Novel sizing role of 3D transesophageal echocardiography in a novel left atrial appendage clip device for patients undergoing video-assisted atrial fibrillation ablation: a cohort study.

Background:Three-dimensional (3D) transesophageal echocardiography (TEE) has been successfully used in the sizing of left atrial appendage (LAA) occlusion devices, but its use has not yet been studied in LAA clip devices. We sought to develop and validate the novel use of 3D-TEE sizing in a novel LAA clip device for atrial fibrillation (AF) patients undergoing video-assisted thoracic surgery (VATS) ablation.Methods:Consecutive patients with isolated AF undergoing LAA clipping or excision during VATS ablation were included in the study between June 2021 and September 2022 at Fuwai Hospital. The patients underwent 3D-TEE examinations preoperatively and postoperatively. The VATS length, LAA clip effective length, and LAA excision margin length were recorded. A correlation analysis, intraclass correlation coefficient (ICC) analysis, and Bland-Altman plot analysis were conducted to examine the TEE parameters, VATS length, LAA clip effective length, and LAA excision margin length.Results:In total, 26 AF patients undergoing LAA clipping and 15 undergoing LAA excision were included in the study. In the LAA clipping group, in which the Atriclip size served as the control, the 3D-TEE with volumetric measurement (the perimeter-derived maximum orifice diameter) (R=0.938; ICC =0.934; Bland-Altman plot variability, 3.85%) showed the best sizing efficacy for the LAA clip device among the 3D-TEE with multiplanar reformatting sizing (the perimeter-derived maximum orifice diameter) (R=0.808; ICC =0.772; Bland-Altman plot variability, 3.85%), VATS sizing (R=0.851; ICC =0.756; Bland-Altman plot variability, 11.54%), and VATS plus 0.5-cm sizing (R=0.851; ICC =0.775; Bland-Altman plot variability, 11.54%) measurements (all P<0.001). In addition, for the distribution of matched sizing in the LAA clip group, 3D-TEE with volumetric measurement sizing (20/26) had a higher proportion than 3D-TEE with multiplanar reformatting sizing (11/26, P=0.011), VATS sizing (9/26, P=0.002), and VATS plus 0.5-cm sizing (14/26, P=0.08). Using the LAA excision margin length as the control, the mean difference in the LAA diameter was 1.17 cm [95% confidence interval (CI): 0.71-1.62 cm , P<0.001] in the maximum orifice diameter of two-dimensional-TEE, 0.15 cm (95% CI: -0.32 to 0.61 cm , P=0.523) in the perimeter-derived 3D multiplanar reformatting (the maximum orifice diameter), and 0.03 cm (95% CI: -0.47 to 0.53, P=0.901) in the perimeter-derived 3D volumetric (3DV) measurement (the maximum orifice diameter), and the related Pearson correlation coefficients for these modalities were 0.760 (P=0.001), 0.843 (P<0.001), and 0.963 (P<0.001), respectively.Conclusions:Our study showed that 3D-TEE might be employed in the sizing of a novel LAA clip device using the VATS approach in patients with AF. The 3DV measurement (the perimeter-derived maximum orifice diameter) was superior to the VATS measurement. These findings might also apply to LAA VATS excision patients with AF.

Superiority of complete bi-atrial ablation procedure for atrial fibrillation in rheumatic mitral valve disease.

INTRODUCTION:The necessity of complete bi-atrial lesion created by radiofrequency clamp and pen for nonparoxysmal atrial fibrillation (AF) in patients with rheumatic mitral valve disease (RMVD) remains unclear.METHODS:From January 2014 to December 2018, patients with RMVD concomitant with nonparoxysmal AF who underwent mitral valve surgery concomitant surgical ablation were retrospectively enrolled. We divided patients into Group A (complete bi-atrial lesion set created by radiofrequency clamp and pen) and Group B (simplified lesion sets created by radiofrequency clamp alone including bi-atrial ablation with incomplete mitral isthmus line and stand-alone left atrial ablation) according to the surgical ablation lesion sets. Propensity score matching was applied to analyze freedom from atrial tachyarrhythmias between the two groups.RESULTS:Two hundred eight (38.5%) and 332 (61.5%) patients were divided into Group A and Group B, respectively. In Group B, the proportion of patients with recurrent atrial flutter in the subgroup of bi-atrial ablation with incomplete mitral isthmus line was higher than that in Group A (p = .044). After propensity score matching, there were 203 patients in each group. Better freedom from atrial tachyarrhythmias without antiarrhythmic drugs was obtained in Group A (83.1%, 79.6%, and 65.4%) than Group B (73.1%, 68.4%, and 52.7%) at 12, 36, and 60 months after operation (p = .012).CONCLUSION:The application of radiofrequency clamp and pen to create complete bi-atrial lesion set in surgical ablation for nonparoxysmal AF in RMVD was associated with superior long-term efficacy.

Bi-atrial versus left atrial ablation for patients with rheumatic mitral valve disease and non-paroxysmal atrial fibrillation (ABLATION): rationale, design and study protocol for a multicentre randomised controlled trial.

INTRODUCTION:Atrial fibrillation (AF) is common in patients with rheumatic mitral valve disease (RMVD) and increase the risk of stroke and death. Bi-atrial or left atrial ablation remains controversial for treatment of AF during mitral valve surgery. The study aims to compare the efficacy and safety of bi-atrial ablation with those of left atrial ablation among patients with RMVD and persistent or long-standing persistent AF.METHODS AND ANALYSIS:The ABLATION trial (Bi-atrial vs Left Atrial Ablation for Patients with RMVD and Non-paroxysmal AF) is a prospective, multicentre, randomised controlled study. The trial will randomly assign 320 patients with RMVD and persistent or long-standing persistent AF to bi-atrial ablation procedure or left atrial ablation procedure in a 1:1 randomisation. The primary end point is freedom from documented AF, atrial flutter or atrial tachycardia of >30 s at 12 months after surgery off antiarrhythmic drugs. Key secondary end point is the probability of freedom from permanent pacemaker implantation at 12 months after surgery. Secondary outcomes include the probability of freedom from any recurrence of atrial tachyarrhythmias with antiarrhythmic drugs, AF burden, incidence of adverse events and cardiac function documented by echocardiography at 12 months after operation.ETHICS AND DISSEMINATION:The central ethics committee at Fuwai Hospital approved the ABLATION trial. The results of this study will be disseminated through publications in peer-reviewed journals and conference presentations.TRIAL REGISTRATION NUMBER:NCT05021601.

Box lesion or bi-atrial lesion set for atrial fibrillation during thoracoscopic epicardial ablation.

OBJECTIVES:Thoracoscopic epicardial ablation with a limited lesion set led to suboptimal results for advanced paroxysmal atrial fibrillation (AF) or persistent AF. Whether additional right atrial lesions improve the result is unclear.METHODS:We conducted a retrospective study involving 80 consecutive patients with paroxysmal or persistent AF, left atrial (LA) dilation (LA diameter >40 mm) and failed prior interventional ablation (40 patients, 50%) who underwent thoracoscopic epicardial ablation with box lesions (36 patients) or bi-atrial (BA) lesion (44 patients) in our institution. Freedom from atrial tachyarrhythmias after the procedures was compared between the box lesion group and BA lesion group.RESULTS:Baseline differences included more patients with persistent AF (86.4% vs 47.2%) and larger left atrium [48.00 (44.00-50.75) vs 42.00 (41.25-44.00) mm] in the BA lesion group. There was no difference in procedural complications between the 2 groups. After a mean follow-up of 32 months, the freedom from atrial tachyarrhythmias off antiarrhythmic drugs at 6, 12 and 24 months was 77.2%, 77.2% and 77.2% in the BA lesion group and 69.4%, 50.0% and 40.6% in the box lesion group, respectively (P = 0.006). After adjustment for sex, age, body mass index, LA diameter, AF type, history of AF, and previous interventional ablation, BA lesion was an independent predictor of lower atrial tachyarrhythmia recurrence (hazard ratio 0.447, 95% confidential interval 0.208-0.963; P = 0.040).CONCLUSIONS:Compared with the box lesion set, thoracoscopic epicardial ablation with BA lesion sets might provide better freedom from atrial tachyarrhythmias for paroxysmal or persistent AF with LA dilation. Randomized control trials are warranted to confirm the benefit of BA lesion sets in these patients.

Influence of operator volume on early outcomes of septal myectomy for isolated hypertrophic obstructive cardiomyopathy.

BACKGROUND:Guidelines on the diagnosis and management of hypertrophic cardiomyopathy (HCM) recommend that septal myectomy be performed by experienced operators. However, the impact of operator volume on surgical treatment outcomes for isolated HCM has been poorly investigated.METHODS:From 2002 to 2014, 435 consecutive patients with isolated HCM undergoing myectomy at the Fuwai Hospital were retrospectively enrolled. All 29 surgeons were divided into beginner surgeons (operator volume ≤20) and experienced surgeons (operator volume >20) according to the guidelines for the diagnosis and treatment of HCM. Propensity score matching of patients in the two groups was performed.RESULTS:Baseline differences included advanced New York Heart Association classification and older age in the experienced surgeon group. After matching, in the beginner surgeon group (107 cases), residual obstruction (18.7% vs. 0.9%, P<0.001) was more common, and the postoperative left ventricular outflow tract pressure gradient (20.7±15.1 vs. 14.3±7.4 mmHg, P<0.001) was higher than that of the experienced surgeon group. In the experienced surgeon group (107 cases), the incidence of mitral valve replacement (1.9% vs. 11.2%, P<0.001) and permanent pacemaker implantation (1.9% vs. 3.7%, P<0.001) was significantly lower than that in the beginner surgeon group. However, there was no difference in procedural mortality (1.9% vs. 1.9%) between the two groups.CONCLUSIONS:Operator volume is an important factor in achieving better obstruction obliteration after septal myectomy in patients with isolated HCM.

Coronary Evaluation Before Heart Valvular Surgery by Using Coronary Computed Tomographic Angiography Versus Invasive Coronary Angiography.

Background Coronary computed tomography angiography (CCTA) is a noninvasive, less expensive, low-radiation alternative to invasive coronary angiography (ICA). ICA is recommended for coronary evaluation before heart valvular surgery, and the supporting evidence for CCTA is insufficient. Our study is a single-center, prospective cohort study designed to evaluate the feasibility of CCTA instead of ICA in detection of coronary artery disease before surgery. Methods and Results Heart valvular surgery candidates were consecutively enrolled between April 2017 and December 2018. Nine hundred fifty-eight patients in the CCTA group underwent CCTA primarily, and those with ≥50% coronary stenosis or uncertain diagnosis underwent subsequent ICA. One thousand five hundred twenty-five patients in the ICA group underwent ICA directly before surgery. Coronary artery bypass grafting decision was made by surgeons according to CCTA or ICA results. Most of the patients (78.8%) in the CCTA group avoided invasive angiography. Thirty-day mortality (0.7% versus 0.9%, P=0.821), myocardial infarction (6.4% versus 6.9%, P=0.680 ), and low cardiac output syndrome (4.2% versus 2.8%, P=0.085) were similar in the CCTA and ICA groups. Median duration of follow-up was 19.3 months (interquartile range, 14.2-30.0 months), cumulative rates of mortality (2.6% versus 2.6%, P=0.882) and major adverse cardiac events (9.6% versus 9.0%, P=0.607) showed no difference between the 2 groups. Coronary evaluation expense was lower in the CCTA group ($149.6 versus $636.0, P<0.001). Conclusions The strategy of using CCTA as a doorkeeper in coronary evaluation before heart valvular surgery showed noninferiority in identification of candidates for coronary artery bypass grafting and postoperative safety.

Midterm results of stand-alone thoracoscopic epicardial ablation with box lesion for atrial fibrillation.

OBJECTIVES:The short-term results of video-assisted thoracoscopic surgical ablation (VTSA) with box lesion have been highly variable, and the actual efficacy requires clarification through longer follow-ups. We aimed to report which patients might benefit more from VTSA with box lesion by longer follow-up.METHODS:From September 2010 to November 2016, patients with atrial fibrillation (AF) who underwent VTSA with box lesion were screened. All enrolled patients visited the outpatient clinic and underwent 24-h Holter monitoring at 3, 6 and 12 months after surgery and annually thereafter.RESULTS:A total of 91 consecutive patients [age, 58.0 (interquartile interval from 52.0 to 62.0) years; male, 71.4%] with paroxysmal (67%) or persistent/long-standing persistent (33%) AF were enrolled. After a median follow-up of 48 months (interquartile interval from 36 to 60 months), freedom from atrial tachyarrhythmias without antiarrhythmic drugs (AADs) was 76.5%, 66.0% and 66.0% for paroxysmal AF and 58.6%, 47.8% and 34.2% for persistent/long-standing persistent AF at 12, 36 and 60 months, respectively (P = 0.017). The preoperative left atrial diameter >40 mm (hazard ratio: 2.837, 95% confidence interval: 1.408-5.716; P = 0.004) and age >50 years (hazard ratio: 2.927, 95% confidence interval: 1.359-6.305; P = 0.006) were associated with recurrences of atrial tachyarrhythmias. In patients with paroxysmal AF and left atrial diameter ≤40 mm (n = 43), freedom from atrial tachyarrhythmias without AADs was 81.4%, 74.3% and 74.3% at 12, 36 and 60 months, respectively.CONCLUSIONS:In patients with paroxysmal AF and left atrial diameter ≤40 mm, 5-year freedom from atrial tachyarrhythmias without AADs was 74.3%, which was better than that in patients with left atrial diameter >40 mm. A larger sample size and improved study design are needed to confirm our conclusions.

Simultaneous hybrid maze procedure for long-standing persistent atrial fibrillation with dilated atrium.

BACKGROUND:The efficacy of catheter-based or thoracoscopic ablation for treating long-standing persistent atrial fibrillation (AF) with a dilated atrium remains suboptimal. This study aimed to assess the feasibility and initial results of simultaneous hybrid ablation with a new biatrial lesion set in these patients.METHODS:Twenty-seven consecutive patients with long-standing persistent AF and dilated atrium underwent simultaneous hybrid ablation with a new biatrial lesion set consistent with the principle of the Cox maze procedure at our institution. Patients were followed up at 3, 6, and 12 months after the procedure and annually thereafter.RESULTS:After thoracoscopic epicardial ablation, endocardial mapping confirmed complete bilateral pulmonary vein isolation in 25 patients (96.2%). All patients were followed for a mean of 18.7 ± 8.9 months. Freedom from atrial tachyarrhythmia at 1 year after the single hybrid procedure was 64% with antiarrhythmic drugs and 60% without antiarrhythmic drugs. Freedom from atrial tachyarrhythmia at latest follow-up after the hybrid procedure and redo catheter ablation was 77.8% with antiarrhythmic drugs and 74.1% without antiarrhythmic drugs. In patients with sinus rhythm restoration, mean left atrial diameter decreased from 54.4 ± 4.3 mm to 45.2 ± 4.1 mm (P < .001), and mean right atrial diameter decreased from 59.4 ± 3.9 mm to 54.9 ± 4.4 mm (P < .001). Postoperative pleural effusion was observed in 3 patients (11.1%), and no adverse events occurred during follow-up.CONCLUSIONS:In patients with long-standing persistent AF and a dilated atrium, simultaneous hybrid ablation with the new biatrial lesion set, in combination with touch-up catheter ablation when necessary, can achieve promising results. More studies are needed to confirm these findings.

A giant right coronary artery aneurysm caused by congenital coronary fistula.

Sinoatrial nodal artery injury in thoracoscopic epicardial ablation for atrial fibrillation.

OBJECTIVES:This study aimed to clarify the incidence of sinoatrial nodal artery (SANa) injury in thoracoscopic epicardial surgical ablation for atrial fibrillation (AF) and its impact on postoperative outcomes, which have not been previously elucidated.METHODS:We enrolled 103 consecutively patients with AF who underwent thoracoscopic epicardial ablation at our institution. In these patients, we evaluated the postoperative incidence of SANa injury by using enhanced cardiac computed tomography. For patients with confirmed SANa injury, 3-day continuous electrocardiographic monitoring and exercise stress tests were performed to assess the sinus rhythm maintenance and sinus node function.RESULTS:Thirteen patients (12.6%) had a confirmed SANa injury (left anterior type in 6 patients, left posterior type in 2 patients and double-branch type in 5 patients). After a median follow-up of 24 months, the patients with SANa injury were not found to be associated with lower sinus rhythm maintenance (hazard ratio 1.09, 95% confidential interval 0.36-3.31) as compared with those without SANa injury after adjustment for patient characteristics. Sinus node function was evaluated in 7 patients with SANa injury who remained in sinus rhythm after the procedure, and no sinus node dysfunction was confirmed in the 3-day electrocardiographic monitoring and exercise stress tests at a median follow-up of 12 months.CONCLUSIONS:The prevalence of SANa injury in the patients who underwent thoracoscopic epicardial ablation for AF was relatively low, and the incidence of SANa injury was not associated with postoperative restoration of sinus rhythm and sinoatrial node dysfunction. More studies are required to better understand SANa injury.

Novel sizing role of 3D transesophageal echocardiography in a novel left atrial appendage clip device for patients undergoing video-assisted atrial fibrillation ablation: a cohort study.

Background:Three-dimensional (3D) transesophageal echocardiography (TEE) has been successfully used in the sizing of left atrial appendage (LAA) occlusion devices, but its use has not yet been studied in LAA clip devices. We sought to develop and validate the novel use of 3D-TEE sizing in a novel LAA clip device for atrial fibrillation (AF) patients undergoing video-assisted thoracic surgery (VATS) ablation.Methods:Consecutive patients with isolated AF undergoing LAA clipping or excision during VATS ablation were included in the study between June 2021 and September 2022 at Fuwai Hospital. The patients underwent 3D-TEE examinations preoperatively and postoperatively. The VATS length, LAA clip effective length, and LAA excision margin length were recorded. A correlation analysis, intraclass correlation coefficient (ICC) analysis, and Bland-Altman plot analysis were conducted to examine the TEE parameters, VATS length, LAA clip effective length, and LAA excision margin length.Results:In total, 26 AF patients undergoing LAA clipping and 15 undergoing LAA excision were included in the study. In the LAA clipping group, in which the Atriclip size served as the control, the 3D-TEE with volumetric measurement (the perimeter-derived maximum orifice diameter) (R=0.938; ICC =0.934; Bland-Altman plot variability, 3.85%) showed the best sizing efficacy for the LAA clip device among the 3D-TEE with multiplanar reformatting sizing (the perimeter-derived maximum orifice diameter) (R=0.808; ICC =0.772; Bland-Altman plot variability, 3.85%), VATS sizing (R=0.851; ICC =0.756; Bland-Altman plot variability, 11.54%), and VATS plus 0.5-cm sizing (R=0.851; ICC =0.775; Bland-Altman plot variability, 11.54%) measurements (all P<0.001). In addition, for the distribution of matched sizing in the LAA clip group, 3D-TEE with volumetric measurement sizing (20/26) had a higher proportion than 3D-TEE with multiplanar reformatting sizing (11/26, P=0.011), VATS sizing (9/26, P=0.002), and VATS plus 0.5-cm sizing (14/26, P=0.08). Using the LAA excision margin length as the control, the mean difference in the LAA diameter was 1.17 cm [95% confidence interval (CI): 0.71-1.62 cm , P<0.001] in the maximum orifice diameter of two-dimensional-TEE, 0.15 cm (95% CI: -0.32 to 0.61 cm , P=0.523) in the perimeter-derived 3D multiplanar reformatting (the maximum orifice diameter), and 0.03 cm (95% CI: -0.47 to 0.53, P=0.901) in the perimeter-derived 3D volumetric (3DV) measurement (the maximum orifice diameter), and the related Pearson correlation coefficients for these modalities were 0.760 (P=0.001), 0.843 (P<0.001), and 0.963 (P<0.001), respectively.Conclusions:Our study showed that 3D-TEE might be employed in the sizing of a novel LAA clip device using the VATS approach in patients with AF. The 3DV measurement (the perimeter-derived maximum orifice diameter) was superior to the VATS measurement. These findings might also apply to LAA VATS excision patients with AF.

Superiority of complete bi-atrial ablation procedure for atrial fibrillation in rheumatic mitral valve disease.

INTRODUCTION:The necessity of complete bi-atrial lesion created by radiofrequency clamp and pen for nonparoxysmal atrial fibrillation (AF) in patients with rheumatic mitral valve disease (RMVD) remains unclear.METHODS:From January 2014 to December 2018, patients with RMVD concomitant with nonparoxysmal AF who underwent mitral valve surgery concomitant surgical ablation were retrospectively enrolled. We divided patients into Group A (complete bi-atrial lesion set created by radiofrequency clamp and pen) and Group B (simplified lesion sets created by radiofrequency clamp alone including bi-atrial ablation with incomplete mitral isthmus line and stand-alone left atrial ablation) according to the surgical ablation lesion sets. Propensity score matching was applied to analyze freedom from atrial tachyarrhythmias between the two groups.RESULTS:Two hundred eight (38.5%) and 332 (61.5%) patients were divided into Group A and Group B, respectively. In Group B, the proportion of patients with recurrent atrial flutter in the subgroup of bi-atrial ablation with incomplete mitral isthmus line was higher than that in Group A (p = .044). After propensity score matching, there were 203 patients in each group. Better freedom from atrial tachyarrhythmias without antiarrhythmic drugs was obtained in Group A (83.1%, 79.6%, and 65.4%) than Group B (73.1%, 68.4%, and 52.7%) at 12, 36, and 60 months after operation (p = .012).CONCLUSION:The application of radiofrequency clamp and pen to create complete bi-atrial lesion set in surgical ablation for nonparoxysmal AF in RMVD was associated with superior long-term efficacy.

Bi-atrial versus left atrial ablation for patients with rheumatic mitral valve disease and non-paroxysmal atrial fibrillation (ABLATION): rationale, design and study protocol for a multicentre randomised controlled trial.

INTRODUCTION:Atrial fibrillation (AF) is common in patients with rheumatic mitral valve disease (RMVD) and increase the risk of stroke and death. Bi-atrial or left atrial ablation remains controversial for treatment of AF during mitral valve surgery. The study aims to compare the efficacy and safety of bi-atrial ablation with those of left atrial ablation among patients with RMVD and persistent or long-standing persistent AF.METHODS AND ANALYSIS:The ABLATION trial (Bi-atrial vs Left Atrial Ablation for Patients with RMVD and Non-paroxysmal AF) is a prospective, multicentre, randomised controlled study. The trial will randomly assign 320 patients with RMVD and persistent or long-standing persistent AF to bi-atrial ablation procedure or left atrial ablation procedure in a 1:1 randomisation. The primary end point is freedom from documented AF, atrial flutter or atrial tachycardia of >30 s at 12 months after surgery off antiarrhythmic drugs. Key secondary end point is the probability of freedom from permanent pacemaker implantation at 12 months after surgery. Secondary outcomes include the probability of freedom from any recurrence of atrial tachyarrhythmias with antiarrhythmic drugs, AF burden, incidence of adverse events and cardiac function documented by echocardiography at 12 months after operation.ETHICS AND DISSEMINATION:The central ethics committee at Fuwai Hospital approved the ABLATION trial. The results of this study will be disseminated through publications in peer-reviewed journals and conference presentations.TRIAL REGISTRATION NUMBER:NCT05021601.

Box lesion or bi-atrial lesion set for atrial fibrillation during thoracoscopic epicardial ablation.

OBJECTIVES:Thoracoscopic epicardial ablation with a limited lesion set led to suboptimal results for advanced paroxysmal atrial fibrillation (AF) or persistent AF. Whether additional right atrial lesions improve the result is unclear.METHODS:We conducted a retrospective study involving 80 consecutive patients with paroxysmal or persistent AF, left atrial (LA) dilation (LA diameter >40 mm) and failed prior interventional ablation (40 patients, 50%) who underwent thoracoscopic epicardial ablation with box lesions (36 patients) or bi-atrial (BA) lesion (44 patients) in our institution. Freedom from atrial tachyarrhythmias after the procedures was compared between the box lesion group and BA lesion group.RESULTS:Baseline differences included more patients with persistent AF (86.4% vs 47.2%) and larger left atrium [48.00 (44.00-50.75) vs 42.00 (41.25-44.00) mm] in the BA lesion group. There was no difference in procedural complications between the 2 groups. After a mean follow-up of 32 months, the freedom from atrial tachyarrhythmias off antiarrhythmic drugs at 6, 12 and 24 months was 77.2%, 77.2% and 77.2% in the BA lesion group and 69.4%, 50.0% and 40.6% in the box lesion group, respectively (P = 0.006). After adjustment for sex, age, body mass index, LA diameter, AF type, history of AF, and previous interventional ablation, BA lesion was an independent predictor of lower atrial tachyarrhythmia recurrence (hazard ratio 0.447, 95% confidential interval 0.208-0.963; P = 0.040).CONCLUSIONS:Compared with the box lesion set, thoracoscopic epicardial ablation with BA lesion sets might provide better freedom from atrial tachyarrhythmias for paroxysmal or persistent AF with LA dilation. Randomized control trials are warranted to confirm the benefit of BA lesion sets in these patients.

Influence of operator volume on early outcomes of septal myectomy for isolated hypertrophic obstructive cardiomyopathy.

BACKGROUND:Guidelines on the diagnosis and management of hypertrophic cardiomyopathy (HCM) recommend that septal myectomy be performed by experienced operators. However, the impact of operator volume on surgical treatment outcomes for isolated HCM has been poorly investigated.METHODS:From 2002 to 2014, 435 consecutive patients with isolated HCM undergoing myectomy at the Fuwai Hospital were retrospectively enrolled. All 29 surgeons were divided into beginner surgeons (operator volume ≤20) and experienced surgeons (operator volume >20) according to the guidelines for the diagnosis and treatment of HCM. Propensity score matching of patients in the two groups was performed.RESULTS:Baseline differences included advanced New York Heart Association classification and older age in the experienced surgeon group. After matching, in the beginner surgeon group (107 cases), residual obstruction (18.7% vs. 0.9%, P<0.001) was more common, and the postoperative left ventricular outflow tract pressure gradient (20.7±15.1 vs. 14.3±7.4 mmHg, P<0.001) was higher than that of the experienced surgeon group. In the experienced surgeon group (107 cases), the incidence of mitral valve replacement (1.9% vs. 11.2%, P<0.001) and permanent pacemaker implantation (1.9% vs. 3.7%, P<0.001) was significantly lower than that in the beginner surgeon group. However, there was no difference in procedural mortality (1.9% vs. 1.9%) between the two groups.CONCLUSIONS:Operator volume is an important factor in achieving better obstruction obliteration after septal myectomy in patients with isolated HCM.

Coronary Evaluation Before Heart Valvular Surgery by Using Coronary Computed Tomographic Angiography Versus Invasive Coronary Angiography.

Background Coronary computed tomography angiography (CCTA) is a noninvasive, less expensive, low-radiation alternative to invasive coronary angiography (ICA). ICA is recommended for coronary evaluation before heart valvular surgery, and the supporting evidence for CCTA is insufficient. Our study is a single-center, prospective cohort study designed to evaluate the feasibility of CCTA instead of ICA in detection of coronary artery disease before surgery. Methods and Results Heart valvular surgery candidates were consecutively enrolled between April 2017 and December 2018. Nine hundred fifty-eight patients in the CCTA group underwent CCTA primarily, and those with ≥50% coronary stenosis or uncertain diagnosis underwent subsequent ICA. One thousand five hundred twenty-five patients in the ICA group underwent ICA directly before surgery. Coronary artery bypass grafting decision was made by surgeons according to CCTA or ICA results. Most of the patients (78.8%) in the CCTA group avoided invasive angiography. Thirty-day mortality (0.7% versus 0.9%, P=0.821), myocardial infarction (6.4% versus 6.9%, P=0.680 ), and low cardiac output syndrome (4.2% versus 2.8%, P=0.085) were similar in the CCTA and ICA groups. Median duration of follow-up was 19.3 months (interquartile range, 14.2-30.0 months), cumulative rates of mortality (2.6% versus 2.6%, P=0.882) and major adverse cardiac events (9.6% versus 9.0%, P=0.607) showed no difference between the 2 groups. Coronary evaluation expense was lower in the CCTA group ($149.6 versus $636.0, P<0.001). Conclusions The strategy of using CCTA as a doorkeeper in coronary evaluation before heart valvular surgery showed noninferiority in identification of candidates for coronary artery bypass grafting and postoperative safety.

Midterm results of stand-alone thoracoscopic epicardial ablation with box lesion for atrial fibrillation.

OBJECTIVES:The short-term results of video-assisted thoracoscopic surgical ablation (VTSA) with box lesion have been highly variable, and the actual efficacy requires clarification through longer follow-ups. We aimed to report which patients might benefit more from VTSA with box lesion by longer follow-up.METHODS:From September 2010 to November 2016, patients with atrial fibrillation (AF) who underwent VTSA with box lesion were screened. All enrolled patients visited the outpatient clinic and underwent 24-h Holter monitoring at 3, 6 and 12 months after surgery and annually thereafter.RESULTS:A total of 91 consecutive patients [age, 58.0 (interquartile interval from 52.0 to 62.0) years; male, 71.4%] with paroxysmal (67%) or persistent/long-standing persistent (33%) AF were enrolled. After a median follow-up of 48 months (interquartile interval from 36 to 60 months), freedom from atrial tachyarrhythmias without antiarrhythmic drugs (AADs) was 76.5%, 66.0% and 66.0% for paroxysmal AF and 58.6%, 47.8% and 34.2% for persistent/long-standing persistent AF at 12, 36 and 60 months, respectively (P = 0.017). The preoperative left atrial diameter >40 mm (hazard ratio: 2.837, 95% confidence interval: 1.408-5.716; P = 0.004) and age >50 years (hazard ratio: 2.927, 95% confidence interval: 1.359-6.305; P = 0.006) were associated with recurrences of atrial tachyarrhythmias. In patients with paroxysmal AF and left atrial diameter ≤40 mm (n = 43), freedom from atrial tachyarrhythmias without AADs was 81.4%, 74.3% and 74.3% at 12, 36 and 60 months, respectively.CONCLUSIONS:In patients with paroxysmal AF and left atrial diameter ≤40 mm, 5-year freedom from atrial tachyarrhythmias without AADs was 74.3%, which was better than that in patients with left atrial diameter >40 mm. A larger sample size and improved study design are needed to confirm our conclusions.

Simultaneous hybrid maze procedure for long-standing persistent atrial fibrillation with dilated atrium.

BACKGROUND:The efficacy of catheter-based or thoracoscopic ablation for treating long-standing persistent atrial fibrillation (AF) with a dilated atrium remains suboptimal. This study aimed to assess the feasibility and initial results of simultaneous hybrid ablation with a new biatrial lesion set in these patients.METHODS:Twenty-seven consecutive patients with long-standing persistent AF and dilated atrium underwent simultaneous hybrid ablation with a new biatrial lesion set consistent with the principle of the Cox maze procedure at our institution. Patients were followed up at 3, 6, and 12 months after the procedure and annually thereafter.RESULTS:After thoracoscopic epicardial ablation, endocardial mapping confirmed complete bilateral pulmonary vein isolation in 25 patients (96.2%). All patients were followed for a mean of 18.7 ± 8.9 months. Freedom from atrial tachyarrhythmia at 1 year after the single hybrid procedure was 64% with antiarrhythmic drugs and 60% without antiarrhythmic drugs. Freedom from atrial tachyarrhythmia at latest follow-up after the hybrid procedure and redo catheter ablation was 77.8% with antiarrhythmic drugs and 74.1% without antiarrhythmic drugs. In patients with sinus rhythm restoration, mean left atrial diameter decreased from 54.4 ± 4.3 mm to 45.2 ± 4.1 mm (P < .001), and mean right atrial diameter decreased from 59.4 ± 3.9 mm to 54.9 ± 4.4 mm (P < .001). Postoperative pleural effusion was observed in 3 patients (11.1%), and no adverse events occurred during follow-up.CONCLUSIONS:In patients with long-standing persistent AF and a dilated atrium, simultaneous hybrid ablation with the new biatrial lesion set, in combination with touch-up catheter ablation when necessary, can achieve promising results. More studies are needed to confirm these findings.

A giant right coronary artery aneurysm caused by congenital coronary fistula.

Sinoatrial nodal artery injury in thoracoscopic epicardial ablation for atrial fibrillation.

OBJECTIVES:This study aimed to clarify the incidence of sinoatrial nodal artery (SANa) injury in thoracoscopic epicardial surgical ablation for atrial fibrillation (AF) and its impact on postoperative outcomes, which have not been previously elucidated.METHODS:We enrolled 103 consecutively patients with AF who underwent thoracoscopic epicardial ablation at our institution. In these patients, we evaluated the postoperative incidence of SANa injury by using enhanced cardiac computed tomography. For patients with confirmed SANa injury, 3-day continuous electrocardiographic monitoring and exercise stress tests were performed to assess the sinus rhythm maintenance and sinus node function.RESULTS:Thirteen patients (12.6%) had a confirmed SANa injury (left anterior type in 6 patients, left posterior type in 2 patients and double-branch type in 5 patients). After a median follow-up of 24 months, the patients with SANa injury were not found to be associated with lower sinus rhythm maintenance (hazard ratio 1.09, 95% confidential interval 0.36-3.31) as compared with those without SANa injury after adjustment for patient characteristics. Sinus node function was evaluated in 7 patients with SANa injury who remained in sinus rhythm after the procedure, and no sinus node dysfunction was confirmed in the 3-day electrocardiographic monitoring and exercise stress tests at a median follow-up of 12 months.CONCLUSIONS:The prevalence of SANa injury in the patients who underwent thoracoscopic epicardial ablation for AF was relatively low, and the incidence of SANa injury was not associated with postoperative restoration of sinus rhythm and sinoatrial node dysfunction. More studies are required to better understand SANa injury.