Outcomes of surgical ablation for atrial fibrillation: a 10-year experience.

AIM: Surgical ablation for atrial fibrillation has been performed at Wellington hospital for 10 years. This audit aims to evaluate the outcomes from surgical intervention for atrial fibrillation and identify variables affecting clinical results. METHOD: A retrospective audit of clinical outcomes was performed including all patients who had received surgical intervention for atrial fibrillation from 2004 to 2013. RESULTS: Forty-seven patients who underwent surgical intervention for atrial fibrillation were identified and reviewed. There were no deaths prior to discharge. At 6 months, 81.4% of patients were in sinus rhythm, this dropped to 58.7% at late follow-up (average of 48 months). Procedure type had a statistically significant effect on outcome. Over 288 patient-years of follow-up, 2 strokes and 7 deaths occurred. CONCLUSIONS: The surgical treatment of atrial arrhythmias in Wellington hospital is a safe and effective management option, although the antiarrhythmic effects do appear to diminish with time. There were lower rates of mortality and stroke long-term than would be expected with simple anticoagulation. It is important that the formal Cox-Maze procedure lesion set is performed to maximise the surgical interventions effectiveness. Atrial size predicts success, and should be considered in patient selection.

Desmopressin for reducing postoperative blood loss and transfusion requirements following cardiac surgery in adults.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in adult patients undergoing cardiac surgery requiring extracorporeal cardiopulmonary bypass (CPB), does administration of desmopressin acetate (DDAVP) reduce postoperative blood loss and transfusion requirements? Altogether 38 papers were found using the reported search, of which 19 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Perioperative administration of DDAVP in adult patients undergoing cardiac surgery requiring CPB may result in a small but significant reduction in postoperative blood loss. However, this does not translate into a reproducible, clinically significant reduction in exposure to transfusion in unselected patients exposed to CPB. Several sub-groups of patients have been identified in whom DDAVP reduces postoperative blood loss and transfusion requirements. These sub-groups include patients who have received preoperative aspirin within 7 days of surgery, patients with CPB times in excess of 140 min and patients with demonstrable pre- or perioperative platelet dysfunction as determined by TEG analysis or platelet function assays. Platelet dysfunction at the time of surgery may be secondary to preoperative administration of antiplatelet medications, the result of pathological processes such as von Willebrands disease, uraemia or aortic stenosis with its associated sheer stress, as well as operative variables such as prolonged exposure to CPB. The evidence does not support the routine use of DDAVP in all cardiac surgery; indeed, it is clear that there is no significant reduction in postoperative blood loss or transfusion requirements with the administration of DDAVP in patients undergoing isolated coronary artery bypass grafting (CABG) in the absence of the features noted above. Given the absence of a clinically significant reduction in exposure to blood transfusion in unselected patients, we cannot recommend the routine use of DDAVP in patients exposed to CPB. However, DDAVP may reduce postoperative bleeding in patients who have received preoperative aspirin within 7 days of surgery, patients with CPB times in excess of 140 min and patients with demonstrable platelet dysfunction and should be used selectively in these subgroups.