Results of Cryoablation for Atrial Fibrillation Concomitant With Video-Assisted Minimally Invasive Mitral Valve Surgery

The frail patient undergoing cardiac surgery: lessons learned and future perspectives

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.

Outcomes of concomitant surgical ablation in patients undergoing surgical myectomy for hypertrophic obstructive cardiomyopathy: A systematic review and meta-analysis

OBJECTIVE

Studies investigating the efficacy of concomitant surgical atrial fibrillation (AF) ablation in hypertrophic obstructive cardiomyopathy (HOCM) patients undergoing myectomy are scarce and limited in terms of sample size. We aim to summarize current outcomes of concomitant surgical AF ablation in HOCM patients undergoing surgical myectomy.

METHODS

This systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included all studies reporting any of the following outcomes of concomitant surgical AF ablation in HOCM patients: freedom from recurrence of AF, overall survival and complications. Outcomes were evaluated using traditional meta-analysis at given time-points and using pooled Kaplan-Meier curves.

RESULTS

A total of 13 studies were included, resulting in a total of 616 individual patients available for analysis. AF was paroxysmal in 68.1% of the patients (95% CI 56.0-78.2%; I2 = 87.1%; 8 studies, 583 participants). The majority of patients (86.2%) underwent either conventional Cox Maze III or IV (95% CI 39.7-98.3%; I2 = 92.4%; 8 studies, 616 patients) procedure. The incidence of early post-operative pacemaker implantation was 6.1% (95% CI 3.1-11.8%). Overall survival at 3, 5 and 7 years was 95.6% (95% CI 93.4-97.9%), 93.6% (95% CI 90.8-96.5%) and 90.5% (95% CI 86.5-94.6%), respectively. Freedom from recurrent AF at 3, 5 and 7 years was 77.6% (95% CI 73.7-81.7%), 70.6% (95% CI 65.8-75.7) and 63.2% (95% CI 56.2-73.8%), respectively.

CONCLUSION

This meta-analysis supports concomitant surgical AF ablation at the time of surgical myectomy in HOCM patients, as it seems to be safe and effective in terminating AF.

[Surgical concepts for atrial fibrillation in patients with concomitant mitral valve disease]

OBJECTIVE

To analyze in-hospital results after «Cox-maze III» and «Cox-maze IV» procedures with concomitant mitral valve surgery.

MATERIAL AND METHODS

This study included patients who underwent «Cox-maze III» and «Cox-maze IV» procedures between January 2015 and February 2022. We distinguished 2 groups using propensity score matching: «Cox-maze III» group (n=15), «Cox-maze IV» group (n=14). All patients had preoperative atrial fibrillation: paroxysmal (3 (10.3%) patients), persistent (5 (17.2%)) and long-standing persistent (21 (72.4%) patients). Mean duration of AF before surgery was 11 [9-60] months in both groups. We used standard statistical methods using the IBM SPSS Statistics 26.0 software package (USA).

RESULTS

Aortic cross-clamping time was significantly less in the «Cox-maze IV» group (p<0.001). There was no in-hospital mortality in both groups. Mean duration of mechanical ventilation was significantly less in the «Cox-maze IV» group (5 [3.5-9] vs. 14 [12-18] hours, respectively, p<0.001). Drainage output in the first postoperative day was significantly less in the «Cox-maze IV» group (295 [220-370] vs. 400 [325-500] ml, respectively, p=0.02). Temporary pacemaker was required in 73.3% and 42.8% of cases, respectively (p=0.03).

CONCLUSION

We should emphasize high efficiency of sinus rhythm recovery after both procedures without significant difference (p=0.16). However, time of aortic cross-clamping, mechanical ventilation and volume of postoperative bleeding were significantly less in the «Cox-maze IV» group.

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

Background

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.

Methods

One hundred eighteen (mean age, 67.4 ± 9.2 years) 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.

Results

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, 6.6 years); 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.

Conclusions

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.

Left Atrial Function after Atrial Fibrillation Cryoablation Concomitant to Minimally Invasive Mitral Valve Repair: A Pilot Study on Long-Term Results and Clinical Implications

Background and Objectives: Surgical atrial fibrillation (AF) ablation concomitant to minimally invasive mitral valve repair has been proven to offer improved short- and long-term sinus rhythm (SR) maintenance compared to mitral valve surgery only. The objective of the present study was to explore, by thorough echocardiographic assessment, long-term morphological and functional left atrial (LA) outcomes after this combined surgical procedure. Materials and Methods: From October 2006 to November 2015, 48 patients underwent minimally invasive mitral valve repair and concomitant surgical AF cryoablation. Results: After 3.8 ± 2.2 years, 30 (71.4%) of those completing the follow-up (n = 42, 87.5%) presented SR. During follow-up, four (9.5%) patients suffered from cerebrovascular accidents and two of these subjects had a long-standing persistent AF relapse and were in AF at the time of the event, while the other two were in SR. An echocardiographic study focused on LA characteristics was performed in 29 patients (69.0%). Atrial morphology and function (e.g., maximal LA volume indexed to body surface area and total LA emptying fraction derived from volumes) in patients with stable SR (60.6 ± 13.1 mL/mq and 25.1 ± 7.3%) were significantly better than in those with AF relapses (76.8 ± 16.2 mL/mq and 17.5 ± 7.4%; respectively, p = 0.008 and p = 0.015). At follow-up, patients who suffered from ischemic cerebral events had maximal LA volume indexed to body surface area 61 ± 17.8 mL/mq, with total LA emptying fraction derived from volumes 23.6 ± 13.7%; patients with strokes in SR showed very enlarged LA volume (>70 mL/mq). Conclusions: AF cryoablation concomitant with minimally invasive mitral valve repair provides a high rate of SR maintenance and this relates to improved long-term morphological and functional LA outcomes. Further prospective studies are needed to define the cut-off values determining an increase in the risk for thromboembolic complications in patients with restored stable SR.

Minimally Invasive Cardiac Surgery in China: Multi-Center Experience

BACKGROUND To the best of our knowledge, there is no nationwide data available on the development of minimally invasive cardiac surgery (MICS) in China. The purpose of this study was to report the results of MICS in 6 experienced centers in China. MATERIAL AND METHODS From September 2014 to July 2016, 1241 patients with cardiac conditions who underwent MICS procedures were randomly enrolled in 6 centers in China, and those patients were randomly selected for inclusion in this study. The MICS procedures were defined as any cardiac surgery performed through a less invasive incision, rather than a complete median sternotomy, mainly including mini-incision surgery (400, 32.2%), video-assisted approach (265, 21.3%), completely thoracoscopic approach without robotic assistance (504, 40.6%), and robotic procedure (55, 4.4%). RESULTS The 5 most common in-hospital complications were respiratory failure (28, 2.3%), reoperation for all reasons (19, 1.5%), renal failure (11, 0.9%), heart failure (9, 0.7%), and stroke (6, 0.5%). The multivariate logistic regression analysis results showed that cardiopulmonary bypass (CPB) time (P=0.033), aortic cross-clamp time (P=0.003), cannulation approach (P=0.010), and left ventricular ejection fraction (LVEF) (P=0.003) at baseline were all significant risk factors of any in-hospital complication of MICS procedures. CONCLUSIONS From our experience, minimally invasive cardiac approaches are safe and reproducible, with acceptable CPB and aortic cross-clamp time duration and low mortality.