Gianluigi Bisleri

ESC Joint Working Groups on Cardiovascular Surgery and the Cellular Biology of the Heart Position Paper : Peri-operativemyocardial injury and infarction in patients undergoing coronary artery bypass graft surgery

Matthias Thielmann*, Vikram Sharma, Nawwar Al-Attar, Heerajnarain Bulluck, Gianluigi Bisleri, Jeroen JH Bunge, Martin Czerny, Péter Ferdinandy, Ulrich H. Frey, Gerd Heusch, Johannes Holfeld, Petra Kleinbongard, Gudrun Kunst, Irene Lang, Salvatore Lentini, Rosalinda Madonna, Patrick Meybohm, Claudio Muneretto, Jean-Francois Obadia, Cinzia Perrino, Fabrice Prunier, Joost P.G. Sluijter, Linda W. Van Laake, Miguel Sousa-Uva, and Derek J. Hausenloy*

Early hemodynamics and clinical outcomes of isolated aortic valve replacement with stentless or transcatheter valve in intermediate-risk patients

Objective: Stentless aortic valves have been developed to overcome obstructive limitations associated with stented bioprostheses. The aim of the current multi‐institutional study was to compare hemodynamics of transcatheter (TAVR) and the Freedom SOLO Stentless (FS) valve in an intermediate risk population undergoing surgical aortic valve replacement. Methods: From 2010 to 2014, 420 consecutive patients underwent isolated surgical aortic valve replacement with FS and 375 patients underwent TAVR. Only patients with intermediate operative risk (Society of Thoracic Surgeons score 4‐10) and small aortic annulus (≤23 mm) were included. After a propensity matched analysis 142 patients in each group were selected. Thirty‐day postoperative clinical and echocardiographic parameters were evaluated. Results: Mean prosthesis diameter was 22.2 ± 0.9 mm for FS and 22.4 ± 1.0 mm for TAVR. In‐hospital mortality was 2.1% for FS and 6.3% for TAVR (P = .02). Postoperative FS peak gradients were 19.1 ± 9.6 mm Hg (mean 10.8 ± 5.9 mm Hg); TAVR peak gradients were 20.2 ± 9.5 mm Hg (mean 10.7 ± 6.9 mm Hg) P = .57 (P = .88). Postoperative effective orifice area was 1.93 ± 0.52 cm2 for FS and 1.83 ± 0.3 cm2 for TAVR (P = .65). There was no prostheses‐patient mismatch in either group. Postoperative grade 2‐3 paravalvular leak was present in 3.5% for TAVR and 0.7% for FS. Postoperative permanent pacemaker implant rate was 12% for TAVR and only 1 case (0.7%) in the FS group (P < .001). Conclusions: In patients with small aortic annulus and intermediate risk, both FS and TAVR demonstrated similar excellent hemodynamic performance. TAVR demonstrated greater mortality and rates of pacemaker insertion. Further studies are warranted to validate TAVR indications in this subset of patients.

Preserved Left Atrial Epicardial Conduction in Regions of Endocardial “Isolation”

Despite the fact that catheter ablation is highly successful for paroxysmal atrial fibrillation (AF), some patients require multiple procedures. The success for persistent AF is significantly lower. One of the major limitations of catheter ablation is the difficulty in assessing the extent of lesion

European prospective multicentre study of hybrid thoracoscopic and transcatheter ablation of persistent atrial fibrillation: the HISTORIC-AF trial

OBJECTIVES The HISTORIC‐AF trial is a prospective, multicentre, single‐arm study designed to evaluate the outcomes of a staged endoscopic and transcatheter ablation in patients with stand‐alone, persistent or long‐standing persistent atrial fibrillation (AF). METHODS From 2012 to 2015, 100 consecutive patients were enrolled and underwent thoracoscopic left atrial epicardial isolation (‘box lesion’) followed by transcatheter ablation in case of AF recurrency. The safety end point was the composite outcome of freedom from major adverse events at 30‐days, while efficacy end points were: (i) primary: freedom from AF and stable sinus rhythm following isolated thoracospic ablation >60% and (ii) secondary: freedom from AF and stable sinus rhythm >80% following hybrid ablation (as per HRS criteria). RESULTS No death occurred and surgical thoracoscopic procedure was successfully completed in all patients. Survival free from major adverse events at 30 days was 94%: there were 3 permanent pacemaker implants, 2 episodes of stroke and 1 revision for bleeding. At discharge, 87% of patients were in sinus rhythm. A staged transcatheter ablation was carried out in all patients with AF recurrences at the end of 3 months blanking period (17% of patients). At 12‐months follow‐up, a stable restoration of sinus rhythm was achieved in 75% and 88% of patients following isolated thoracoscopic ablation and hybrid ablation, respectively. CONCLUSIONS The HISTORIC‐AF trial showed that thoracoscopic isolated surgical ablation reached both the safety and the efficacy end points. Hybrid ablation steadily improved rhythm outcomes and may be considered in the future as the treatment of choice for patients with persistent and long‐standing persistent AF. ClinicalTrials.gov Identifier NCT01622907.

Primary prevention of post-pericardiotomy syndrome using corticosteroids: a systematic review

ABSTRACT Introduction: Post-pericardiotomy syndrome is a well-recognized inflammatory phenomenon that commonly occurs in patients following cardiac surgery. Due to the increased morbidity and resource utilization associated with this condition, research has recently focused on ways of preventing its prevention this condition; primarily using colchicine, NSAIDs and corticosteroids. Areas covered: This systematic review summarizes the three clinical studies that have used corticosteroids for PPS primary prevention in the perioperative period. Due to the heterogeneity amongst these three studies in terms of population (both pediatric and adult patients), surgical procedure, administration regimen and results (only 1/3 studies reporting a positive effect), the effectiveness of corticosteroids remains unproven. Expert commentary: Corticosteroids have shown to be useful in the treatment of PPS but have thus far have shown mixed results as a primary prevention method. Research on patients taking corticosteroids pre-operatively have shown a significant reduction in the risk of developing PPS. Further research is required to determine if corticosteroids are helpful in preventing PPS in patient undergoing cardiac surgery, before any recommendations regarding their use in cardiovascular surgery can be made.

Long term follow-up of total arterial versus conventional and hybrid myocardial revascularization: A propensity score matched analysis

PURPOSE To evaluate the impact of the revascularization technique (by means of conventional, total arterial or hybrid myocardial revascularization) in patients with multivessel coronary artery disease. METHODS A propensity-score analysis of patients undergoing myocardial revascularization from 1998 to 2012 was performed based on the surgical technique utilized, either total arterial (Group1, G1,n° = 89), conventional CABG(LIMA on LAD plus veins, Group2, G2,n° = 89), or hybrid revascularization (LIMA on LAD plus PTCA on non-LAD vessels, Group3, G3, n° = 89). Primary end-points were overall survival and cardiac-related death while secondary composite end-point was survival freedom from major adverse cardiac and cerebrovascular events (MACCEs) defined as myocardial infarction, cardiac death, stroke and repeated target vessel revascularization. RESULTS Study population was mostly affected by double-vessels disease (G1 = 2.35 vs G2 = 2.3 vs G3 = 2.4, p = 0.14) with a preserved LV function(G1 = 48% vs G2 = 49% vs G3 = 50%, p = 0.12). Hospital mortality was 0% in all groups. At a mean follow-up of 6 ± 2 years overall survival was significantly better in patients receiving total arterial myocardial revascularization (G1 = 90.4 ± 3.5% vs G2 = 82.3 ± 4.2% vs G3 = 82.1 ± 5.9%, p = 0.049) as well as freedom from MACCEs (G1 = 95.2 ± 2.4% vs G2 = 86.5 ± 4% vs G3 = 68 ± 6.9%, p = 0.001) while survival free from cardiac-related death was similar(G1 = 97.7 ± 1.6% vs G2 = 95.1 ± 2.4% vs G3 = 89.5 ± 5.4%, p = 0.08). Conversely, at 10 years follow-up only freedom from MACCEs was significantly better in patients of Group 1(G1 = 78.9 ± 8.6% vs G2 = 72.4 ± 5.7% vs G3 = 52 ± 8.7%, p < 0.001). CONCLUSIONS Total arterial revascularization provides improved outcomes at mid and long term follow-up compared with conventional or hybrid revascularization. The latter technique is particularly associated with a significantly higher incidence of late myocardial infarction and repeat revascularization.

Hybrid ablation for persistent atrial fibrillation: how to merge the best from both worlds

A close collaboration between the cardiac surgeon and the electrophysiologist in a hybrid fashion has represented a novel and intriguing opportunity in order to address the most common supra-ventricular tachyarrhythmia (i.e., atrial fibrillation) and to overcome the drawbacks and suboptimal results of both catheter ablation and minimally invasive surgical procedures, especially in the most complex and chronic scenarios.