The use of intraoperative epiaortic ultrasonography in monitoring patients over 75 years old treated with aortic valve replacement.

INTRODUCTION: Epiaortic ultrasound scanning (EAS) extended the use of ultrasound to the intraoperative diagnosis of aortic pathology. Surgical palpation of the ascending aorta underestimates the presence and severity of atherosclerotic plaques. Epiaortic ultrasound scanning has been used as an adjunct to transesophageal echocardiography (TEE) or as a primary direct diagnostic tool for imaging the ascending aorta as well as the aortic arch, which gained prominence as part of a multipronged intraoperative strategy to reduce atherosclerotic emboli. AIM: To compare the epiaortic examination with transthoracic and transesophageal echo (transthoracic echocardiography (TTE) and TEE), X-ray, surgical intraoperative palpation, and postoperative neurological status. MATERIAL AND METHODS: The analyzed group consisted of 35 patients (mean age: 81.3 years) treated with aortic valve replacement (AVR), either alone (60%) or combined with coronary artery bypass grafting (CABG; 22.8%) or aortic aneurysm replacement (11.42%). In 2 patients, only CABG was performed because intraoperatively reevaluated strategy. Thierteen patients have got a history of diabetes, 10 chronic renal failure and 3 of cerebral stroke. RESULTS: In more than 80% of patients, positive EAS results had an influence on the choice of aortic clamping site and in 50% of patients on the site of cannulation. Female sex, peripheral vascular disease, history of previous stroke, and calcifications in the ascending aorta in TTE have significant predictive value for recognizing atherosclerotic changes in EAS and the risk of postoperative neurological complications in octogenarians treated with AVR. CONCLUSIONS: Epiaortic ultrasound scanning imaging is superior to TTE and manual palpation in the detection and localization of ascending atherosclerosis. This technique should be introduced as a standard perioperative examination in older patients at risk of neurological complications.

Early and late outcome after microwave ablation for chronic valvular atrial fibrillation.

BACKGROUND: Microwave energy ablation is one of the newer therapeutic options for surgically treating patients with chronic atrial fibrillation (AF) concomitant with mitral valve disease. The aim of this study was to retrospectively evaluate potential risk factors that may have influenced early as well as remote outcome in a set of patients undergoing microwave energy ablation for chronic AF. METHODS: Patients (n = 42) underwent ablation on an arrested heart concomitant with mitral valve surgery. Twelve patients also underwent tricuspid valve repair or replacement. Logistic regression analyses were performed to evaluate effect of potential risk factors on postablation rhythm status at discharge and at latest follow-up examination. RESULTS: With control for age, patients with recurrent AF at discharge (10/42 [24%]) tended to have preoperative AF of significantly longer duration (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.15-2.35; P = .01) and greater left atrial diameter (OR, 1.14; 95% CI, 1.03-1.26, P = .01) than patients in sinus rhythm (32/42 [76%]). At latest follow-up examination, risk of AF was significantly heightened with longer duration of preoperative AF (OR, 1.47; 95% CI, 1.09-1.96; P = .01) and larger left atrium (OR, 1.12; 95% CI, 1.02-1.23; P = .02) after adjustment for age, length of follow-up time, and presence of early arrhythmia recurrence. CONCLUSIONS: Results for this consecutive series of patients indicated that early and late success after surgical energy ablation may be associated with discrete patient characteristics. Longer arrhythmia duration and greater left atrial diameter seem to be factors independently influencing early and remote success, and there seems to be a self-protective effect of the presence of sinus rhythm at discharge. Further study would be valuable to confirm our findings.

Atrial pacing of transplanted heart.

UNLABELLED: Orthotopic heart transplantation (OHT) is most effective method for treatment of irreversible heart failure. Patients after OHT considered for permanent pacing consist still present a challenge for the implanting physician due to distorted atrial geometry and specific electrophysiological conditions of atrium. The aim of our study was to analyse the effectiveness of permanent atrial pacing in these patients. PATIENTS AND METHODS: We implanted atrial lead in 37 SND pts., 2 months--7 years after OHT, (3 pts with coexisting AV block received ventricular lead). Only straight BP screw-in leads and manually formed stylets were used; we found satisfactory pacing/sensing conditions in 25 pts in RA appendage or anterior/lateral wall, in 10 pts--in CS ostium region and in 2--in proximal part of CS. RESULTS: All implantations were successful and no patient received VVI pacing system. One dislodged lead required revision (1/37, 3%) but this was not related to endomyocardial biopsy. In 2 pts, due to unacceptable low RA potential and/or high PTh values atrial lead was implanted to CS for sensing/pacing of left atrium. The average acute value of A wave were 2.4 mV and chronic 2.2 mV; values of pacing threshold were 0.9 V and 1.6 V respectively. Only in 13/37 pts native A waves were recorded but with amplitude < 0.6 mV. Wenckebach point was 120/min only in 2 pts., in borders 130-160 bpm in 15 pts. and exceeded 170 bpm. in remained 20 pts. Retrograde VA conduction was intact in 33/37 pts, but in 4 pts exceeded 260/min. During long term follow-up in no patient we observed AV conduction disturbances. In 6 pts. treadmill exercise (Bruce's protocol) was repeated three times during: sinus (spontaneous) rhythm, AAI pacing 70/min, AAI-R (DDD-R) pacing. AAI 70 bpm did not influence significantly attained workload, heart rate on peak exercise or duration of exercise. But atrial rate modulated pacing increased values of examined parameters significantly. CONCLUSIONS: 1. Atrial pacing (and atrial based pacing modes) are possible in majority of transplanted heart patients. 2. Frequency of atrial lead dislocation, appearance of atrial sensing problems and AV conduction disturbances (all in about 3%) are comparable to non-transplanted patients. 3. In most patients with SND after OHT AV conduction remains within normal limits; it indicates safety of rate responsive pacing modes in these patients. 4. Rate modulated atrial pacing improves exercise tolerance in heart transplanted patients with SND. 5. High ("supra-normal") values of Wenckebach's point observed in most of patients with transplanted (dennervated) heart may have clinical importance in cases of atrial arrhythmias in these patients.