Lindsey L. Saint

Cox-Maze IV Results for Patients With Lone Atrial Fibrillation Versus Concomitant Mitral Disease

BACKGROUND This study compared Cox-Maze IV (CMIV) outcomes for the treatment of atrial fibrillation (AF) in patients with lone AF vs those with AF and mitral valve (MV) disease. METHODS Since 2002, 200 patients have undergone a CMIV procedure for lone AF (n=101) or concomitantly with MV operations (n=99). Preoperative, perioperative, and late outcomes between these groups were compared. Data were collected prospectively and reported at 3, 6, and 12 months. RESULTS Lone AF patients had AF of longer duration; patients with AF and MV disease were older, with larger left atria and worse New York Heart Association classification (p<0.05). Operative mortality (1% vs 4%, p>0.05, respectively) was similar between both groups. Perioperative atrial tachyarrhythmias were more prevalent in patients with concomitant MV operations (57% vs 41%, p=0.03); however, freedom from AF and antiarrhythmics was similar for both groups at 12 months (76% and 77%). The only predictor for atrial tachyarrhythmia recurrence or arrhythmic drug dependence was failure to isolate the posterior left atrium (p<0.01). CONCLUSIONS Patients with AF and MV disease have distinct comorbidities compared with patients with lone AF. However, the CMIV is safe and effective in both groups and should be considered for patients with AF undergoing MV operations. Patients with MV disease had more atrial tachyarrhythmias at 3 months, but freedom from AF and antiarrhythmics was similar to patients with lone AF at 1 year. The posterior left atrium should be isolated in every patient, because this was the only predictor for failure of the CMIV for either group.

Predictors and Risk of Pacemaker Implantation After the Cox-Maze IV Procedure

BACKGROUND The incidence of and causes for permanent pacemaker implantation (PPM) after surgical arrhythmia procedures remain poorly understood because of the varied lesion patterns and energy sources reported in small series. This study characterized the incidence, indications, and risk factors for PPM after the Cox-maze IV (CMIV) procedure when performed as either a lone or a concomitant procedure. METHODS A retrospective analysis of 340 patients undergoing a CMIV as either a lone (n = 112) or a concomitant (n = 228) procedure was conducted. The incidence, indication, and variables associated with PPM implantation within 1 year of the operation were assessed. Follow-up was conducted at 30 days and 1 year and was 90% complete. RESULTS The incidence of PPM after a lone CMIV procedure was 5%. Patients with concomitant cardiac operations had a nonsignificant increase in PPM insertion at 30 days (11% vs 5%, p = 0.14) and 1 year (15% vs 6%, p = 0.06) when compared with lone CMIV patients. Of patients who required pacemakers, sinus node dysfunction was present in 79% (35/44) of patients in the entire series and in 88% (8/9) after lone CMIV. After PPM, 84% (37/44) of patients remained paced at last follow-up. Multivariate analysis identified age (odds ratio = 1.10 [1.06-1.14], p < 0.001) as the only variable associated with higher risk of a PPM after any CMIV procedure. CONCLUSIONS The risk of PPM implantation after a lone CMIV is 5% and increases with age. The need for a PPM after a CMIV is largely due to SA node dysfunction, which appears unlikely to recover. These data should help physicians counsel patients regarding the perioperative risks associated with the CMIV.

Detection of atrial fibrillation after surgical ablation: Conventional versus continuous monitoring

BACKGROUND Current guidelines recommend at least 24-hour Holter monitoring at 6-month intervals to evaluate the recurrence of atrial fibrillation (AF) after surgical ablation. In this prospective multicenter study, conventional intermittent methods of AF monitoring were compared with continuous monitoring using an implantable loop recorder (ILR). METHODS From August 2011 to January 2014, 47 patients receiving surgical treatment for AF at 2 institutions had an ILR placed at the time of operation. Each atrial tachyarrhythmia (ATA) of 2 minutes or more was saved. Patients transmitted ILR recordings bimonthly or after any symptomatic event. Up to 27 minutes of data was stored before files were overwritten. Patients also underwent electrocardiography (ECG) and 24-hour Holter monitoring at 3, 6, and 12 months. ILR compliance was defined as any transmission between 0 and 3 months, 3 and 6 months, or 6 and 12 months. Freedom from ATAs was calculated and compared. RESULTS ILR compliance at 12 months was 93% compared with ECG and Holter monitoring compliance of 85% and 76%, respectively. ILR devices reported a total of 20,878 ATAs. Of these, 11% of episodes were available for review and 46% were confirmed as AF. Freedom from ATAs was no different between continuous and intermittent monitoring at 1 year. Symptomatic events accounted for 187 episodes; however, only 10% were confirmed as AF. CONCLUSIONS ILR was equivalent at detecting ATAs when compared with Holter monitoring or ECG. However, the high rate of false-positive readings and the limited number of events available for review present barriers to broad implementation of this form of monitoring. Very few symptomatic events were AF on review.

How I do it: Minimally invasive Cox-Maze IV procedure

Our patient is a 66-year-old female with a 2-year history of atrial fibrillation (AF) and mitral valve prolapse who presented with dyspnea on exertion. She was found to be in AF upon her admission electrocardiogram. A transthoracic echocardiogram was performed demonstrating moderateto-severe mitral regurgitation (MR) with a left atrial (LA) diameter of 5.1 cm and normal left ventricular (LV) function. After completion of her workup, it was decided that the patient would best be treated by a minimally invasive Cox-Maze IV (CMIV) and concomitant mitral valve procedure given her significant MR and symptoms. This article and accompanying video will discuss how the minimally invasive CMIV procedure is performed. Surgical techniques Preparation In order to perform a mini-thoracotomy mitral valve maze procedure, the patient is positioned with the right chest elevated 45° and the hips flat. Transesophageal echocardiography (TEE) is performed to assess the MR, and examine for a patent foramen ovale or clot in the LA appendage. The aortic valve is also evaluated since significant aortic insufficiency is a contraindication to this approach. The patient is prepped and draped in the usual fashion.

Incomplete coronary revascularization: a cautionary tale

Recently, Chang et al . found that incomplete coronary revascularization using drug-eluting stents demonstrated similar mortality to complete coronary revascularization in multivessel coronary artery disease (1). The authors found a higher risk of post-intervention myocardial infarction in patients with incomplete revascularization, but other important outcomes such as death, stroke, and repeat revascularization were no different. These results suggest that a less rigorous approach to percutaneous revascularization might be tolerable, but must be interpreted with caution due to several significant limitations of the study.