Sari D. Holmes

Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: A prospective randomized controlled trial

OBJECTIVE The purpose of this study was to test the hypothesis that a liberal blood glucose strategy (121-180 mg/dL) is not inferior to a strict blood glucose strategy (90-120 mg/dL) for outcomes in patients after first-time isolated coronary artery bypass grafting and is superior for glucose control and target blood glucose management. METHODS A total of 189 patients undergoing coronary artery bypass grafting were investigated in this prospective randomized study to compare 2 glucose control strategies on patient perioperative outcomes. Three methods of analyses (intention to treat, completer, and per protocol) were conducted. Observed power was robust (>80%) for significant results. RESULTS The groups were similar on preoperative hemoglobin A(1c) and number of diabetic patients. The liberal group was found to be noninferior to the strict group for perioperative complications and superior on glucose control and target range management. The liberal group had significantly fewer patients with hypoglycemic events (<60 mg/dL; P < .001), but severe hypoglycemic events (<40 mg/dL) were rare and no group differences were found (P = .23). These results were found with all 3 methods of analysis except for blood glucose variability, maximum blood glucose, and perioperative atrial fibrillation. CONCLUSIONS This study demonstrated that maintenance of blood glucose in a liberal range after coronary artery bypass grafting led to similar outcomes compared with a strict target range and was superior in glucose control and target range management. On the basis of the results of this study, a target blood glucose range of 121 to 180 mg/dL is recommended for patients after coronary artery bypass grafting as advocated by the Society of Thoracic Surgeons.

Do we increase the operative risk by adding the Cox Maze III procedure to aortic valve replacement and coronary artery bypass surgery

OBJECTIVE Recent reports from Europe and the United States have suggested that patients presenting for open surgery with a significant history of atrial fibrillation (AF) have inferior early and late outcomes if AF is left untreated. On the other hand, there is reluctance among surgeons to treat AF surgically, especially when atriotomies may be required otherwise, which is the case with aortic valve replacement (AVR) or coronary artery bypass grafting (CABG). The objective of this study was to explore the potential impact of the addition of the Cox Maze III procedure on short- and long-term outcomes of patients when combined with AVR or CABG. METHODS Since 2005, 485 patients have undergone the Cox Maze III procedure at Inova Heart and Vascular Institute, 95 of whom had a full Cox Maze III with an AVR or CABG (Cox Maze III/AVR = 30; Cox Maze III/CABG = 47; Cox Maze III/AVR/CABG = 18). In addition, 4255 patients with no history of AF underwent AVR or CABG without surgical ablation (AVR = 422; CABG = 3518; AVR/CABG = 315). Data from our CABG, valve, and AF registries were used for analyses. Patients with and without the Cox Maze III were propensity score matched using a 0.10 caliper to improve balance on clinical and demographic variables. Differences in perioperative and postoperative outcomes by group were evaluated using the Fisher exact test, and a Kaplan-Meier survival analysis was completed. Health-related quality of life (Short Form 12) was obtained at baseline and 6 months post-surgery (n = 72). RESULTS All 95 patients who underwent the Cox Maze III were propensity score matched with patients who did not undergo the Cox Maze III. Mean age (t = 0.3, P = .79) and European System for Cardiac Operative Risk Evaluation score (t = -1.8, P = .07) were similar between the groups. There were no significant differences in major postoperative morbidities between the groups despite the Cox Maze III group being on bypass longer (164.4 vs 108.8 minutes; t = -9.8, P < .001). Pacemaker implantation was significantly higher in the Cox Maze III group (P = .03). Survival during follow-up (mean = 35 months) was not different between patients who did and did not undergo the Cox Maze III procedure (log rank = 0.49, P = .48). Improvement in physical health-related quality of life was similar for both groups (F = 0.01, P = .94). At 1 year, 94% of the patients (60/64) who underwent the Cox Maze III procedure were in sinus rhythm (81% off class I and III antiarrhythmic drugs). CONCLUSIONS The addition of the Cox Maze III procedure to AVR or CABG did not convey an increase in major morbidity and perioperative risk. Patients who underwent the Cox Maze III procedure demonstrated similar survival over time with improvement in health-related quality of life. The Cox Maze III should not be denied to patients in whom the cardiac surgical procedure does not include atriotomies because of the perceived increased operative risk. The Cox Maze III may significantly improve their outcome.

The CHADS Score Role in Managing Anticoagulation After Surgical Ablation for Atrial Fibrillation

BACKGROUND Managing anticoagulation after surgical ablation is challenging, especially when sinus rhythm has been restored and the left atrial appendage has been surgically managed. The study purpose was to examine the applicability of the CHADS(2) in determining anticoagulation strategies after surgical ablation. CHADS(2) is a scoring system (0 to 6) used to indicate a patients risk for a thromboembolic stroke and used for anticoagulation strategies. One point is given for any of the following conditions: C, congestive heart failure; H, hypertension; A, age 75 years old or greater; D, diabetes mellitus; and S, stroke which receives 2 points. A score of 2 or greater is an indication for a patient to be placed on warfarin unless otherwise contraindicated. METHODS A prospective, longitudinally designed study where CHADS(2) was calculated for all patients (n = 385). Clinical data on rhythm, anticoagulation medication, bleeding, and embolic stroke-transient ischemic attack (TIA) was obtained every 3 months. Logistic regression models were used to determine significant predictors of either event. RESULTS Of the 385 patients, 17% presented with a history of stroke-TIA. In a mean follow-up of 32.77 ± 16.33 months, embolic stroke-TIA events occurred in 4 patients (4.2 first events per 1,000 patient years) and bleeding events occurred in 69 patients (72.8 first events per 1,000 patient years). There was no significant difference in mean CHADS(2) between the stroke event and nonevent group (0.75 vs 1.46, respectively; p = 0.21), but there was a significant difference in CHADS(2) between the major bleed event group and the nonevent group (2.31 vs 1.41, respectively; p < 0.003). The logistic regression model was not predictive of stroke-TIA, but was significantly predictive of bleeding events (χ(2) = 10.30, p < 0.02). CONCLUSIONS The number of thromboembolic events after surgical ablation procedure is low and appears unrelated to the CHADS(2). This, together with the higher rate of bleeding, raises questions regarding the applicability of the CHADS(2) for patients after surgical ablation. A randomized study is required to define the risks and anticoagulation strategies for patients after surgical ablation.

The Impact of Surgical Ablation for Atrial Fibrillation in High-Risk Patients

BACKGROUND Data reported by The Society of Thoracic Surgeons adult cardiac surgery database demonstrate that only 38% of patients with atrial fibrillation (AF) underwent a concomitant surgical ablation. Surgeons are reluctant to add complexity and potential morbidity by including an additional procedure when performing surgery in higher operative risk patients. We investigated perioperative and long-term outcomes in high-risk patients who underwent open heart surgery with or without surgical ablation for AF. METHODS An additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) higher than 6 defined high-risk patients. Perioperative outcomes were captured prospectively, and long-term survival and quality of life were assessed. Propensity score matching using a 0.25 caliper was conducted between the surgical ablation group and the nonablation group (no history of AF). RESULTS The propensity score matching analysis included 178 patients per group. The groups were similar on preoperative characteristics including age, ejection fraction, EuroSCORE, and surgical procedures. The perioperative outcomes were similar between groups, including length of stay, permanent stroke, renal failure, 30-day readmissions, and operative (<30 days) mortality. Cumulative survival over 5 years also did not differ between groups (74.4% versus 69.7%, p=0.34). CONCLUSIONS The addition of an AF surgical ablation procedure did not add operative risk to patients considered high risk, and potentially improved long-term outcome for the subgroup of patients who had their AF ablated. This study suggests that the degree of surgical risk should not be the only decision factor when evaluating this challenging group of patients for surgical ablation.

Association of operative risk with the outcome of concomitant Cox Maze procedure: A comparison of results across risk groups

OBJECTIVES Cardiac surgery patients with atrial fibrillation face increased risks for perioperative morbidity and decreased survival, yet only 39% of patients presenting with atrial fibrillation undergo concomitant surgical ablation. This low percentage may relate to the perception of lower yield for surgical ablation, especially in patients with complex clinical presentations. In this study, we compared outcomes after a concomitant Cox maze III/IV procedure in patients with high, intermediate, and low predicted operative risk. METHODS Outcome data were prospectively captured after surgery. The additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) was greater than 6 for high-risk patients (n = 145), 3 or less for low-risk patients (n = 76), and greater than 3 and 6 or less for intermediate-risk patients (n = 149). RESULTS No differences were found for perioperative morbidities, including operative mortality (high vs low risk, 2% vs 1%, P = 1.00; high vs intermediate risk, 2% vs 0.7%, P = .37). Median length of stay was longer in high-risk patients versus low-risk patients (8 vs 5 days, P < .001) and intermediate-risk patients (8 vs 6 days, P < .001). Return to sinus rhythm was comparable for high-risk versus low- and intermediate-risk patients at 6, 12, and 24 months. Physical health-related quality of life scores improved similarly for all groups at 12 months. No difference in long-term survival was found (log rank = 0.40; P = .82). CONCLUSIONS The Cox maze III/IV procedure can be performed safely and effectively in patients with higher operative risk, who fare well when compared with lower-risk patients. The Cox maze III/IV procedure should be considered carefully in patients with a significant history of atrial fibrillation.

Minimally Invasive Stand-Alone Cox-Maze Procedure for Patients With Nonparoxysmal Atrial Fibrillation

BACKGROUND Catheter-based ablation for atrial fibrillation (AF) performed percutaneously is shown to be limited in patients with nonparoxysmal AF (non-PAF). The full Cox-Maze surgical procedure demonstrated good success with non-PAF, but concerns were raised regarding increased morbidity eliminating the effect of the success rate. This study assessed the safety and efficacy of a stand-alone on-pump Cox-Maze procedure for non-PAF. METHODS Since 2005, 104 stand-alone Cox-Maze procedures for non-PAF were performed through a right minithoracotomy (6 cm) with femoral cannulation. Patients were monitored prospectively through our AF registry. Rhythm was verified by electrocardiogram and 24-hour Holter monitoring. Health-related quality of life (SF-12 Health Survey, Quality Metric, Lincoln, RI) and AF symptoms were assessed. RESULTS Patients were a mean age of 55.9±9.0 years, and 78% had long-standing persistent AF. Patient outcomes included no operative (30 days) deaths or renal failure, 1 pacemaker, and 1 transient ischemic attack. The return to sinus rhythm at 6, 12, 24, 36 months was 94%, 94%, 92%, 92%, and off antiarrhythmic drugs was 87%, 87%, 79%, 80%, respectively. The success rate at 6 months after the initial 20 patients improved from 89% to 94%. Multivariate analysis found duration of AF predicted rhythm at 6 months (odds ratio, 1.15; 95% confidence interval, 1.01 to 1.31; p=0.04). Significant improvement was noted for health-related quality of life and decreased AF symptoms at 1 year. CONCLUSIONS The long-term success rate after the Cox-Maze III procedure in a challenging group of non-PAF patients is acceptable. Our experience suggests the development of educational strategies to overcome the initial learning curve and patient selection criteria for AF surgical ablation.

Expert consensus guidelines: Examining surgical ablation for atrial fibrillation

From the Department of Cardiovascular and Thoracic Surgery, and WVU Heart and Vascular Institute, West Virginia University Morgantown, WVa; Washington Adventist Hospital, Adventist HealthCare, Takoma Park, Md; Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, Mo; Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md; Department of Cardiothoracic Surgery, Academic Hospital Maastricht, Maastricht, The Netherlands; Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan; Sana Cardiac Surgery Stuttgart GmbH, Stuttgart, Germany; Center for the Study of Chronic Illness and Disability, George Mason University, Fairfax, Va; and Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic, Cleveland, Ohio. Received for publication Dec 21, 2016; revisions received Jan 27, 2017; accepted for publication Feb 1, 2017; available ahead of print April 5, 2017. Address for reprints: Niv Ad, MD, Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, 1 Medical Center Drive, Morgantown, WV 26506 (E-mail: nivadmd14@gmail.com). J Thorac Cardiovasc Surg 2017;153:1330-54 0022-5223/

Patient Disposition and Long-Term Outcomes After Valve Surgery in Octogenarians

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.02.027 Forest plot: Improved perioperative survival (<30 days) with concomitant surgical ablation.

The state of surgical ablation for atrial fibrillation in patients with mitral valve disease.

BACKGROUND Valve surgery is performed routinely in octogenarians. This study explored variables affecting patient discharge disposition (home versus other facility) and whether patient disposition was related to long-term survival. METHODS Patients 80 years or older who presented for aortic valve or mitral valve surgery from 2002 to 2010 were included. Baseline demographic, perioperative, and long-term outcomes were captured. Disposition was categorized into 2 groups; home (n=184) or other facility (n=123). The National Death Index and Social Security Death Index verified deaths. RESULTS Mean age was 82.9±2.5; 46% (140 of 307) were female. Discharge location logistic regression, adjusted for gender (odds ratio [OR]=1.45, p=0.17) and European System for Cardiac Operative Risk Evaluation score (OR=1.09, p=0.10), predicted that older (OR=1.18, p<0.001), unmarried (OR=2.07, p=0.006) patients with at least 1 major complication (OR=3.86, p<0.001) were more likely to be not discharged home. Kaplan-Meier analysis found significantly lower 1- and 2-year (85.8% vs 94.6%, p=0.009; 80.1% vs 90.3%, respectively, p=0.01) cumulative survival in patients not discharged home. A multivariate Cox proportional hazards model demonstrated poorer 1- and 2-year survival (hazard ratio [HR]=2.56, p=0.04; HR=2.06, p=0.05, respectively). Predictors of follow-up mortality for patients not discharged home were length of stay (OR=1.06, p=0.03) and any major complication (OR=6.90, p=0.002); lower body mass index was marginally significant (OR=1.12, p=0.06). The significant predictor for patients discharged home was length of stay (OR=1.17, p=0.002). CONCLUSIONS Octogenarians can expect excellent survival after valve surgery. Those not discharged home had poorer long-term survival. Therefore, adequate resources should be secured so sicker patients receive the appropriate level of care.

The association between early atrial arrhythmia and long-term return to sinus rhythm for patients following the Cox maze procedure for atrial fibrillation †

Purpose of review Atrial fibrillation has been shown to be associated with less favorable short and long-term outcomes in patients having mitral valve surgery. Despite the growing evidence related to the potential benefits of surgical ablation for atrial fibrillation at the time of the mitral valve operation, there is a significant variability among surgeons in their approaches to atrial fibrillation. The purpose of this review is to discuss the current state of surgical ablation for atrial fibrillation as reported in the literature, as well as to discuss the significance of atrial fibrillation and the different surgical approaches to treat patients with mitral valve disease who may also concurrently suffer from tricuspid valve disease and atrial fibrillation. Recent findings Increased mortality and morbidity are expected when atrial fibrillation is left untreated in patients undergoing mitral valve surgery. Modern surgical ablations resulted in a shift from the cut and sew maze procedure to the vast majority of cases being performed using different ablation technologies. The use of ablation technology simplifies the procedure. The expectation is that the vast majority of patients with atrial fibrillation will be ablated at the time of their mitral valve surgery. Summary Patients who have mitral valve with or without tricuspid valve disease with a significant history of atrial fibrillation may benefit from surgical ablation to eliminate atrial fibrillation. No increased perioperative morbidity or mortality has been documented with an improved long-term survival and very low incidence of thromboembolic events.