Long-Term Performance of Epicardial versus Transvenous Left Ventricular Leads for Cardiac Resynchronization Therapy.

Aims: to study the technical performance of epicardial left ventricular (LV) leads placed via video assisted thoracic surgery (VATS), compared to transvenously placed leads for cardiac resynchronization therapy (CRT). Methods: From 2001 until 2013, a total of 644 lead placement procedures were performed for CRT. In the case of unsuccessful transvenous LV lead placement, the patient received an epicardial LV lead. Study groups consist of 578 patients with a transvenous LV lead and 66 with an epicardial LV lead. The primary endpoint was LV-lead failure necessitating a replacement or deactivation. The secondary endpoint was energy consumption. Results: The mean follow up was 5.9 years (epicardial: 5.5 ± 3.1, transvenous: 5.9 ± 3.5). Transvenous leads failed significantly more frequently than epicardial leads with a total of 66 (11%) in the transvenous leads group vs. 2 (3%) in the epicardial lead group (p = 0.037). Lead energy consumption was not significantly different between groups. Conclusions: Epicardial lead placement is feasible, safe and shows excellent long-term performance compared to transvenous leads. Epicardial lead placement should be considered when primary transvenous lead placement fails or as a primary lead placement strategy in challenging cases.

Surgical clip closure of the left atrial appendage.

Atrial fibrillation (AF) is the most common atrial arrhythmia, but it is not a benign disease. AF is an important risk factor for thromboembolic events, causing significant morbidity and mortality. The left atrial appendage (LAA) plays an important role in thrombus formation, but the ideal management of the LAA remains a topic of debate. The increasing popularity of surgical epicardial ablation and hybrid endoepicardial ablation approaches, especially in patients with a more advanced diseased substrate, has increased interest in epicardial LAA management. Minimally invasive treatment options for the LAA offer a unique opportunity to close the LAA with a clip device. This review highlights morphologic, electrophysiologic, and surgical aspects of the LAA with regard to AF surgery, and aims to illustrate the importance of surgical clip closure of the LAA.

Obesity is associated with impaired long-term success of pulmonary vein isolation: a plea for risk factor management before ablation.

Aims: Obesity is an increasing health problem and is an important risk factor for the development of atrial fibrillation (AF). We investigated the association of body mass index (BMI) on the safety and long-term efficacy of pulmonary vein isolation (PVI) for drug-refractory AF. Methods: 414 consecutive patients who underwent transcatheter PVI for AF between 2003 and 2013 were included. Successful PVI was defined as absence of atrial arrhythmia on Holter monitoring or ECG, without and with antiarrhythmic drugs during follow-up. Obesity was defined as BMI≥30 kg/m². Results: Mean age was 56±10 years, 316 (76%) were male, 311 (75%) had paroxysmal AF and 111 (27%) were obese. After a mean follow-up of 46±32 months (1590 patient-years), freedom from atrial arrhythmia and antiarrhythmic drugs was significantly lower in patients with obesity compared with non-obese patients (30% vs 46%, respectively, P=0.005, log-rank 0.016). With antiarrhythmic drugs, freedom from atrial arrhythmia was 56% vs 68% (P=0.036). No differences in minor and major adverse events were observed between patients with obesity and non-obese patients (major 6% vs 3%, P=0.105, and minor 5% vs 5%, P=0.512). Sensitivity analyses demonstrated that BMI (as continuous variable) was associated with PVI outcome (HR 1.08, 95% CI 1.02 to 1.14, P=0.012). Conclusion: Obesity is associated with reduced efficacy of PVI for drug-refractory AF. No relation between obesity and adverse events was found.

Impact of Thoracoscopic Pulmonary Vein Isolation on Right Ventricular Function: A Pilot Study.

OBJECTIVE: Thoracoscopic surgical pulmonary vein isolation (sPVI) has been added to the treatment of atrial fibrillation (AF), showing excellent efficacy outcomes. However, data on right ventricular (RV) function following sPVI has never been studied. Our aim was to investigate RV function following sPVI and compare it to patients who underwent endocardial cryoballoon PVI. METHODS: 25 patients underwent sPVI and were pair-matched according to age, sex, and AF type with 21 patients who underwent cryoballoon PVI. RV function was measured using tricuspid annular plane systolic excursion (TAPSE) and RV strain with 2D speckle tracking. Echocardiography was performed at baseline and at median 6-month follow-up. RESULTS: Age was 54 ± 9 years and 84% were male; AF was paroxysmal in 92%. In the sPVI group, TAPSE was reduced with 31% at follow-up echocardiography (p < 0.001) and RV strain showed a 25% reduction compared to baseline (p = 0.018). In the control group, TAPSE and RV strain did not change significantly (-3% and +13%, p = 0.410 and p = 0.148). Change in TAPSE and RV strain was significantly different between groups (p ≤ 0.001 and p = 0.005). CONCLUSIONS: This study shows that RV function is significantly decreased following sPVI. This effect was not observed in the cryoballoon PVI control group.

Atrial remodelling and function: implications for atrial fibrillation surgery.

The exact mechanism of atrial fibrillation (AF) is still incompletely understood. A number of alterations that impact focal electrical discharge, the atrial substrate and modulating factors contribute to its pathogenesis. Atrial remodelling (resulting in atrial cardiomyopathy) sets the stage for AF development. Once present, AF results in the loss of synchronized atrial contraction, which affects ventricular filling and atrial reservoir and conduit functions. Passive atrial function is particularly important in patients with left ventricular diastolic dysfunction. AF can cause tachycardiomyopathy, a mostly reversible cardiac alteration induced by tachycardia. At a structural level, atrial support is also instrumental to the function of atrioventricular valves. All of these functions can be recovered to variable degrees via rhythm control strategies. Surgical and hybrid ablation show very promising results, especially in patients with a more advanced disease substrate. This review highlights the pathophysiological aspects of AF related to left atrial function and their practical implications for surgical rhythm management.

Surgical Left Atrial Appendage Exclusion Does Not Impair Left Atrial Contraction Function: A Pilot Study.

BACKGROUND: In order to reduce stroke risk, left atrial appendage amputation (LAAA) is widely adopted in recent years. The effect of LAAA on left atrial (LA) function remains unknown. The objective of present study was to assess the effect of LAAA on LA function. METHODS: Sixteen patients with paroxysmal AF underwent thoracoscopic, surgical PVI with LAAA (LAAA group), and were retrospectively matched with 16 patients who underwent the same procedure without LAA amputation (non-LAAA group). To objectify LA function, transthoracic echocardiography with 2D Speckle Tracking was performed before surgery and at 12 months follow-up. RESULTS: Mean age was 57 ± 9 years, 84% were male. Baseline characteristics did not differ significantly except for systolic blood pressure (p = 0.005). In both groups, the contractile LA function and LA ejection fraction were not significantly reduced. However, the conduit and reservoir function were significantly decreased at follow-up, compared to baseline. The reduction of strain and strain rate was not significantly different between groups. CONCLUSIONS: In this retrospective, observational matched group comparison with a convenience sample size of 16 patients, findings suggest that LAAA does not impair the contractile LA function when compared to patients in which the appendage was unaddressed. However, the LA conduit and reservoir function are reduced in both the LAAA and non-LAAA group. Our data suggest that the LAA can be removed without late LA functional consequences.

Long-term results of surgical minimally invasive pulmonary vein isolation for paroxysmal lone atrial fibrillation.

AIMS: Transcatheter pulmonary vein ablation is the current treatment of choice for symptomatic drug-refractory atrial fibrillation (AF). Video-assisted surgical pulmonary vein isolation (sPVI) is an alternative therapy to percutaneous ablation for the treatment of AF. Long-term results of sPVI are currently unknown. The aim of this study was to report on the long-term efficacy and safety of sPVI in patients with paroxysmal AF. METHODS AND RESULTS: The study design was observational and retrospective. From July 2005 to January 2011, 42 patients with drug-refractory paroxysmal AF underwent video-assisted sPVI in two different centres. Patients were eligible for sPVI when suffering from symptomatic, drug-refractory paroxysmal AF and they agreed to the alternative of sPVI. The median preoperative AF duration was 24 months (range 3-200). Success was defined as the absence of AF on 24 h or 96 h Holter monitoring during follow-up, off antiarrhythmic drugs (AAD). Adverse events and follow-up monitoring were based on the Heart Rhythm Society Consensus Statement 2012 for the catheter and surgical ablation of AF. Mean age was 55 ± 10 years, and 76% were males. After a mean follow-up of 5 years (SD 1.7), 69% of all patients were free from atrial arrhythmias without the use of AAD, and 83% with the use of AAD. Major peri-procedural adverse events occurred in four (9.5%) patients, no strokes or mortalities were registered during long-term follow-up. CONCLUSION: This retrospective study shows that sPVI for the treatment of paroxysmal AF is effective and that the outcomes are maintained at long-term follow-up.

A new beating-heart off-pump coronary artery bypass grafting training model.

OBJECTIVES: Training models are essential in mastering the skills required for off-pump coronary artery bypass grafting (OPCAB). We describe a new, high-fidelity, effective and reproducible beating-heart OPCAB training model in human cadavers. METHODS: Human cadavers were embalmed according to the 'Thiel method' which allows their long-term and repeated use. The training model was constructed by bilateral ligation of the pulmonary veins, cross-clamping of the aorta, positioning of an intra-aortic balloon pump (IABP) in the left ventricle (LV) through the apex (tightened with pledget-reinforced purse strings) and finally placing of a fluid line in the LV through the left atrial appendage (tightened with a pledget-reinforced purse string). The LV was filled with saline to the desired pressure through the fluid line and the IABP was switched on and set to a desired frequency [usually 60-80 beats per minute (bpm)]. RESULTS: A high-fidelity simulation has known limitations, but a more complex, realistic training environment with an actual beating (human) heart strengthens the entire training exercise and is of incremental value. All types of coronary artery anastomosis can be trained with this model. Training should be performed under the supervision of an experienced OPCAB surgeon and training progress is best evaluated with serial Objective Structured Assessment of Technical Skills (OSATS). A score of at least 48 points on the final OSATS ('good' on all components) is recommended before trainees can start their training on patients. CONCLUSIONS: The entire set-up provides a versatile training model to help develop and improve the skills required to safely perform beating heart OPCAB anastomoses.

The classic elephant trunk technique for staged thoracic and thoracoabdominal aortic repair: long-term results.

OBJECTIVE: The classic elephant trunk (ET) technique has become the standard approach for patients with diffuse aortic disease requiring a staged thoracic and thoracoabdominal aortic repair. The aim of this study was to assess long-term outcomes and predictors for survival after surgical repair of extensive thoracic aortic disease with the ET technique. METHODS: Between 1984 and 2013, 248 consecutive patients were treated in our institution and analyzed retrospectively. Follow-up consisted of outpatient clinic visits including postoperative computed tomography imaging at 3 months and annually thereafter. Second-stage intervention was indicated if the diameter of the descending or thoracoabdominal aorta was greater than or equal to 60 mm, in case of a rapidly growing aneurysm and/or symptoms. RESULTS: Mean age was 65 ± 10 years; 44% were male. After first-stage ET, in-hospital mortality was 8% and permanent neurologic deficits were observed in 2% of patients. Median follow-up after the first stage was 48 months (range, 1-210 months). One hundred twelve patients (45%) underwent second-stage ET. Overall survival after first-stage ET was 75% and 67% at 5 and 10 years, respectively. Survival in patients with second-stage ET was 87%, compared with 65% in the group who did not undergo second-stage ET at the 5-year follow-up (P < .001) and 67% compared with 36% at the 10-year follow-up (P < .001). Predictor for mortality was the absence of second-stage ET (P = .044). CONCLUSIONS: A 2-stage approach for diffuse aortic disease is a safe method. The acceptable mortality at the first stage justifies the use of the classic ET technique and allows subsequent repair of the distal aorta. Long-term survival is increased when both stages are completed.

Surgical vs. transcatheter pulmonary vein isolation as first invasive treatment in patients with atrial fibrillation: a matched group comparison.

AIMS: Pulmonary vein isolation (PVI) can be considered for treatment of symptomatic atrial fibrillation (AF). Nowadays, in addition to transcatheter ablation, thoracoscopic surgical PVI is available. The aim of this study is to compare clinical outcome of surgical with transcatheter PVI as first invasive treatment strategy of AF. METHODS AND RESULTS: From June 2009 to November 2011, 33 patients underwent minimally invasive surgical PVI, and were matched (1:2 fashion) retrospectively according to age, sex, and AF type, with 66 patients who underwent transcatheter PVI. Success was defined as freedom from atrial arrhythmias on 24 h Holter monitoring without use of anti-arrhythmic drugs (AADs) at 1 year. Mean age was 52 ± 10 years, 82% were male. Paroxysmal AF was present in 76 patients (77%), persistent AF in 23 (23%) patients. None underwent prior ablations, and failed on 1.2 ± 0.6 AADs. At 12 months, complete freedom from atrial arrhythmias without AADs in the surgical PVI group was 88% compared with 41% in the transcatheter PVI group (P < 0.001). Freedom from atrial arrhythmias with AADs was 91 vs. 62%, in the surgical vs. transcatheter PVI group, respectively (P = 0.002). Complications occurred in seven (21%) surgical PVI patients, and three (5%) transcatheter PVI patients (P = 0.015). CONCLUSION: In present matched study comparing a surgical with transcatheter PVI treatment strategy in symptomatic AF patients failed on AADs, but without prior ablations, a surgical PVI strategy was more effective to prevent recurrence of atrial arrhythmias, than a transcatheter PVI treatment strategy. However, complications were more frequent with surgical PVI.

Surgical minimally invasive pulmonary vein isolation for lone atrial fibrillation: midterm results of a multicenter study.

OBJECTIVE: Minimally invasive surgical pulmonary vein isolation (SMI-PVI) is an emerging therapy for the treatment of symptomatic drug-refractory atrial fibrillation (AF). Nevertheless, the midterm and long-term results of SMI-PVI remain unknown. The aim of this retrospective multicenter study was to report on midterm efficacy and safety of SMI-PVI. METHODS: The study design was retrospective, multicentric, and observational. From July 2005 to November 2011, a total of 86 patients with drug-refractory paroxysmal or persistent AF underwent SMI-PVI in three centers. Patients were eligible for SMI-PVI if they had symptomatic, drug-refractory AF or after failed transcatheter pulmonary vein isolation. Success was defined as absence of AF on 24- or 96-hour Holter monitoring during follow-up, in the absence of antiarrhythmic drugs (AADs). RESULTS: The mean ± SD age was 54 ± 11 years, and 78% were men. The median AF duration was 30 months (range, 2-203); paroxysmal AF was present in 86% of the patients, persistent in 14%. Fifteen patients (17%) underwent previous transcatheter ablations. After a median follow-up of 24 months (range, 6-78), 72% of all patients were free from atrial arrhythmias without the use of AADs. With AADs, this was 83%. Major perioperative adverse events occurred in 7 patients (8%). CONCLUSIONS: This retrospective multicenter study shows that SMI-PVI is effective at a median follow-up of 24 months for the treatment of mostly paroxysmal drug-refractory AF. Perioperative adverse events do remain a point of caution.

Cardiac dynamic magnetic resonance of a giant lung carcinoma invading the left atrium: do not let the imaging fool you.

This study aimed to report on a non-small-cell lung cancer (NSCLC) originating from the right lung lower lobe and circulatory extension into the left atrium. Atrial involvement is an uncommon feature of advanced NSCLC, occurring in up to 10% of patients with bronchogenic carcinoma. In this case, the neoplastic mass was enormous and diagnosed as a lung pleiomorph carcinoma, staged T4N2M0 and so far considered irresectable. Conventional static imaging (chest CT-positron emission tomography scan; cardiac MRI) failed to rule out any direct invasion into surrounding structures. Surgery is the gold standard treatment for the local control of NSCLC without distant metastasis. Finally, preoperative cardiac dynamic magnetic resonance imaging and transoesophageal echocardiography were crucial to assess resectability, showing the absence of tumour invasion inside the pulmonary circulation and in the left atrium, supporting the decision-making for a radical, curative, surgical resection.