients who did or did not develop POAF (>5 minutes), and prognostic factors for POAF were identified. Univariate associations with POAF (41 of 191; 22% patients) included older age (P = .04), male sex (P = .01), hypertension (P = .03), increased body mass index (P = .01), and prolonged transmitral flow deceleration time (P < .0001), whereas BNP was not statistically significant (P = .07). Stepwise logistic regression analysis showed that both increasing transmitral flow deceleration time (continuous data log base 2 transformed; odds ratio, 16.05; 95% confidence interval, 3.74-68.96; P = .0002) and left atrial diastolic volume index (continuous data log base 2 transformed; odds ratio, 3.29; 95% confidence interval, 1.22-8.91; P = .02) were independent risk factors of POAF (area under the receiver operating characteristic curve = 0.73). There was no significant interaction between BNP and the 2 independent variables (P = .60, and P = .90), respectively. In a cohort of patients who had echocardiography and BNP measurements before undergoing major thoracic surgery, this study showed that when evaluated together greater preoperative left atrial diastolic volume index and transmitral flow deceleration time but not BNP levels were independent predictors for POAF.

Incidence and predictors of atrial fibrillation after coronary artery bypass surgery: detection by event loop recorder monitoring from a contemporary multicentre cohort

Background Atrial fibrillation (AF) is a frequent complication after cardiac surgery. We explored the incidence and predictors of post-operative AF at 30-day follow-up in an unselected multi-centre cohort of patients undergoing elective coronary artery bypass grafting (CABG) in contemporary practice.Methods and results We enrolled 740 consecutive patients scheduled for elective CABG with or without valve surgery. Cardiac rhythm was continuously monitored for 15 days after surgery by an ambulatory event loop recorder. Clinical follow-up for the occurrence of arrhythmias was performed for the next 15 days by office visits. The primary end point was the incidence of AF at 30-day follow-up. Mean age was 56.5 ± 8.9 years; 69.5% were males; 80% had diabetes. All patients completed 30-day follow-up. At the end of 30 days, AF occurred in 77 patients (10.4%). Most episodes (47 out of 77 episodes, 61%) of AF occurred during post-operative day 2. Episodes of AF were very rare after the first 5 post-operative days (3 out of 77 episodes, 3.9%). Multivariable regression analysis identified the following independent predictors of AF at 30-day follow-up: the lack of beta blocker use (hazard ratio 0.37, 95% confidence interval 0.21-0.64, P < 0.001), and the preoperative left atrial volume index (hazard Ratio 2.21, 95% confidence interval 1.79-2.74, P < 0.001).Conclusions In patients undergoing elective CABG, the incidence of post-operative AF at 30-day follow-up is rather low; the lack of beta blocker use in the perioperative period, and the preoperative left atrial volume index independently predicted the occurrence of AF at 30 days.

Atrial longitudinal strain parameters predict left atrial reverse remodeling after mitral valve surgery: a speckle tracking echocardiography study.

Volume overload in chronic severe mitral regurgitation (MR) causes left atrial (LA) remodeling. Volume overload generally diminishes after mitral valve surgery and LA size and shape are expected to recover. The recovery of LA functions named as reverse remodeling is said to be related with prognosis and mortality. A few clinical and echocardiographic parameters have been reported to be associated with LA reverse remodeling. In this study, we investigated the relationship between LA peak longitudinal strain (reservoir strain) assessed with 2-dimensional speckle tracking echocardiography (2D STE) and LA reverse remodeling. 53 patients (24 females and 29 males, mean age: 45.7 ± 13.5 years) with severe MR and preserved left ventricular systolic function were included in the study. All patients had normal sinus rhythm. The etiology of MR was mitral valve prolapse (MVP) in 37 patients and rheumatic valvular disease in 16 patients. Mitral valve repair was performed in 30 patients while 23 underwent mitral valve replacement. Echocardiography was performed before the surgery and 6 months later. LA peak atrial longitudinal strain (PALS) was assessed with speckle tracking imaging. LA reverse remodeling was defined as a percent of decrease in LA volume index (LAVI). Left atrial volume index significantly decreased after surgery (58.2 ± 16.6 vs. 43.9 ± 17.2 ml/m2, p ≤ 0.001). Mean LAVI reduction was 22.5 ± 27.2%. There was no significant difference in LAVI reduction between mitral repair and replacement groups (22.1 ± 22.6 vs. 23.1 ± 32.8 %, p = 0.9). Although the decrease in LAVI was higher in MVP group than rheumatic group, it was not statistically significant (24.4 ± 26.8 vs. 18.2 ± 28.9%, p = 0.4). Correlates of LAVI reduction were preoperative LAVI (r 0.28, p = 0.039), PALS (r 0.36, p = 0.001) and age (r -0.36, p = 0.007). Furthermore, in multivariate linear regression analysis (entering models), preoperative LAVI, age and PALS were all significant predictors of LA reverse remodeling (p ≤ 0.001, p = 0.04, p = 0.001 respectively). Left atrial peak longitudinal strain measured by 2D STE, in conjunction with preoperative LAVI and age is a predictor of LA reverse remodeling in patients undergoing surgery for severe MR. We suggest that in this patient population, PALS may also be used as a preoperative prognostic marker.

Preoperative left atrial volume index predicts postoperative atrial fibrillation in patients with severe aortic valve stenosis

Left atrial enlargement correlates with the severity of diastolic dysfunction and is a predictor of cardiovascular complications such as atrial fibrillation. Aortic valve stenosis (AS) causes left atrial enlargement and progression of diastolic dysfunction. The aim of this study was to investigate the efficacy of the preoperative left atrial volume index (LAVI) in predicting postoperative outcome in patients with severe AS. Forty-seven patients with severe AS who underwent aortic valve replacement were examined. Transthoracic echocardiography and LAVI measurement were performed on admission. Patients were divided into two groups according to optimal cut-off values of LAVI derived from receiver operating characteristic curves for postoperative atrial fibrillation (POAF) (group S: LAVI <52 ml/m(2), group L: LAVI ≥52 ml/m(2)). The incidence of POAF, ventilation time, inotropic support time, duration of stay in intensive care, and overall duration of hospital stay were evaluated. By univariate analysis, the incidence of POAF in group S was significantly lower than that in group L (25.9 and 65.0%, respectively; P < 0.01). Values for other parameters were higher in group L, although the differences were insignificant. In patients with severe AS, a preoperative LAVI of ≥52 ml/m(2) may be a useful predictor of POAF, although the efficacy of this index for predicting other postoperative outcomes has yet to be determined.