A. Marc Gillinov

ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons.

Sidney C. Smith, Jr, MD, FACC, FAHA, Chair Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair Cynthia D. Adams, RN, PhD, FAHA[§][1] Jeffrey L. Anderson, MD, FACC, FAHA[§][1] Christopher E. Buller, MD, FACC Mark A. Creager, MD, FACC, FAHA Steven M. Ettinger, MD, FACC David P. Faxon, MD, FACC,

2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.

Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons Andrew E. Epstein, MD, FACC, FAHA, FHRS, Chair ; John P. DiMarco, MD, PhD, FACC, FHRS; Kenneth A. Ellenbogen. MD, FACC, FAHA, FHRS; N.A. Mark Estes III, MD, FACC, FAHA, FHRS; Roger A.

Durability of mitral valve repair for degenerative disease

BACKGROUND Degenerative mitral valve disease is the most common cause of mitral regurgitation in the United States. Mitral valve repair is applicable in the majority of these patients and has become the procedure of choice. OBJECTIVE This study was undertaken to identify factors influencing the durability of mitral valve repair. PATIENTS AND METHODS Between 1985 and 1997, 1072 patients underwent primary isolated mitral valve repair for valvular regurgitation caused by degenerative disease. Repair durability was assessed by multivariable risk factor analysis of reoperation. It was supplemented by a search for valve-related risk factors for death before reoperation. Three hospital deaths occurred (0.3%); complete follow-up (4152 patient-years) was available in 1062 of 1069 hospital survivors (99.3%). RESULTS At 10 years, freedom from reoperation was 93%. Among 30 patients who required reoperation for late mitral valve dysfunction, the repair failed in 16 (53%) as a result of progressive degenerative disease. Durability of repair was adversely affected by pathologic conditions other than posterior leaflet prolapse, use of chordal shortening, annuloplasty alone, and posterior leaflet resection without annuloplasty. Durability was greatest after quadrangular resection and annuloplasty for posterior leaflet prolapse and was enhanced by the use of intraoperative echocardiography. Death before reoperation was increased in patients having isolated anterior leaflet prolapse or valvular calcification and by use of chordal shortening or annuloplasty alone. CONCLUSIONS Repair durability is greatest in patients with isolated posterior leaflet prolapse who have posterior leaflet resection and annuloplasty. Chordal shortening, annuloplasty alone, and leaflet resection without annuloplasty jeopardize late results.

Phased-array intracardiac echocardiography monitoring during pulmonary vein isolation in patients with atrial fibrillation: impact on outcome and complications.

Background—The objective of this study was to assess the impact of intracardiac echocardiography (ICE) on the long-term success and complications in patients undergoing pulmonary vein isolation (PVI) for treatment of atrial fibrillation (AF). Methods and Results—Three hundred fifteen patients underwent PVI for treatment of AF. Each patient underwent ostial isolation of all PVs using a cooled-tip ablation catheter. PVI was performed using circular mapping (CM) alone (group 1, 56 patients), CM and ICE (group 2, 107 patients), and CM and ICE with titration of radiofrequency energy based on visualization of microbubbles by ICE (group 3, 152 patients). After a mean follow-up time of 417±145 days, 19.6% (11 of 56), 16.8% (18 of 107), and 9.8% (15 of 152) of patients in groups 1, 2, and 3 experienced recurrence of AF, respectively. Moreover, whereas no group 3 patient experienced severe (>70%) PV stenosis, severe PV stenosis was documented in 3 (3.5%) of 56 patients in group 1 and in 2 (1.8%) of 107 patients in group 2 (P <0.05). No embolic events were detected in group 3 patients. Conclusions—Intracardiac echocardiography improves the outcome of cooled-tip PVI. Power adjustment guided by direct visualization of microbubble formation reduces the risk of PV stenosis and improves long-term cure.

ACC/AHA/HRS 2008 Guidelines for device-based therapy of cardiac rhythm abnormalities.

the American College of Cardiology Foundation Board of ssociation Science Advisory and Coordinating Committee, oard of Trustees in February 2008. iology Foundation, American Heart Association, and Heart s document be cited as follows: Epstein AE, DiMarco JP, I, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, y MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, CC/AHA/HRS 2008 guidelines for device-based therapy of report of the American College of Cardiology/American n Practice Guidelines (Writing Committee to Revise the deline Update for Implantation of Cardiac Pacemakers and oll Cardiol 2008;51:e1–62. This article h 2008 issue of H Copies: Thi College of C americanheart.o document, plea reprints@elsevie Permissions: tion of this doc College of Ca Society. Pleas elsevier.com. avid L. Hayes, MD, FACC, FAHA, FHRS* ark A. Hlatky, MD, FACC, FAHA . Kristin Newby, MD, FACC, FAHA ichard L. Page, MD, FACC, FAHA, FHRS ark H. Schoenfeld, MD, FACC, FAHA, FHRS ichael J. Silka, MD, FACC ynne Warner Stevenson, MD, FACC, FAHA‡ ichael O. Sweeney, MD, FACC*

Success of Surgical Left Atrial Appendage Closure : Assessment by Transesophageal Echocardiography

OBJECTIVES We sought to determine which surgical technique of left atrial appendage (LAA) closure is most successful by assessing them with transesophageal echocardiography (TEE). BACKGROUND Atrial fibrillation is a risk factor for stroke, with 90% of clots occurring in the LAA. Several surgical techniques of LAA closure are used to theoretically reduce the stroke risk, with varying success rates. METHODS A total of 137 of 2,546 patients who underwent surgical LAA closure from 1993 to 2004 had a TEE after surgery. Techniques consisted of either excision or exclusion by sutures or stapling. The TEE measurements included color Doppler flow in the LAA and interrogation for thrombus. Patent LAA, remnant LAA (residual stump >1 cm), or excluded LAA with persistent flow into the LAA were identified as unsuccessful closure. RESULTS Of the 137 patients, 52 (38%) underwent excision and 85 (62%) underwent exclusion (73 suture and 12 stapler). Only 55 of 137 (40%) of closures were successful. Successful LAA closure occurred more often with excision (73%) than suture exclusion (23%) and stapler exclusion (0%) (p < 0.001). We found LAA thrombus to be present in 28 of 68 patients (41%) with unsuccessful LAA exclusion versus none with excision. At time of TEE, 6 patients with successful LAA closure (11%) and 12 with unsuccessful closure (15%) had evidence of stroke/transient ischemic attack (p = 0.61). CONCLUSIONS There is a high occurrence of unsuccessful surgical LAA closure. Of the various techniques, excision appears to be the most successful.

The Cox-Maze procedure: the Cleveland Clinic experience.

The Cox-Maze procedure was designed to address the consequences of atrial fibrillation, tachycardia, hemodynamic impairment, and thromboembolism. From 1991 until June 1999, 100 patients underwent the Maze operation at the Cleveland Clinic Foundation. The group included 72 men with a mean age of 58 +/- 11 years (range, 23 to 78 years). Initially, the Maze-I procedure was performed primarily for patients with lone atrial fibrillation. However, since 1995, the Maze-III procedure has been performed exclusively, and it is typically combined with mitral valve repair. Twenty-three patients had only a Maze procedure, 60 patients had the Maze procedure/mitral valve repair, 10 patients had Maze procedure/coronary artery bypass, 6 had Maze procedure/mitral valve replacement, and 1 had Maze procedure/atrial septal defect repair. Chronic atrial fibrillation was present in 78% of patients for a mean of 8 +/- 9 years. There was a 1% perioperative mortality and 5% late mortality rate. Median hospital stay was 9 +/- 5 days. Six patients required new early permanent pacemaker insertion. With a mean follow-up of 3 years, 90.4% of patients are in sinus rhythm (or atrial pacing). Preoperative symptoms were reduced: 24% had preoperative syncope; none had syncope in follow-up; 14% of patients preoperatively had cerebral or systemic emboli; and there were no perioperative or late embolic events. The Maze procedure effectively addressed the major complications of atrial fibrillation and was associated with low perioperative and late morbidity rates.

Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation

BACKGROUND In a trial comparing coronary-artery bypass grafting (CABG) alone with CABG plus mitral-valve repair in patients with moderate ischemic mitral regurgitation, we found no significant difference in the left ventricular end-systolic volume index (LVESVI) or survival after 1 year. Concomitant mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation, but patients had more adverse events. We now report 2-year outcomes. METHODS We randomly assigned 301 patients to undergo either CABG alone or the combined procedure. Patients were followed for 2 years for clinical and echocardiographic outcomes. RESULTS At 2 years, the mean (±SD) LVESVI was 41.2±20.0 ml per square meter of body-surface area in the CABG-alone group and 43.2±20.6 ml per square meter in the combined-procedure group (mean improvement over baseline, -14.1 ml per square meter and -14.6 ml per square meter, respectively). The rate of death was 10.6% in the CABG-alone group and 10.0% in the combined-procedure group (hazard ratio in the combined-procedure group, 0.90; 95% confidence interval, 0.45 to 1.83; P=0.78). There was no significant between-group difference in the rank-based assessment of the LVESVI (including death) at 2 years (z score, 0.38; P=0.71). The 2-year rate of moderate or severe residual mitral regurgitation was higher in the CABG-alone group than in the combined-procedure group (32.3% vs. 11.2%, P<0.001). Overall rates of hospital readmission and serious adverse events were similar in the two groups, but neurologic events and supraventricular arrhythmias remained more frequent in the combined-procedure group. CONCLUSIONS In patients with moderate ischemic mitral regurgitation undergoing CABG, the addition of mitral-valve repair did not lead to significant differences in left ventricular reverse remodeling at 2 years. Mitral-valve repair provided a more durable correction of mitral regurgitation but did not significantly improve survival or reduce overall adverse events or readmissions and was associated with an early hazard of increased neurologic events and supraventricular arrhythmias. (Funded by the National Institutes of Health and Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT00806988.).

Tricuspid Valve Tethering Predicts Residual Tricuspid Regurgitation After Tricuspid Annuloplasty

Background—Tricuspid valve (TV) annuloplasty is recommended for functional tricuspid regurgitation (TR), which is caused by TV annulus dilatation and tethering of the leaflets. However, the impact of TV deformations on the outcome of TV annuloplasty remains unknown. The goal of this study was to investigate the relationship between preoperative TV deformation and residual TR after TV annuloplasty. Methods and Results—Two hundred sixteen patients with functional TR had 2D echocardiography before and after TV annuloplasty. Right ventricular fractional area change and left ventricular ejection fraction were determined with the apical views. Minimal TV annulus diameter was determined by frame-by-frame analysis. The distance of TV tethering was measured from the annulus plane to the coaptation point and tethering area by tracing the leaflets from the annulus plane. TR severity was determined by the ratio of the maximal jet area to the corresponding right atrial area. The severity of residual TR was associated with age, right and left ventricular dysfunction, tethering distance and area, and severity of preoperative TR (all P<0.05). TV annular dimension was not associated with outcome of TV annuloplasty. Multivariate analysis revealed that age, tethering distance, and severity of preoperative TR (all P<0.001) were independent parameters predicting residual TR. The sensitivity and specificity in predicting residual TR after surgery were 86% and 80% for tethering distances >0.76 cm and 82% and 84% for tethering areas >1.63 cm2, respectively. Conclusions—Severe TV tethering predicted residual TR after TV annuloplasty, whereas preoperative TV annular dimension was not associated with outcome of TV annuloplasty.

Atrial fibrillation: current surgical options and their assessment

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with morbidity and mortality. Traditional surgical treatment of AF is the Cox-Maze III procedure, a complicated operation. New surgical approaches include alternate energy sources (radiofrequency, microwave, cryothermy) and simplified left atrial lesion sets. These operations cure AF in 70% to 80% of patients. This review describes contemporary and emerging surgical approaches to AF, synthesizes results of these operations, and proposes new standards for reporting results of AF treatment.