Outcomes and prognostic factors of cytoreductive surgery and perioperative intraperitoneal chemotherapy in high-volume peritoneal carcinomatosis.

BACKGROUND AND OBJECTIVES: The management of patients with extensive appendiceal mucinous neoplasms and mesothelioma is controversial. Our aims were to analyze overall survival (OS), disease-free survival (DFS) and independent prognostic factors associated with high peritoneal cancer index (PCI) status in patients who underwent cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy (PIC). METHODS: A prospectively-maintained database for patients with appendiceal neoplasms and mesothelioma undergoing CRS/PIC from year 1996 to 2018 was retrospectively analyzed. Patients who achieved complete cytoreduction were stratified into limited (PCI < 30) and extensive (PCI ≥ 30) disease groups. RESULTS: 260 female and 235 male patients were identified. The 5-year survival for low-grade appendiceal mucinous neoplasms (LAMN) was significantly higher in the low PCI group (96.2% vs. 63.5%, p < 0.001). There was no difference in the OS across both groups in high-grade appendiceal mucinous neoplasms (HAMN) (63 vs. 69 months; p = 0.942) and mesothelioma (72 vs. 42 months; p = 0.058). Overall mortality was 2%. Grade III/IV complications were significantly higher in extensive disease (68% vs. 36.6%, p < 0.001). On multivariate analysis, use of EPIC and blood transfusion (>8 units) were independent positive and negative prognostic factors, respectively, associated with OS. Meanwhile, use of EPIC conferred benefit in DFS while increased blood transfusion (>8 units) and elevated preoperative CA125 were predictive of a poor DFS. CONCLUSION: Long-term survivals following CRS/PIC are achievable with acceptable mortality and higher morbidity rates in extensive appendiceal mucinous neoplasms and mesothelioma. High PCI status does not preclude treatment with CRS/PIC.

Atrial fibrillation ablation by single ring isolation versus wide antral isolation: Effects on left atrial size and function.

BACKGROUND: Pulmonary vein isolation (PVI) by single ring isolation (SRI) has been demonstrated to reduce recurrence of atrial fibrillation (AF) compared to the standard technique of wide antral isolation (WAI). In this study, we examine the differential effect of these techniques on left atrial size and function. METHODS: We examined left atrial (LA) size (LA maximum and LA minimum volumes) and function (LA emptying fraction and LA expansion index) over a period of 6 months following PVI as measured by transthoracic echocardiography in 187 patients that were enrolled in a randomised controlled trial of SRI vs WAI. RESULTS: Compared to pre-ablation, at 6 months post-PVI, there was a small decrease in the LA maximum volume in the WAI group (67.3 vs 62.7 mL, p=0.02). The LA size did not change significantly over 6 months in the SRI group. Patients who underwent SRI had a small reduction in the LA expansion index at 6 months post-PVI compared to baseline (80.6 vs 66.6%, p=0.02). LA function did not change significantly over 6 months in the WAI group. However, at 6 months, there was no difference in any measure of LA size or function between the SRI and WAI groups. CONCLUSIONS: SRI, whilst previously demonstrated to be more effective than WAI in preventing AF recurrence, is associated with minimal adverse effects on left atrial function at medium term follow-up despite the isolation of a larger region of LA myocardium.

Single-ring posterior left atrial (box) isolation results in a different mode of recurrence compared with wide antral pulmonary vein isolation on long-term follow-up: longer atrial fibrillation-free survival time but similar survival time free of any atrial arrhythmia.

BACKGROUND: Electric isolation of the pulmonary veins and posterior left atrium with a single ring of radiofrequency lesions (single-ring isolation [SRI]) may result in fewer atrial fibrillation (AF) recurrences than wide antral pulmonary vein isolation (wide antral isolation [WAI]) by abolishing extravenous AF triggers. The effect of mitral isthmus line (MIL) ablation on outcomes after SRI has not previously been assessed. METHODS AND RESULTS: We randomly assigned 220 consecutive patients (58 ± 10 years old; 82% men) with highly symptomatic AF (61% paroxysmal, 39% persistent/longstanding persistent) to undergo either SRI or WAI. Half of each cohort was also randomly allocated to have left lateral MIL ablation (2 ×2 factorial study design). Patients were followed clinically and with 7-day Holter studies for arrhythmia recurrences. The primary end points were recurrence of AF and organized atrial tachyarrhythmias. AF-free survival at 2 years was better after SRI (74% [95% CI, 65%-82%]) than WAI (61% [51%-70%]; P=0.031). Organized atrial tachyarrhythmia-free survival was similar after SRI and WAI (67% [57%-75%] ersus 64% [54%-72%], respectively, at 2 years; P=0.988). MIL ablation resulted in better 2-year organized atrial tachyarrhythmia-free survival (71% [62%-79%] versus 60% [50%-69%]; P=0.07), which approached statistical significance. Survival free of any atrial arrhythmia after one procedure was not significantly affected by isolation technique or MIL ablation. Conclusions- SRI resulted in fewer AF recurrences compared with WAI on long-term follow-up but did not reduce the recurrence of all atrial arrhythmias. MIL ablation may reduce organized atrial tachyarrhythmia recurrences. Clinical Trial Registration- http://www.anzctr.org.au; ACTRN12606000467538.

Serial Doppler echocardiographic assessment of diastolic dysfunction during acute myocardial infarction.

OBJECTIVES: We performed serial Doppler echocardiography in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) to describe the temporal changes in Doppler parameters following STEMI. BACKGROUND: Data on comprehensive Doppler assessment of diastolic dysfunction following STEMI, incorporating tissue Doppler imaging (TDI), are lacking. Severe diastolic dysfunction in stable patients usually manifests as a restrictive mitral filling pattern (RFP), reduced TDI-derived annular velocities (E'), and elevated E/E' ratios >15. METHODS: Twenty-eight patients (19 males, mean age 60 ± 10 years) with a first-ever STEMI who underwent PCI were prospectively assessed with echocardiography and invasive left ventricular end-diastolic pressure (LVEDP) measurements prior to PCI. Repeat echocardiograms were performed at day 3 and 12 months. RESULTS: During STEMI: (i) LVEDP was significantly elevated but decreased post revascularization (26.1 ± 6.2 vs. 20.8 ± 5.2 mmHg, P = 0.002); (ii) the predominant mitral inflow pattern was an abnormal relaxation pattern (n = 14 [50%]), whereas restrictive filling pattern was only observed in seven (25%) patients; (iii) E' velocities were only modestly reduced (septal E' 7.4 ± 2.2 cm/sec, lateral E' 9.6 ± 2.2 cm/sec), and (iv) a septal E/E'ratio >15 seen in only one patient, whereas all other patients had an E/E' ratio of 8-15. Serial TDI showed that E'velocity decreased at day 3 (septal E' 7.4 ± 2.1 cm/sec vs. 5.9 ± 1.6 cm/sec, P = 0.002) and remained reduced at 1 year follow-up, suggesting persistence of diastolic dysfunction. CONCLUSIONS: During STEMI, contrary to findings in stable patients, the predominant Doppler manifestation of the severe diastolic dysfunction and elevated LVEDP was an abnormal relaxation mitral inflow pattern accompanied by E/E' ratios of 8-15. Serial Doppler assessment suggests incomplete diastolic recovery following STEMI.

Impact of duration of ischemia on left ventricular diastolic properties following reperfusion for acute myocardial infarction.

We sought the correlation between duration of myocardial ischemia and severe left ventricular (LV) diastolic dysfunction (restrictive filling pattern [RFP]) in patients with acute ST-elevation myocardial infarction (STEMI). Duration of ischemia determines infarct size and survival after STEMI. However, the impact of duration of ischemia on LV diastolic function has not been previously studied. Ninety-five consecutive patients with first-ever STEMI underwent transthoracic echocardiography 3 days after primary percutaneous coronary intervention (PCI). RFP was defined as a mitral inflow E/A ratio >2.0 and/or E-wave deceleration time <140 ms. Composite major adverse cardiovascular events (death, reinfarction, heart failure, revascularization) were determined at 12 months. Twenty patients (21%) had RFP on day 3. Symptom-to-reperfusion time in the RFP group was 413 ± 287 versus 252 ± 138 minutes in the non-RFP group (p = 0.014). Peak troponin T levels were higher in the RFP group (12.2 ± 8.4 vs 5.7 ± 3.6 ng/ml, p = 0.002). Logistic regression identified symptom-to-reperfusion time (hazard ratio 1.02, 95% confidence interval 1.01 to 1.03, p = 0.010) and infarct size by peak troponin T levels (hazard ratio 1.54, 95% confidence interval 1.14 to 2.10, p = 0.005) as independent predictors of RFP. Major adverse cardiovascular events occurred in 10 patients (50%) in the RFP group and 6 patients (8%) in the non-RFP group. On multivariate Cox proportional hazards analysis, RFP was an independent predictor of major adverse cardiovascular events at 12 months (hazard ratio 5.43, 95% confidence interval 1.52 to 19.39, p = 0.001). In conclusion, delayed reperfusion after STEMI was associated with severe LV diastolic dysfunction, which in turn independently predicted adverse long-term outcomes. LV diastolic dysfunction represents a significant pathophysiologic link among duration of myocardial ischemia, infarct size, and outcomes.

Atrial arrhythmias after single-ring isolation of the posterior left atrium and pulmonary veins for atrial fibrillation: mechanisms and management.

BACKGROUND: Single-ring isolation of the posterior left atrium is feasible, but the incidence and mechanisms of postprocedural arrhythmias have not been described in detail. METHODS AND RESULTS: The first 100 consecutive patients (58.8+/-11.2 years old, 80 male) who underwent single-ring isolation for atrial fibrillation (66 intermittent, 18 persistent, 16 long-standing persistent) were followed up for 9.1+/-4.5 months. Recurrences were diagnosed by clinical symptoms and Holter monitoring. Patients with recurrences of sustained atrial arrhythmia >3 months after the procedure were offered a repeat procedure and were studied to determine the mechanisms of recurrence. Forty-six patients (46%) experienced sustained postprocedural atrial arrhythmias (35 had atrial fibrillation, and 34 had atrial flutter). Of these, 34 required a second procedure 7.0+/-3.1 months after their initial procedure. Reconnection of the posterior left atrium was seen in all patients with atrial fibrillation. Atrial flutter was most commonly due to mitral isthmus-dependent macroreentry (n=8, cycle length 368+/-116 ms) or macroreentry through 2 gaps in the ring of lesions (n=6, cycle length 328+/-115 ms). Posterior left atrium reisolation was achieved at the second procedure in all patients. Atrial flutter was successfully ablated and rendered noninducible in all patients. Six months after their last procedure, the Kaplan-Meier estimate of freedom from recurrence for all 100 patients was 81+/-5%. CONCLUSIONS: Atrial fibrillation and atrial flutter recurrence is common after single-ring isolation. Reconnection of the posterior left atrium and macroreentry are the common mechanisms. Repeat ablation results in satisfactory short-term outcomes.