A single center's experience with pacemaker implantation after the Cox maze procedure for atrial fibrillation.

OBJECTIVE: The Cox maze procedure (CM) is safe and effective for all atrial fibrillation (AF) types. A recent randomized trial found alarming rates of pacemaker implantation (PMI) during hospitalization after CM. The purpose of this study was to assess the rate of PMI and its impact on outcomes after CM. METHODS: Incidence of PMI was captured for all CM patients (2005-2015; N = 739). Data were collected prospectively. Multivariable logistic regression was conducted to determine risk factors for PMI. Propensity score matching was conducted between concomitant CM patients and patients without surgical ablation since 2011. RESULTS: Fifty-two patients (7.0%) had in-hospital PMI after CM. Most common primary indication for PMI was sick sinus syndrome (67%), followed by complete heart block (23%) and sinus bradycardia (10%). The only risk factor for in-hospital PMI was type of procedure (P = .020). Patients with multiple valve procedures were at greatest risk (P = .004-.035). STS-defined perioperative outcomes were similar for patients with and without in-hospital PMI. Sinus rhythm off antiarrhythmic drugs were similar by PMI. After propensity score matching (n = 180 per group), in-hospital PMI was similar in CM patients and those without surgical ablation (5% vs 4%, P = .609). CONCLUSIONS: This study demonstrated lower incidence of PMI after CM procedures than recently reported. When indicated, PMI was not associated with increased short- or long-term morbidity or inferior freedom from atrial arrhythmia. Efforts to increase surgeon training with the CM procedure and postoperative management awareness are warranted to improve rhythm outcome and minimize adverse events and PMI.

Left-Sided Surgical Ablation for Patients With Atrial Fibrillation Who Are Undergoing Concomitant Cardiac Surgical Procedures.

BACKGROUND: Growing evidence indicates the effectiveness of surgical ablation confined to the left atrium, especially with short duration of atrial fibrillation (AF) and smaller left atrial (LA) size. This study examined rhythm status and predictors of failure in this group of patients. METHODS: Of 800 patients who underwent concomitant surgical ablation (2005 to 2015), 110 had LA-only ablation. Rhythm status was defined according to Heart Rhythm Society guidelines: sinus rhythm (SR) without class I/III antiarrhythmic drugs (AADs). Multivariate analyses examined predictors for SR without AADs. Predictors of failure were also stratified as age 75 years or older, LA size 5 cm or larger, AF duration 5 years or more, and nonparoxysmal AF type for secondary analyses. RESULTS: Mean age was 70.7 ± 9.4 years, mean EuroSCORE II (European System for Cardiac Operative Risk Evaluation) was 4.7 ± 4.3%, mean LA size was 4.4 ± 0.8 cm, median (interquartile range) AF duration was 3.5 months (range, 0.4 to 21 months), 26% of patients were female, 59% had coronary artery bypass graft procedures, 36% had aortic valve procedures, and 25% had mitral valve procedures. SR without AADs at 6, 12, and 24 months was 82% (79 of 96), 87% (78 of 90), and 79% (61 of 77), respectively. The only independent predictor of SR without AADs at 6 months was smaller LA size (odds ratio, 0.35; p = 0.014). Return to SR without AADs at 6, 12, and 24 months was as follows: 92%, 93%, and 91%, respectively, for patients with no traditional predictors of failure (n = 32); 88%, 90%, and 77%, respectively, for one predictor (n = 47); and 66%, 76%, and 70% for two or more predictors (n = 31). CONCLUSIONS: LA-only ablation yielded acceptable success rates, primarily in patients with shorter AF duration and smaller LA. However, success was reduced in patients with traditional predictors of failure. Well-designed studies with standardized lesion sets and ablation tools are required to determine whether full Cox maze yields better outcomes in patients with more advanced AF.

The Effects of Frailty in Patients Undergoing Elective Cardiac Surgery.

BACKGROUND: The Society of Thoracic Surgeons (STS) recommends using gait speed as a marker of frailty to identify cardiac surgery patients at risk for adverse outcomes. However, a single marker of frailty may not provide consistently reliable risk information. We evaluated the impact of frailty and gait speed on patient outcomes after elective cardiac surgery. METHODS: This was a prospective study of 167 older (≥65 years) coronary artery bypass grafting (CABG) and/or valve surgery patients. Patients were assessed using Cardiovascular Health Study (CHS) Frailty Index criteria: weight loss, exhaustion, physical activity, gait speed, and grip strength. RESULTS: Frailty was identified in 39 patients (23%) using CHS criteria. Frail patients had longer median intensive care unit stays (54 vs. 28 h, p = 0.003), longer median length of stay (8 vs. 5 days, p < 0.001), and greater likelihood of STS-defined complications (54% vs. 32%, p = 0.011) and discharge to an intermediate-care facility (45% vs. 12%, p < 0.001) but were not different from nonfrail patients on major outcome, operative mortality, or readmissions. After multivariate adjustment, frail and nonfrail patients were similar on perioperative outcomes. Absolute gait speed and slow gait speed using a cutoff were not related to incidence of STS-defined complications or major outcome in multivariate analyses. However, higher body mass index was correlated with slower gait speed (rs = 0.30, p < 0.001). CONCLUSIONS: The CHS index did not identify "frail" patients at increased risk for adverse outcomes. No relationship was found between gait speed and outcome. There is a need for alternative multidimensional measures to assess frailty in cardiac surgical patients. doi: 10.1111/jocs.12699 (J Card Surg 2016;31:187-194).