Angelo Graffigna

Left atrial isolation associated with mitral valve operations

Surgical isolation of the left atrium was performed for the treatment of chronic atrial fibrillation secondary to valvular disease in 100 patients who underwent mitral valve operations. From May 1989 to September 1991, 62 patients underwent mitral valve operations (group I); 19, mitral valve operations and DeVega tricuspid annuloplasty (group II); 15, mitral and aortic operations (group III); and 4, mitral and aortic operations and DeVega tricuspid annuloplasty (group IV). Left atrial isolation was performed, prolonging the usual left paraseptal atriotomy toward the left fibrous trigone anteriorly and the posteromedial commissure posteriorly. The incision was conducted a few millimeters apart from the mitral valve annulus, and cryolesions were placed at the edges to ensure complete electrophysiological isolation of the left atrium. Operative mortality accounted for 3 patients (3%). In 79 patients (81.4%) sinus rhythm recovered and persisted until discharge from the hospital. No differences were found between the groups (group I, 80.7%; group II, 68.5%; group III, 86.7%; group IV, 75%; p = not significant). Three late deaths (3.1%) were registered. Long-term results show persistence of sinus rhythm in 71% of group I, 61.2% of group II, 85.8% of group III, and 100% of group IV. The unique risk factor for late recurrence of atrial fibrillation was found to be preoperative atrial fibrillation longer than 6 months. Due to the satisfactory success rate in recovering sinus rhythm, we suggest performing left atrial isolation in patients with chronic atrial fibrillation undergoing valvular operations.

Surgical treatment of Wolff-Parkinson-White syndrome: Epicardial approach without the use of cardiopulmonary bypass

Abstract Epicardial dissection without the use of cardiopulmonary bypass (CPB) was performed in 88 patients (56 males and 32 females, mean age 31.9 years). With intraoperative epicardial mapping, 101 accessory pathways were detected, with multiple pathways in 11 patients. CPB was avoided in all but one patient due to frequent onset of atrial fibrillation with rapid ventricular rate. Surgical ablation was successful in 86 patients (97.6%). Three patients required multiple surgical procedures because of persistence of conduction along a component of the original pathway. All but two patients were discharged without antiarrhythmic medication; these two patients were given quinidine therapy because of atrial fibrillation, but had normal early and late electrophysiological studies. Surgical ablation of Kent bundles by the epicardial approach for the treatment of Wolff‐Parkinson‐White syndrome can be achieved without the use of CPB. Optimal and steady exposure of the area are mandatory for the procedure, and dissection is eased by avoidance of heparin required for CPB.

Coronary artery narrowing after aortic root reconstruction with resorcin-formalin glue

Severe stenosis of right and left main coronary artery ostia developed after aortic root reconstruction with gelatin-resorcin-formol glue for correction of acute type A aortic dissection. Surgical treatment of this condition required grafting of the right and left anterior descending arteries with bilateral mammary arteries on the beating heart.

Surgical ablation of ventricular tachycardia secondary to congenital ventricular septal aneurysm

Three patients underwent surgical ablation for ventricular tachycardia resulting from an aneurysm of the membranous portion of the ventricular septum. Two patients had a definite history of cardiac murmur during infancy, and one of them was found at the time of operation to have a left-to-right shunt through the apex of the aneurysm. The earliest ventricular activation sites were located around the neck of the aneurysm and were ablated in 1 patient by encircling the endocardial ventriculotomy and by cryoablation in the remaining 2. After focus resection had been completed, aneurysm resection and ventricular septal reconstruction were performed. All patients were alive and free of ventricular tachycardia and did not need medication as of 61, 66, and 88 months postoperatively. Spontaneous closure of a ventricular septal defect may lead to the formation of an aneurysm in the ventricular septum that may sustain ventricular tachycardias. Such arrhythmias can be effectively treated using electrically guided surgical techniques.

Surgical treatment for ectopic atrial tachycardia

Atrial tachycardia is an infrequent but potentially dangerous arrhythmia which often determines cardiac enlargement. Surgical ablation of the arrhythmia is effective and safe, provided a careful atrial mapping is performed and the surgical technique is tailored to the individual focus location. Eight patients underwent surgical ablation of ectopic atrial tachycardia between 1977 and 1990. Different techniques were adopted for each patient according to the anatomical location of the focus and possibly associated arrhythmias. Whenever possible, a closed heart procedure was chosen. In 1 patient a double focal origin was found and treated by separate procedures. In 1 patient with ostium secundum atrial septal defect and atrial flutter, surgical isolation of the right appendage and the ectopic focus was performed. In all patients ectopic atrial tachycardia was ablated with maintenance of the sinoatrial and atrioventricular nodal function as well as internodal conduction. In follow-up up to December 1991, no recurrency was recorded.

Pulmonary valve lipoma presenting as syncope

We report a case of a pulmonary valve lipoma presenting as syncope in a 28-year-old woman. Surgical excision of the mass was performed in urgency and the patient was discharged uneventfully.

Long-term biatrial recordings in post-operative atrial fibrillation

Although atrial fibrillation (AF) is a common complication of cardiac surgery, its pathophysiology remains unclear. The study of post-operative AF demands for the recording of cardiac electrical activity in correspondence of AF onset and progression. Long-term recordings in post-surgery patients could provide this information, but, to date, have been limited to surface signals, which precludes a characterization of the arrhythmic triggers and substrate. In this study we demonstrate the feasibility of a continuous long-term recording of atrial electrical activities from the right and left atria in post-surgery patients. Local atrial epicardial electrograms are acquired by positioning temporary pacing wires in the right and left atria at the end of the intervention, while three day recordings are obtained by a digital holter recorder, adapted to epicardial signal features. The capability of the system to map local atrial activity and the possibility to obtain quantitative information on atrial rate and synchronization from the processed epicardial signals are proven in representative examples. The quantitative description of local atrial properties opens new perspective in the investigation of post-surgery AF.

Minimally Invasive Thoracoscopic Technique for LV Lead Implantation in CRT Patients

Background: Epicardial placement of the left ventricular (LV) lead is an alternative approach to the standard cardiac resynchronization therapy (CRT) procedure. In our center we developed a minimally invasive thoracoscopic technique. We reviewed our experience to evaluate the long-term safety and effectiveness of the technique. Methods: The procedure is performed under general anesthesia with oro-tracheal intubation and right-sided ventilation, and requires 3 thoracoscopic ports (two 5-mm and one 15-mm). We analyzed 94 consecutive patients referred to our center for epicardial LV lead implantation. Results: Five patients were excluded because of concomitant conditions precluding surgery or lack of indication for CRT. The remaining 89 patients underwent the procedure. Of these, 57 had undergone previous unsuccessful LV lead implantation (Group 1). In the remaining 32 patients, effective CRT was discontinued owing to LV lead dislodgment (Group 2). LV lead implantation was successful in all patients (median pacing threshold 0.8V, IQR: 0.6-1.2, at 0.5 ms, no phrenic nerve stimulation) and CRT was successfully established in all but one patient. No complications were reported, except for 2 cases of transitory peri-electrode bleeding and 3 cases of ventricular fibrillation induced during the procedure (no sequelae). The median procedure time was 75 min (IQR: 55-95). During a median follow-up of 24 [IQR: 13-39] months, 21 patients died and 4 additional device-related complications were reported (comparable rates between groups). Conclusions: Our thoracoscopic approach proved to be safe and effective. It is a viable alternative to the standard transvenous approach in the case of failed de novo implantation and in those patients who positively respond to CRT but experience LV lead dislodgment.

TCT-660 Efficacy and Safety of the cerebral embolic protection device during TAVI

METHODS We performed a systematic review and study-level metaanalysis of RCTs that tested the efficacy and safety of EP during TAVR. RCTs using any type of EP and TAVR vascular access were included. Primary imaging efficacy endpoints were total lesion volume (TLV; in mm3) and number of new ischemic lesions. Primary clinical efficacy endpoints were any deterioration in National Institute of Health Stroke Scale (NIHSS) and Montreal Cognitive Assessment (MoCA) score at hospital discharge. Primary analyses were performed with the intention-to-treat approach. RESULTS A total of 4 RCTs (total n1⁄4252) have been included. Use of EP was associated with lower TLV (Figure; standardized mean difference [SMD]: -0.65; 95% confidence interval [CI]: -1.06 to -0.25; p1⁄40.002) and lower number of new ischemic lesions (Figure; SMD: -1.27; 95% CI: -2.45 to -0.09; p1⁄40.03). EP was associated with a trend to lower risk of deterioration in NIHSS at discharge (RR: 0.55; 95% CI: 0.27 to 1.09; p1⁄40.09) and higher MoCA score (SMD: +0.40; 95% CI: +0.04 to +0.76; p1⁄40.03). Risk of overt stroke and all-cause mortality were non-significantly lower in the EP group.

A spectral approach for the quantitative description of cardiac collagen network from nonlinear optical imaging.

The assessment of collagen structure in cardiac pathology, such as atrial fibrillation (AF), is essential for a complete understanding of the disease. This paper introduces a novel methodology for the quantitative description of collagen network properties, based on the combination of nonlinear optical microscopy with a spectral approach of image processing and analysis. Second-harmonic generation (SHG) microscopy was applied to atrial tissue samples from cardiac surgery patients, providing label-free, selective visualization of the collagen structure. The spectral analysis framework, based on 2D-FFT, was applied to the SHG images, yielding a multiparametric description of collagen fiber orientation (angle and anisotropy indexes) and texture scale (dominant wavelength and peak dispersion indexes). The proof-of-concept application of the methodology showed the capability of our approach to detect and quantify differences in the structural properties of the collagen network in AF versus sinus rhythm patients. These results suggest the potential of our approach in the assessment of collagen properties in cardiac pathologies related to a fibrotic structural component.