Daniel Pereda

Thoracoscopic pulmonary vein isolation in patients with atrial fibrillation and failed percutaneous ablation.

OBJECTIVE Pulmonary vein isolation is indicated in patients with symptomatic isolated atrial fibrillation not controlled with antiarrhythmic therapy. We describe our surgical experience with thoracoscopic pulmonary vein isolation in patients in whom percutaneous ablation has failed. METHODS Thirty-four adult patients with unsuccessful catheter ablations (range 1-4, mean 2 +/- 1) underwent thoracoscopic bipolar-radiofrequency pulmonary vein isolation. Seventeen patients had paroxysmal atrial fibrillation, 12 with persistent and 5 with long-standing persistent fibrillation, for a mean of 6 years (range 3-10 years), 13 years (5-25 years), and 9 years (3-15 years), respectively. RESULTS There was no mortality during the procedure or follow-up (mean 16 +/- 11 months). Two patients needed conversion to thoracotomy owing to hemorrhage, and ablation could not be completed. Antiarrhythmic therapy was withdrawn 3 months postoperatively. Postoperative sinus rhythm was maintained in 82% of those with paroxysmal atrial fibrillation (13/15 at 6 months, 9/11 at 12 months), 60% had persistent atrial fibrillation (8/12 at 6 months and 6/10 at 12 months), and 20% had long-standing persistent atrial fibrillation (1/5 at 6 and 12 months). Preoperative left atrial diameter significantly differed between patients with paroxysmal fibrillation (mean 42 +/- 6 mm) and those with persistent and long-standing persistent fibrillation (means 50 +/- 4 and 47 +/- 2 mm). Left atrial size greater than 45 mm and atrial fibrillation type were preoperative factors that significantly influenced outcome in the univariate logistic regression analysis. CONCLUSIONS Thoracoscopic pulmonary vein isolation in patients with previously unsuccessful catheter ablations demonstrates satisfactory sinus rhythm maintenance rates in paroxysmal and persistent atrial fibrillation, but not in long-standing persistent atrial fibrillation. As with other minimally invasive surgical techniques, there is an important learning curve.

Anatomic aspects of the atrioventricular junction influencing radiofrequency Cox maze IV procedures

OBJECTIVE This study analyzes the anatomic structure of the mitral and tricuspid annuli, their relationship with the coronary arteries and veins, and how this anatomic distribution may affect atrial ablation with bipolar radiofrequency clamps, the only technology that ensures transmurality. METHODS Nine explanted fresh human hearts were studied, two of them with left coronary dominance. Two types of bipolar radiofrequency clamps were positioned to reach the mitral and tricuspid annuli, and relationships within the atrioventricular junction were analyzed, including coronary sinus and coronary arteries. RESULTS In all hearts studied, the coronary arteries and veins within the adipose tissue of the right or left atrioventricular groove lay in the atrial side, 3 to 18 mm away from the mitral or tricuspid annuli. When the bipolar radiofrequency clamp was closed toward the mitral annulus, the coronary sinus was always included between the jaws, and in left coronary-dominant hearts, the circumflex artery was also included. Nevertheless, the clamp never reached the annulus owing to the increase in thickness of the adipose tissue around the groove and the ventricular mass, leaving 5 to 10 mm of atrial myocardium free from the radiofrequency electrodes. In the right atrium, clamp placement toward the tricuspid annulus excluding the right coronary left 8 to 18 mm of atrial muscle free from the bipolar electrodes. CONCLUSIONS Bipolar radiofrequency clamps are not sufficient to complete a Cox maze IV procedure. Moreover, they may compromise coronary arteries in patients with left coronary dominance. Lines to the atrioventricular annuli need to be completed with the cut-and-sew technique or with alternative monopolar energy devices.

Safety and feasibility of a novel adjustable mitral annuloplasty ring: a multicentre European experience

OBJECTIVES Recurrent mitral regurgitation is a significant problem after mitral valve repair in patients with functional valve disease. We report the safety and feasibility of a novel adjustable mitral annuloplasty device that permits downsizing of the anterior–posterior diameter late after initial surgery. METHODS In this multicentre, non-randomized, observational register, patients with moderate or severe mitral regurgitation undergoing surgical mitral valve repair with the MiCardia EnCorSQ™ Mitral Valve Repair system were evaluated. Patient characteristics, operative specifications and results as well as postoperative follow-up were collected for all five centres. RESULTS Ninety-four patients with a median age of 71 (64–75) years (EuroSCORE II 6.7 ± 6.3; 66% male, 48% ischaemic MR, 37% dilated cardiomyopathy and 15% degenerative disease) were included. Operative mortality was 1% and the 1-year survival was 93%. Ring adjustment was attempted in 12 patients at a mean interval of 9 ± 6 months after surgery. In three of these attempts, a technical failure occurred. In 1 patient, mitral regurgitation was reduced two grades, in 2 patients mitral regurgitation was reduced one grade and in 6 patients, mitral regurgitation did not change significantly. The mean grade of mitral regurgitation changed from 2.9 ± 0.9 to 2.1 ± 0.7 (P = 0.02). Five patients were reoperated after 11 ± 9 months (Ring dehiscence: 2; failed adjustment: 3). CONCLUSION We conclude that this device may provide an additional treatment option in patients with functional mitral regurgitation, who are at risk for reoperation due to recurrent mitral regurgitation. Clinical results in this complex disease were ambiguous and patient selection seems to be a crucial step for this device. Further trials are required to estimate the clinical value of this therapeutic concept.

Exclusion of the left atrial appendage with the TigerPaw II system: a word of caution

Exclusion of the left atrial appendage (LAA) may significantly reduce the incidence of stroke associated with atrial fibrillation (AF), since this is the main thrombus source. LAA closure is becoming a therapeutic target for preventing AF-related stroke, attracting much interest in recent years. Different devices are available to provide LAA exclusion during cardiac surgery. We describe herein our experience with the recently introduced TigerPaw II system for LAA exclusion, and report a high prevalence of device malfunction. Design improvements may address these issues and increase safety for new technological devices designed for surgical LAA closure.

Reintervenciones en una Unidad de Cuidados Intensivos de Cirugía Cardiovascular

BACKGROUND To analyze the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. METHODS Retrospective analysis of consecutive non-selected adult patients operated in the ICU. All operations were included. Descriptive statistics were used. RESULTS Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients, 70 male (64.2%) and 39 female (35.8%) with a mean age of 61.6 years (12-80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/tamponade in the operating room. The index interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischemic heart disease (15.6%), combined valvular/ischemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxyphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis (0,9%), with no difference from patients operated in the regular operating room. CONCLUSIONS Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings.

279. El derrame pericárdico postoperatorio en cirugía cardíaca: Incidencia e impacto en los resultados quirúrgicos

Objetivos El derrame pericardico (DP) es una complicacion (40–65%) que puede determinar taponamiento diferido letal. Determinamos la incidencia de DP grave en el postoperatorio de cirugia cardiaca. Material y metodos Estudio prospectivo de cohorte de pacientes consecutivos no seleccionados con intervenciones mayores de cirugia cardiaca. Se practico estudio ecocardiografico prealta. Se diagnostico DP por criterios de Horowitz en modo M. Para la ecocardiografia-2D se consideraron diagnosticos de taponamiento cardiaco: colapso diastolico precoz del ventriculo derecho, compresion de cavidades cardiacas, pletora de vena cava inferior y variaciones superiores al 30% del flujo mitral. Con independencia de los estudios intraoperatorios o en cuidados intensivos, se programo estudio prealta a partir del septimo dia postoperatorio. Las ecocardiografias se practicaron en el laboratorio de ecocardiografia. Si la condicion del paciente no lo permitio, el estudio se realizo en las unidades de hospitalizacion en los casos urgentes. Se usaron los ecografos Vivid i/Vivid 7 (General Electric, Fairfield, CT). Todos los estudios fueron supervisados por los ecocardiografistas expertos del servicio de cardiologia. Resultados De noviembre de 2009 – noviembre de 2011 se intervinieron 1.186 pacientes; 125 fueron trasladados precozmente a su hospital; 88 fallecieron sin estudio. De 973 pacientes, 53 (5,4%) presentaron DP grave o taponamiento por criterios clinicos/ecocardiograficos; 31/53 (58%) estaban asintomaticos. En 22/53 (42%) hubo sospecha clinica. Fueron reintervenidos 21 (40%). En 16 (30%) se administraron antiinflamatorios no esteroideos (AINE) y corticoides. La mortalidad fue 3,8% (2/53). Conclusion La ecocardiografia es una exploracion inocua que permite el diagnostico rapido de DP potencialmente letal, que tiene un componente medicolegal. Debe realizarse a todo postoperado de cirugia cardiaca.