Krishna Khargi

Saline-irrigated, cooled-tip radiofrequency ablation is an effective technique to perform the maze procedure.

BACKGROUND We evaluated the effectiveness of the saline-irrigated-cooled-tip-radiofrequency ablation (SICTRA) to produce linear intraatrial lesions. METHODS Thirty patients with chronic atrial fibrillation and mitral valve disease were consecutively randomized to have mitral valve operation either with a Maze procedure (group A) or without (group B). Intraatrial linear lesions were made with an SICTRA catheter (20 to 32 W; 200 to 320 mL/h saline). An echocardiography and 24-hour electrocardiogram were obtained 12 months postoperatively. RESULTS The cumulative frequencies of sinus rhythm in group A and B were 0.80 and 0.27 (p < 0.01). Restored biatrial contraction was present in 66.7% (6 of 9) of the group A patients in sinus rhythm. One patient from each group received a permanent pacemaker because of bradycardia. A fatal renal bleeding and mediastinitis occurred in 2 group A patients, 6 weeks postoperatively. One group A patient had sudden cardiac death at home, 4 months after operation. One patient from each group had lethal respiratory failure, 7 and 10 months after operation. Survival after 12 months for group A and B was 73% and 93% (p = 0.131). CONCLUSIONS The SICTRA appeared to be an effective technique to perform the Maze procedure.

Left atrial versus bi-atrial maze operation using intraoperatively cooled-tip radiofrequency ablation in patients undergoing open-heart surgery: Safety and efficacy

OBJECTIVES We sought to determine whether limited left atrial Maze surgery encircling each of the pulmonary veins, using cooled-tip radiofrequency (RF) ablation, is as effective as the bi-atrial approach? BACKGROUND The original Cox/Maze operation effectively restores sinus rhythm (SR) in patients with atrial fibrillation (AF). Ablation procedures aimed at eliminating pulmonary vein foci have produced promising short-term success. METHODS This was a prospective analysis of patients with chronic AF undergoing open-heart surgery in addition to the Maze operation, using intraoperatively cooled-tip RF ablation either in the left atrium alone (group A) or in both atria (group B). RESULTS Patients in group A (n = 21) and group B (n = 49) did not differ in terms of their baseline characteristics. Concomitant open-heart surgical procedures included mitral valve replacement (3 vs. 25), mitral valve plasty (0 vs. 2), mitral and aortic valve replacement (1 vs. 1), aortic valve replacement (4 vs. 6) and coronary artery bypass grafting (13 vs. 15) in groups A and B, respectively. Follow-up ranged from 1 to 50 months. The overall cumulative rates of SR were 82% in group A and 75% in group B, without a statistically significant difference (p = 0.571). Bi-atrial contraction was revealed in 92.3% of patients in SR in group A and in 79.2% in group B. The cumulative survival rates were 90.5% in group A and 77.9% in group B (p = 0.880). CONCLUSIONS A left or bi-atrial Maze operation using intraoperatively cooled-tip RF ablation can safely be combined with open-heart surgery. A left atrial Maze procedure seems to be as effective as the bi-atrial procedure and restores SR in 82% of patients.

Pulmonary function and postoperative complications after wedge and flap reconstructions of the main bronchus

Between 1980 and 1989, 8 wedge and 17 flap main bronchoplasties were done in 24 patients (4 carcinoid tumors, 4 benign lesions, 17 carcinomas). Bronchial anastomotic stenoses, pulmonary function, and survival were evaluated. Preoperative ventilation/perfusion scans with preoperative and postoperative spirometry were done in all patients except two who underwent a wedge bronchoplasty. Postoperative bronchoscopy was done in all patients. Follow-up was complete for the patients with carcinoma (N = 17). In the wedge group bronchial anastomotic stenoses occurred in three (38%) of eight patients. All three patients had serious postoperative complications (persistent atelectasis in one, prolonged ventilatory support in two); one patient died and the other two had impaired postoperative pulmonary function. Complete function recovery occurred in only three (38%) of eight patients who underwent wedge bronchoplasty. In the flap group, bronchostenosis occurred in 3 (18%) of 17 patients. The associated complications (mucus retention, minor atelectasis, partial lobar torsion) were mild. Complete pulmonary function recovery occurred in 13 (76%) of 17 patients who had flap bronchoplasty. Actuarial survival, for the patients with carcinoma, was 88%, 47%, and 41% after 1, 3, and 5 years, respectively. The local recurrence rate was 25% (4/16). In our series, flap main bronchoplasties were effective for the resection of bronchial tumors with local involvement of the adjacent main bronchus. Wedge main bronchoplasties, however, were associated with substantial postoperative complications.

Surgical treatment of atrial fibrillation : a systematic review.

ZusammenfassungDie große Anzahl von Publikationen aus jüngster Zeit zur chirurgischen Therapie von Vorhofflimmern (VHF), in denen verschiedenste Methoden angewandt wurden, erschwert eine exakte Angabe zur Erfolgsrate der chirurgischen Behandlung von VHF. Infolgedessen ist der „Gold Standard“ der chirurgischen Operationstechnik unzureichend definiert.MethodikIn der vorliegenden Übersicht wurde die Effektivität alternativer Energiequellen (Radiofrequenz-Mikrowelle und Kryoablation; Gruppe 1) mit der klassischen „cut and sew“-Cox-Maze III (Gruppe II), für die eine Sinusrhythmus-(SR) und somit Erfolgs- Rate von 97–99% angegeben wird, in der operativen Therapie von VHF verglichen. Wir führten eine Computer-gestützte Suche in Pub-Med- und Medline-Datenbanken durch. Nur englischsprachige Originalarbeiten zur chirurgischen Therapie von VHF, die einen klinischen Endpunkt berichteten (inklusive der postoperativen SR-Rate), wurden berücksichtigt. Folgende Daten wurden analysiert: Die absolute Zahl und der Prozentsatz behandelter Patienten, Geschlechtsverteilung, Arrhythmietyp (permanent oder paroxysmal), Operationstyp (begleitende Mitralklappenoperation, begleitende andere Operation, alleinige VHFOperation), die postoperative Morbidität (Blutungen, Notwendigkeit einer intraaortalen Ballonpumpe, zerebrovaskuläre Ereignisse), postoperative Schrittmacher-Implantation, 30-Tages-Mortalität, Überleben und Anzahl der Patienten im SR. Mittelwerte für Alter (in Jahren), linksatrialen Diameter (mm), präoperative Dauer des VHF (Jahre) und der linksventrikulären Ejektionsfraktion (%) wurden ebenfalls betrachtet.ErgebnisseWir schlossen 48 Studien mit insgesamt 3832 Patienten in die Analyse ein; 2279 in Gruppe I und 1553 in Gruppe II. Die mittlere VHF-Dauer (5,4 und 5,5 p=0,90), der linksatriale Diameter (55,5 und 57,8 mm, p=0,23) und die linksventrikuläre Ejektionsfraktion (57 und 58%, p=0,63) waren vor Operation nicht unterschiedlich, jedoch waren die Patienten der Gruppe II jünger (55,0 versus 61,2 Jahre; p=0,005) und hatten häufiger paroxysmales (22,9 versus 8,0%) und „lone“ VHF (19,3 versus 1,6%). Die postoperative SR-Rate für Gruppe I und II waren 78,3 und 84,9% (p=0,03). Alternative Energiequellen wurden vor allem zur Behandlung von permanentem VHF angewandt (92,0%), fast immer im Zusammenhang mit einer weiteren chirurgischen Prozedur (98,4%) und insbesondere in Kombination mit Nicht-MitralklappenOperationen (18,5%). Nach Korrektuktur dieser Parameter waren die postoperativen SR-Raten für die Gruppen I und II nicht mehr signifikant unterschiedlich.SchlussfolgerungenWir fanden keinen signifikanten Unterschied bezüglich des Anteils an Patienten mit postoperativem SR zwischen der klassischen ,cut and sew‘-Operationstechnik und alternativen Energiequellen in der chirurgischen Therapie von Vorhofflimmern.SummaryBackgroundThe recently published overwhelming number of publications on the surgical treatment of AF, using a wide variety of techniques, blurred any precise appreciation of the nowadays surgical treatment of AF. As a consequence, the “state of the art” of the surgical technique of AF is ill-defined.ObjectivesIn this review the efficacy of the alternative sources of energy (radiofrequency-microwave and cryoablation; (group I) and the classical “cut and sew” Cox-Maze III (group II), which claims a 97–99% sinus rhythm (SR) success rate, were evaluated in the surgical treatment of atrial fibrillation (AF).MethodsA computerized search in the PubMed and Medline database was conducted. Only original, English written, clinical manuscripts on the surgical treatment of atrial fibrillation citing the clinical outcome, including the postoperative sinus rhythm, were included. The following data were registered: the absolute numbers and percentages of treated patients, gender (male versus female) distribution, the type of arrhythmia (permanent or paroxysmal AF), type of surgery (mitral or non-mitral valve or a lone AF surgical procedure), postoperative morbidity (bleeding, the use of an intra-aortic balloon pump, cerebral vascular accident), postoperative pacemaker implantations, 30-day mortality, survival and sinus rhythm conversion. The mean values for age (years), left atrial diameter (mm), preoperative duration of AF (years) and left ventricular ejection fraction (%) were also recorded.ResultsForty-eight studies were included comprising 3832 patients: 2279 in group I and 1553 in group II. The mean duration of AF, left atrial diameter and LVEF were 5.4 versus 5.5 years (p=0.90), 55.5 versus 57.8 mm (p=0.23) and 57 versus 58% (p=0.63). The postoperative SR rates for group I and II were 78.3 versus 84.9% (p=0.03). However, the “cut and sew” Cox-Maze III was conducted in younger patients (55.0 versus 61.2 years; p=0.005), more often to treat paroxysmal (22.9 versus 8.0%) and lone AF (19.3 versus 1.6%). Alternative sources of energy were predominantly used to treat permanent AF (92.0%), almost always as a concomitant surgical procedure (98.4%) and increasingly in combination with non-mitral valve surgery (18.5%). After correction for these variations, the postoperative SR conversion rates for group I and II did not differ significantly anymore.ConclusionsWe could not identify any significant difference in the postoperative SR conversion rates between the classical ‘cut and sew’ and the alternative sources of energy, which were used to treat atrial fibrillation.Atrial fibrillation is a very common arrhythmia that carries a considerable risk of thromboembolic complications. Surgical treatment is an effective way to convert atrial fibrillation into sinus rhythm and significantly prevents thromboembolism postoperatively. In this review we describe recent advancements in the surgical options and detail our strategy for the surgical treatment of atrial fibrillation.

Irrigated radiofrequency ablation is a safe and effective technique to treat chronic atrial fibrillation

OBJECTIVE The safety of intraoperative non-irrigated temperature-controlled radiofrequency ablation to treat atrial fibrillation is a matter of debate. This study evaluates a different operative technique using saline-irrigated-cooled-tip radiofrequency ablation (SICTRA) to treat atrial fibrillation. PATIENTS AND METHODS One hundred and twenty-four concomitant anti-arrhythmic procedures, using SICTRA were performed; 113 to treat chronic AF (>6 months) and 11 to cure paroxysmal AF. RESULTS Twenty-eight MVP, 42 MVR, 17 AVR and six double valve procedures with or without CABG, one ASD closure and 30 solitary CABG were performed. The mean (S.D.) left atrial diameter, preoperative duration of AF, aortic cross-clamp time were 50.5 mm (9.8), 57 months (64) and 99 min (21). Thirty day mortality was 4.8% (6/124; euroscore 17, 11, 8, 8, 6, 5). Autopsies did not reveal any esophageal, pulmonary orifice, or circumflex artery injuries. No ablation related bleeding was observed. Mean follow-up (S.D.) was 19.7 months (14.4). Fourteen patients died during follow-up. The cumulative postoperative SR at 6 and 12 months was 60% and 70%. The cumulative survival at 1 and 2 years was 86% and 83%. CONCLUSION Irrigated radiofrequency ablation was effective. It was not associated with procedural complications in our series.

Long‐Term Sinus Rhythm Stability after Intraoperative Ablation of Permanent Atrial Fibrillation

Introduction: Short‐ and medium‐term sinus rhythm (SR) rates after intraoperative radiofrequency ablation to treat permanent atrial fibrillation (AF) are well documented. Is rhythm success stable during a long‐term follow‐up?

Antiarrhythmic Surgery to Cure Atrial Fibrillation—Subgroups and Postoperative Management

Antiarrhythmic surgical procedures to cure atrial fibrillation (AF) are widely used in cardiac surgery. Whereas the Cox maze procedure remains the highly effective gold-standard a variety of different antiarrhythmic procedures aim at reducing the extent and duration of the procedure. Antiarrhythmic procedures are especially effective in patients undergoing mitral valve surgery. In 110 patients with permanent AF undergoing various surgical procedures sinus rhythm was re-established in 75%. Subgroup analyses revealed no significant differences in rhythm or survival after antiarrhythmic intraoperative ablation indicating the usefulness and feasibility of this procedure in patients with a wide range of characteristics. Because conversion usually occurs spontaneously within the first 6 months and antiarrhythmic medication does not increase the incidence of conversion it seems reasonable to wait for spontaneous occurrence of sinus rhythm after antiarrhythmic intraoperative ablation. In patients with permanent AF undergoing open heart surgery additional antiarrhythmic procedures have been shown to be safe and effective.

Sicherheit und Effektivität der intraoperativen gekühlten linearen Hochfrequenzstromablation bei Patienten mit Vorhofflimmern während eines kardiochirurgischen Eingriffs

Antiarrhythmic surgical procedures are highly effective in restoring sinus rhythm in patients with atrial fibrillation. Is a modified approach using intraoperatively cooled-tip radiofrequency ablation to induce linear lesions safe and effective in the treatment of atrial fibrillation in cardiosurgical patients? A total of 113 patients with chronic permanent (104) or paroxysmal (9) atrial fibrillation underwent open heart surgery plus an additional antiarrhythmic procedure using saline-irrigated cooled-tip radiofrequency ablation (SICTRA) for biatrial or left atrial linear lesions. Ablation was performed with steps of short (5 seconds) ablation around the pulmonary vein ostia and interconnecting lines. Postoperative complications and conversions to sinus rhythm were followed up (mean follow-up duration 17±14 months). Of the 113 patients, 16 died during follow-up (day 3 up to 33 months) resulting in a cumulative survival of 79% (2 sudden cardiac deaths, 2 gastrointestinal bleedings, 1 renal bleeding, 2 mediastinitis, 1 endocarditis, 1 hemorrhagic insult, 2 respiratory insufficiencies and 2 unknown). Three patients died between day 3 and 6 (30-day mortality 3%) due to low cardiac output. Complications occurred in 19% of the patients including 4% bleeding, 1% pneumothorax, 3% sternal dehiscence, 3% reversible low cardiac output, 6% reversible respiratory insufficiency, 2% TIAs and 1% intraaortoal balloon pump implantation. Conversion to sinus rhythm usually occurred spontaneously within 6 months resulting in a cumulative percentage of 80% in sinus rhythm. In these patients, 85% showed biatrial contraction. SICTRA to treat atrial fibrillation can safely and effectively be combined with different surgical procedures. Mortality and complication rates are comparable to cardiac surgery without antiarrhythmic procedures. No severe procedure-related complications were noted when a stepwise ablation approach during open heart surgery was used. Antiarrhythmische operative Verfahren nach dem Vorbild der Cox-Maze-Operation haben eine hohe Effektivität in der Heilung von Vorhofflimmern (VHF). Ist eine modifizierte „Maze“-Operation mit intraoperativer gekühlter Hochfrequenzstromablation während eines kardiochirurgischem Eingriffs ausreichend sicher und effektiv in der Behandlung von chronischem VHF? Bei 113 Patienten mit chronisch permanentem (104) oder chronisch paroxysmalem (9) VHF wurde zusätzlich zu einem geplanten kardiochirurgischen Eingriff intraoperativ entweder eine links- oder biatriale lineare gekühlte Katheterablation durchgeführt. Postoperative Komplikationen sowie Konversionsraten wurden regelmäßig untersucht (mittlere Nachuntersuchungszeit 17±14 Monate). 16 der 113 Patienten verstarben mit einer kumulativen Überlebensrate von 79% nach 3 Jahren und einer 30- Tage-Mortalität von 3% (3 Patienten verstarben am Low Cardiac Output nach 3 bis 6 Tagen). Bei 19% der Patienten traten therapiebedürftige Komplikationen auf (4% Blutungskomplikationen, 1% Pneumothorax, 3% sternale Dehiszenz, 3% reversibles Low Cardiac Output, 6% reversible respiratorische Insuffizienz, 2% TIA, 1% intraaortale Ballonpumpe). Die Konversion in den Sinusrhythmus erfolgte überwiegend spontan innerhalb der ersten 6 Monate. Die kumulative Rate an Sinusrhythmus lag bei 80%, wobei 85% dieser Patienten eine biatriale Vorhofkontraktion aufwiesen. Die schrittweise Erzeugung linearer Ablationen kann sicher und effektiv mit einer gekühlten Hochfrequenzstromsonde durchgeführt und mit anderen kardiochirurgischen Eingriffen kombiniert werden. Sie hat eine hohe Effektivität in der Wiederherstellung von Sinusrhythmus und einer biatrialen Kontraktion. Schwere prozedur-bezogene Komplikationen wie atrio-ösophageale Fistelung wurden in diesem Patientenkollektiv nicht dokumentiert.

[Intraoperative cooled-tip radiofrequency ablation in patients with atrial fibrillation undergoing open heart surgery].

Antiarrhythmic surgical procedures are highly effective in restoring sinus rhythm in patients with atrial fibrillation. Is a modified approach using intraoperatively cooled-tip radiofrequency ablation to induce linear lesions safe and effective in the treatment of atrial fibrillation in cardiosurgical patients? A total of 113 patients with chronic permanent (104) or paroxysmal (9) atrial fibrillation underwent open heart surgery plus an additional antiarrhythmic procedure using saline-irrigated cooled-tip radiofrequency ablation (SICTRA) for biatrial or left atrial linear lesions. Ablation was performed with steps of short (5 seconds) ablation around the pulmonary vein ostia and interconnecting lines. Postoperative complications and conversions to sinus rhythm were followed up (mean follow-up duration 17±14 months). Of the 113 patients, 16 died during follow-up (day 3 up to 33 months) resulting in a cumulative survival of 79% (2 sudden cardiac deaths, 2 gastrointestinal bleedings, 1 renal bleeding, 2 mediastinitis, 1 endocarditis, 1 hemorrhagic insult, 2 respiratory insufficiencies and 2 unknown). Three patients died between day 3 and 6 (30-day mortality 3%) due to low cardiac output. Complications occurred in 19% of the patients including 4% bleeding, 1% pneumothorax, 3% sternal dehiscence, 3% reversible low cardiac output, 6% reversible respiratory insufficiency, 2% TIAs and 1% intraaortoal balloon pump implantation. Conversion to sinus rhythm usually occurred spontaneously within 6 months resulting in a cumulative percentage of 80% in sinus rhythm. In these patients, 85% showed biatrial contraction. SICTRA to treat atrial fibrillation can safely and effectively be combined with different surgical procedures. Mortality and complication rates are comparable to cardiac surgery without antiarrhythmic procedures. No severe procedure-related complications were noted when a stepwise ablation approach during open heart surgery was used. Antiarrhythmische operative Verfahren nach dem Vorbild der Cox-Maze-Operation haben eine hohe Effektivität in der Heilung von Vorhofflimmern (VHF). Ist eine modifizierte „Maze“-Operation mit intraoperativer gekühlter Hochfrequenzstromablation während eines kardiochirurgischem Eingriffs ausreichend sicher und effektiv in der Behandlung von chronischem VHF? Bei 113 Patienten mit chronisch permanentem (104) oder chronisch paroxysmalem (9) VHF wurde zusätzlich zu einem geplanten kardiochirurgischen Eingriff intraoperativ entweder eine links- oder biatriale lineare gekühlte Katheterablation durchgeführt. Postoperative Komplikationen sowie Konversionsraten wurden regelmäßig untersucht (mittlere Nachuntersuchungszeit 17±14 Monate). 16 der 113 Patienten verstarben mit einer kumulativen Überlebensrate von 79% nach 3 Jahren und einer 30- Tage-Mortalität von 3% (3 Patienten verstarben am Low Cardiac Output nach 3 bis 6 Tagen). Bei 19% der Patienten traten therapiebedürftige Komplikationen auf (4% Blutungskomplikationen, 1% Pneumothorax, 3% sternale Dehiszenz, 3% reversibles Low Cardiac Output, 6% reversible respiratorische Insuffizienz, 2% TIA, 1% intraaortale Ballonpumpe). Die Konversion in den Sinusrhythmus erfolgte überwiegend spontan innerhalb der ersten 6 Monate. Die kumulative Rate an Sinusrhythmus lag bei 80%, wobei 85% dieser Patienten eine biatriale Vorhofkontraktion aufwiesen. Die schrittweise Erzeugung linearer Ablationen kann sicher und effektiv mit einer gekühlten Hochfrequenzstromsonde durchgeführt und mit anderen kardiochirurgischen Eingriffen kombiniert werden. Sie hat eine hohe Effektivität in der Wiederherstellung von Sinusrhythmus und einer biatrialen Kontraktion. Schwere prozedur-bezogene Komplikationen wie atrio-ösophageale Fistelung wurden in diesem Patientenkollektiv nicht dokumentiert.

Lung function and perfusion after bronchial and pulmonary arterial sleeve resection

Between January 1985 and December 1991, six patients underwent arterial and bronchial sleeve resections of the left upper lobe. Preoperative and postoperative spirometry, preoperative split pulmonary radionuclide ventilation/perfusion (V/Q) scans and postoperative bronchoscopy were obtained in four patients. Postoperative serial digital vascular images (DVI) of the pulmonary artery were obtained in three patients and one patient had a postoperative V/Q scan. For each patient the preoperative and postoperative forced expiratory volume in is (FEV1) were determined to assess the postoperative ventilatory recovery. At bronchoscopy all patients had a patent bronchial anastomosis. At postoperative DVI, in three patients, vascularization of the residual left lung was delayed and less intense compared with the non-operated right lung. Postoperative V/Q scan, in one patient, showed reduced ventilation and perfusion of the residual lung. Preoperative and postoperative FEV1 of the four patients were 2688/1998 ml, 2154/1752 ml, 2618/2100 ml and 2277/2015 ml. Operative mortality was zero. One patient had a postoperative atelectasis of the left lower lobe. In our series, ventilation and vascularization of the reimplanted and revascularized left lower lobe were reduced. But, in our opinion, the preserved residual lung parenchyma was still a relevant advantage.