Convergent approach to persistent atrial fibrillation ablation: long-term single-centre safety and efficacy.

Background: Efforts to maintain sinus rhythm in patients with persistent atrial fibrillation (PsAF) remain challenging, with suboptimal long-term outcomes. Methods: All patients undergoing convergent PsAF ablation at our centre were retrospectively analysed. The Atricure Epi-Sense® system was used to perform surgical radiofrequency ablation of the LA posterior wall followed by endocardial ablation. Results: A total of 24 patients underwent convergent PsAF ablation, and 21 (84%) of them were male with a median age of 63. Twelve (50%) patients were obese. In total, 71% of patients had a severely dilated left atrium, and the majority (63%) had preserved left ventricular function. All were longstanding persistent. Eighteen (75%) patients had an AF duration of >2 years. There were no endocardial procedure complications. At 36 months, all patients were alive with no new stroke/transient ischaemic attack (TIA). Freedom from documented AF at 3, 6, 12, 18, 24, and 36 months was 83%, 78%, 74%, 74%, 74%, and 61%, respectively. There were no major surgical complications, with five minor complications recorded comprising minor wound infection, pericarditic pain, and hernia. Conclusions: Our data suggest that convergent AF ablation is effective with excellent immediate and long-term safety outcomes in a real-world cohort of patients with a significant duration of AF and evidence of established atrial remodelling. Convergent AF ablation appears to offer a safe and effective option for those who are unlikely to benefit from existing therapeutic strategies for maintaining sinus rhythm, and further evaluation of this exciting technique is warranted. Our cohort is unique within the published literature both in terms of length of follow-up and very low rate of adverse events.

Carbofuran-induced toxicity in rats: protective role of vitamin C.

Erythrocytes are prone to oxidative stress due to the presence of hemoglobin and polyunsaturated fatty acids. Oxidative stress (OS) is associated with increased osmotic fragility (OF) of erythrocytes. Organophosphate and organocarbamate pesticides are known to cause OS in erythrocytes. We have investigated the effect of a single sub-acute dose of carbofuran (CF), an organocarbamate pesticide and ameliorating role of vitamin C on OF and OS in erythrocytes of Wistar rats. OF and OS were assessed by determining membrane stability in terms of erythrocyte OF and the activities of free radicals scavenging enzymes such as superoxide dismutase (SOD), catalase (CAT) and glutathione-S-transferase (GST). We observed a significant alteration in the mean erythrocyte fragility (MEF) at relatively higher NaCl concentration (0.67%) as compared to MEF at 0.55%, 0.58% and 0.56% of NaCl in control, vitamin C- and vitamin C + CF-treated groups, respectively. The activities of CAT and SOD were observed to be elevated by 74.35% and 85.56%, respectively, with significance level of p < or = 0.001, whereas GST activity got significantly (p < or = 0.001) diminished by 46.30% in the erythrocytes of CF-treated rats. Vitamin C treatment exhibited marked (p < or = 0.05) prevention of carbofuran-induced oxidative stress as well as erythrocyte osmotic fragility in the Wistar rats. These results suggest that CF treatment induces OF and OS in the erythrocytes of rats, and pretreatment with vitamin C can mitigate these toxic effects.

Coronary collateral circulation: effect on early and midterm outcomes after off-pump coronary artery bypass surgery.

BACKGROUND: The purpose of this study was to assess the prognostic effect of coronary collaterals on early and midterm clinical outcomes in patients undergoing first time isolated off-pump coronary artery bypass (OPCAB) surgery. METHODS: Preoperative angiograms from 861 patients were evaluated to assess the presence and extent of coronary collaterals (Rentrop classification). Coronary collaterals (CC) were present in 485 (56.3%) patients (CC group). Patients with coronary collaterals had a higher incidence of preoperative myocardial infarction, lower ejection fraction, and higher Parsonnet scores compared with patients without coronary collaterals (no-CC group). RESULTS: Coronary collaterals were associated with myocardial protection during OPCAB surgery, as evidenced by a significantly lower incidence of intraoperative ST-segment changes (propensity matched cohort, p = 0.008). No other statistically significant differences in in-hospital outcomes were detected between the two groups. Five years after surgery patient survival was 84.8% (95% confidence interval [CI] 79.4 to 88.8) in the CC group compared with 89.2% (95% CI 84.4 to 92.6) in the no-CC group (p = 0.48). Cardiac-related event-free survival after 5 years was 50.6% (95% CI 43.5 to 57.3) in the CC group and 54.5% (95% CI 47.1 to 61.4) in the no-CC group (p = 0.96), with no significant differences between both groups, before or after risk adjustment, or when comparing propensity-matched cohort. CONCLUSIONS: Although patients with coronary collaterals had more extensive coronary artery disease, poor left ventricular function, and more cardiac risk factors than patients without collaterals, the early and midterm clinical outcome after OPCAB surgery was comparable between the two groups.

Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.

BACKGROUND: Red blood cell transfusion can both benefit and harm. To inform decisions about transfusion, we aimed to quantify associations of transfusion with clinical outcomes and cost in patients having cardiac surgery. METHODS AND RESULTS: Clinical, hematology, and blood transfusion databases were linked with the UK population register. Additional hematocrit information was obtained from intensive care unit charts. Composite infection (respiratory or wound infection or septicemia) and ischemic outcomes (myocardial infarction, stroke, renal impairment, or failure) were prespecified as coprimary end points. Secondary outcomes were resource use, cost, and survival. Associations were estimated by regression modeling with adjustment for potential confounding. All adult patients having cardiac surgery between April 1, 1996, and December 31, 2003, with key exposure and outcome data were included (98%). Adjusted odds ratios for composite infection (737 of 8516) and ischemic outcomes (832 of 8518) for transfused versus nontransfused patients were 3.38 (95% confidence interval [CI], 2.60 to 4.40) and 3.35 (95% CI, 2.68 to 4.35), respectively. Transfusion was associated with increased relative cost of admission (any transfusion, 1.42 times [95% CI, 1.37 to 1.46], varying from 1.11 for 1 U to 3.35 for >9 U). At any time after their operations, transfused patients were less likely to have been discharged from hospital (hazard ratio [HR], 0.63; 95% CI, 0.60 to 0.67) and were more likely to have died (0 to 30 days: HR, 6.69; 95% CI, 3.66 to 15.1; 31 days to 1 year: HR, 2.59; 95% CI, 1.68 to 4.17; >1 year: HR, 1.32; 95% CI, 1.08 to 1.64). CONCLUSIONS: Red blood cell transfusion in patients having cardiac surgery is strongly associated with both infection and ischemic postoperative morbidity, hospital stay, increased early and late mortality, and hospital costs.