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OBJECTIVES Papillary muscle rupture (PMR) is a rare but potentially fatal complication of acute myocardial infarction. The aim of this study was to analyse the patient characteristics and early outcomes of the surgical management of post-infarction PMR from an international multicentre registry. METHODS Patients underwent surgery for post-infarction PMR between 2001 through 2019 were retrieved from database of the CAUTION study. The primary end point was in-hospital mortality. RESULTS A total of 214 patients were included with a mean age of 66.9 (standard deviation: 10.5) years. The posteromedial papillary muscle was the most frequent rupture location (71.9%); the rupture was complete in 67.3% of patients. Mitral valve replacement was performed in 82.7% of cases. One hundred twenty-two patients (57%) had concomitant coronary artery bypass grafting. In-hospital mortality was 24.8%. Temporal trends revealed no apparent improvement in in-hospital mortality during the study period. Multivariable analysis showed that preoperative chronic kidney disfunction [odds ratio (OR): 2.62, 95% confidence interval (CI): 1.07–6.45, P = 0.036], cardiac arrest (OR: 3.99, 95% CI: 1.02–15.61, P = 0.046) and cardiopulmonary bypass duration (OR: 1.01, 95% CI: 1.00–1.02, P = 0.04) were independently associated with an increased risk of in-hospital death, whereas concomitant coronary artery bypass grafting was identified as an independent predictor of early survival (OR: 0.38, 95% CI: 0.16–0.92, P = 0.031). CONCLUSIONS Surgical treatment for post-infarction PMR carries a high in-hospital mortality rate, which did not improve during the study period. Because concomitant coronary artery bypass grafting confers a survival benefit, this additional procedure should be performed, whenever possible, in an attempt to improve the outcome. Clinical trial registration clinicaltrials.gov: NCT03848429.

Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction (AMI). Surgical repair, though challenging, is the only definitive treatment. However, given the rarity of this condition, results following surgery are still not well established. The aim of this study was to review a multicenter experience with the surgical management of post-infarction LVFWR and analyze the associated early outcomes. Background: Left ventricular free-wall rupture (LVFWR) is an uncommon but serious mechanical complication of acute myocardial infarction. Surgical repair, though challenging, is the only definitive treatment. Given the rarity of this condition, however, results after surgery are still not well established. The aim of this study was to review a multicenter experience with the surgical management of post-infarction LVFWR and analyze the associated early outcomes. Methods: Using the CAUTION (Mechanical Complications of Acute Myocardial Infarction: an International Multicenter Cohort Study) database, we identified 140 patients who were surgically treated for post–acute myocardial infarction LVFWR in 15 different centers from 2001 to 2018. The main outcome measured was operative mortality. Multivariate analysis was carried out by constructing a logistic regression model to identify predictors of postoperative mortality. Results: The mean age of patients was 69.4 years. The oozing type of LVFWR was observed in 79 patients (56.4%), and the blowout type in 61 (43.6%). Sutured repair was used in the 61.4% of cases. The operative mortality rate was 36.4%. Low cardiac output syndrome was the main cause of perioperative death. Myocardial rerupture after surgery occurred in 10 patients (7.1%). Multivariable analysis revealed that preoperative left ventricular ejection fraction (P

Mesothelial or monocytic incidental cardiac excrescence (MICE) is a rare, benign lesion composed of a mixture of mesothelial and inflammatory cells, histiocytes and fibrin without a vascular network usually accidentally found during cardiac surgery or after cardiac catherization. We report the case of a 45-year-old man admitted for suspected myxoma on the mitral valve. The lesion was removed via a minimally invasive video-assisted approach, without compromising the valve competency. The histopathological exam led to the diagnosis of MICE. The 2-yearfollow-up echocardiography confirmed normal mitral function without recurrence. Most of the cases were treated concomitantly to other cardiac procedure, lesions were more frequently founded in the left cardiac chambers or valves, our experience suggest that these lesions should be safely treated alone by surgical removal, to prevent embolic events.

OBJECTIVES The aim of this study is to evaluate the immediate and mid-term effects of omitting coronary artery bypass grafting in patients with moderate coronary artery stenosis who have a primary indication for valvular surgery. METHODS We included 77 consecutive patients admitted to our Institution for aortic or mitral valve surgery between June 2012 and June 2017 in whom a de novo diagnosis of ≥50%, but RESULTS There were no in-hospital deaths. In only 1 patient, acute myocardial infarction occurred postoperatively, which was immediately treated by percutaneous coronary intervention (PCI). The 6-year overall survival was 94.7 ± 2.59%. At 6 years, no cardiac deaths were recorded. At follow-up, 4 patients underwent elective PCI after a positive stress myocardial perfusion test. Only 1 patient underwent urgent PCI due to acute coronary syndrome. At 6 years, the cumulative incidence function of PCI, with death as competing risk, was 8 ± 3.9%. CONCLUSIONS In our experience, moderate coronary stenosis, occasionally discovered at the time of valvular heart surgery, can be safely overlooked and do not need any further treatment at follow-up in the majority of cases. Our results open up the opportunity to apply this ‘intentional omission strategy’ in different situations, such as minimally invasive heart surgery, percutaneous procedures and complex patients.

Objective To analyze Italian Cardiac Surgery experience during the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) identifying risk factors for overall mortality according to coronavirus disease 2019 (COVID‐19) status. Methods From February 20 to May 31, 2020, 1354 consecutive adult patients underwent cardiac surgery at 22 Italian Centers; 589 (43.5%), patients came from the red zone. Based on COVID‐19 status, 1306 (96.5%) were negative to SARS‐CoV‐2 (COVID‐N), and 48 (3.5%) were positive to SARS‐CoV‐2 (COVID‐P); among the COVID‐P 11 (22.9%) and 37 (77.1%) become positive, before and after surgery, respectively. Surgical procedures were as follows: 396 (29.2%) isolated coronary artery bypass grafting (CABG), 714 (52.7%) isolated non‐CABG procedures, 207 (15.3%) two associate procedures, and three or more procedures in 37 (2.7%). Heart failure was significantly predominant in group COVID‐N (10.4% vs. 2.5%, p = .01). Results Overall in‐hospital mortality was 1.6% (22 cases), being significantly higher in COVID‐P group (10 cases, 20.8% vs. 12, 0.9%, p

Objective: The aim of this multicenter study was to evaluated whether cold or warm cardioplegia are associated with postoperative atrial fibrillation (POAF) and the prognostic role of the latter on early stroke and neurological mortality.Method: This was a retrospective analysis of prospective collected data from 9 cardiac centers in Italy and the United States including patients undergoing surgery between 2010 and 2018. From the 9 institutional databases, 17,231 patients underwent isolated CABG on-pump, using either warm cardioplegia (n = 7730) or cold cardioplegia (n = 9501); among the latter group blood and crystalloid cardioplegia were used in 691 and 8810 patients, respectively. After matching, two pairs of 4162 patients (overall cohort 8324) were analyzed.Results: In matched population, the rate of POAF was 18% (1472 cases), 15% (608) in warm group versus 21% (864) in cold group (p < 0.001). Multivariable analysis confirmed that cold cardioplegia was associated with higher rate of POAF, along with age, hypercholesterolemia, LVEF, reoperation, preoperative IABP, previous stroke, cardiopulmonary and cross-clamp. Moreover, cold cardioplegia as well as POAF increased the rate of postoperative stroke as well as early mortality and neurological mortality Propensity-weighted cohort included 11,830 (70%) patients out of 17,231. After adjustment, both cold blood and cold crystalloid cardioplegia negatively influenced POAF, stroke and neurological mortality.Conclusions: Warm cardioplegia may reduce the rate of POAF in CABG patients with respect to cold cardioplegia, either blood or crystalloid. This has a prognostic impact on postoperative stroke and neurological mortality. (C) 2020 Elsevier B.V. All rights reserved.

BackgroundPulmonary complications after cardiac surgery are a leading cause of morbidity and mortality. The aim of this study was to develop predictive models for postoperative lung dysfunction and mortality.MethodsThis was a single-center, observational, retrospective study, which took place in a tertiary care University Hospital. We retrospectively analyzed data regarding 11285 adult patients who underwent all types of cardiac surgery from 2003 to 2015. We developed logistic predictive models for in-hospital mortality, for postoperative pulmonary complications (PPC) occurring in the intensive care unit (ICU), and the need for postoperative non-invasive mechanical ventilation (NIMV) when clinically indicated.ResultsAge, preoperative ejection fraction, New York Heart Association (NYHA) class, emergency surgery, pharmacological and mechanical circulatory support, creatinine peak in the ICU, tracheostomy, and a lower PaO2/FiO2 ratio at ICU discharge were predictors of mortality. Age, ejection fraction, body mass index, creatinine peak in the ICU, blood-product use, inotropic support, and a lower PaO2/FiO2 ratio were predictors of postoperative NIMV. Preoperative lung disease, ejection fraction, NYHA class, inotropic and mechanical support, and preoperative serum creatinine were predictors of PPC.ConclusionsWe provide three models for the prediction of major pulmonary complications and mortality following cardiac surgery.

OBJECTIVES The goal of this study was to assess the applicability of a novel classification of patients with tricuspid regurgitation based on 5 stages and to evaluate outcomes following isolated surgical treatment. METHODS All patients treated with isolated tricuspid valve repair or tricuspid valve replacement (TVR) from March 1997 to January 2020 at a single institution were retrospectively reviewed. Patients were divided according to a novel clinical-functional classification, based on the degree of regurgitation together with symptoms, right ventricular size and function and medical therapy. A total of 195 patients were treated; however, 23/195 were excluded due to lack of sufficient preoperative data. RESULTS A total of 172 patients were considered; of these, 129 (75%) underwent TVR and 43 (25%) had tricuspid valve repair. The distribution of patients showed that 46.5% of patients who underwent tricuspid valve repair were in stage 2, whereas 51.9% who underwent TVR were in stage 3. TVR patients were in more advanced stages of the disease, with dilated right ventricles, more pronounced symptoms and development of organ damage. Hospital mortality was 5.8%, in particular 0% in stages 2 and 3 and 15.3% in stages 4 and 5 (P CONCLUSIONS Patients in more advanced stages had higher hospital mortality and longer hospitalizations. Timely referral is associated with lower mortality, short postoperative course and mostly valve repair.

OBJECTIVES The best treatment for rheumatic mitral regurgitation is still under debate. Our goal was to assess the long-term results of mitral repair for rheumatic mitral regurgitation performed in 2 referral centres for mitral repair. METHODS Patients who underwent mitral valve repair between 1999 and 2009 were selected. Preoperative and postoperative data were prospectively entered into a dedicated database and retrospectively reviewed. Kaplan–Meier estimates were used to analyse long-term survival. Competing risk analysis was performed by calculating the cumulative incidence function for time to recurrence of mitral regurgitation ≥3+, mitral regurgitation ≥2+, mitral reoperation and the combined end point of repair failure (mitral regurgitation ≥ 3+ and/or mean gradient ≥ 10 mmHg and/or mitral valve REDO) with death as a competing risk. RESULTS A total of 72 patients were included. Mitral calcifications were present in 25 patients (34.7%). Most of the patients (65/72, 90.3%) underwent annuloplasty, and mixes of reparative techniques were used in 21 patients (29.2%). In-hospital mortality was 2.8%. Mean follow-up was 11.6 ± 5.16 (max 19.1 years), 98.6% completed. Survival at 14 years was 70 ± 6.27%. At 14 years, the cumulative incidence function of repair failure was 36.7 ± 6.52%. The presence of severe mitral annulus calcification was an independent predictor of repair failure. CONCLUSIONS Mitral repair for rheumatic mitral regurgitation is characterized by a high rate of failure in the long term (14 years), particularly in patients with severe annular calcifications. These results call for a very selective approach when considering a repair strategy in this setting, especially in case of unfavourable anatomical conditions.

Background Left circumflex coronary (LCx) artery injury during mitral valve surgery is a life-threatening complication. This report describes a series of patients with this complication in a high-volume mitral surgery center. Methods Between January 2004 and December 2017, a total of 6501 mitral valve procedures were performed at the San Raffaele Scientific Institute in Milan, Italy. An LCx injury occurred in 10 patients (10 of 6501; 0.15%) after either mitral valve repair (n = 5) or replacement (n = 5). Coronary angiography was performed in 9 patients and showed 5 cases of left coronary artery dominance, 2 cases of right dominance, and 2 cases of codominance. All data were prospectively collected in the hospital database and were retrospectively reviewed. Results Suspicion of LCx injury was raised in the operating room in 5 patients and in the intensive care unit in the other 5 patients. Postoperative coronary angiography confirmed the LCx lesion. In the presence of total LCx occlusion, coronary artery bypass grafting (n = 3) or partial removal of the annuloplasty ring(n = 1) was performed. In cases of partial kinking (n = 4), percutaneous coronary intervention (PCI) was preferred. In the 2 patients with extrinsic subocclusion of the LCx, rescue PCI was initially attempted, but both procedures were complicated by artery disruption and stent underexpansion. Conclusions In our series, LCx occlusion occurred more commonly in patients with left-dominant coronary artery circulation. Clinical presentation may be variable. Rescue PCI is a valid option in cases of kinking of the artery, but in other cases emergency coronary bypass grafting should be the first choice. Repositioning of the prosthesis may be an option in specific circumstances.

OBJECTIVES Patients with recurrent mitral regurgitation after surgical repair are currently treated with a re-repair procedure or valve replacement. The aim of this study was to compare outcomes of our series of patients who underwent re-repair versus replacement in this setting. METHODS From 2003 to 2017, a total of 79 patients with recurrent mitral regurgitation underwent re-repair, group A (39), or replacement, group B (40). Mean follow-up was 7.4 ± 3.27 years (max 14.4). Inverse Probability of Treatment Weighting was used to create comparable distributions of the covariates; the Kaplan–Meier method was used for survival and competing risk analysis for time to cardiac death, time to recurrence of MR ≥3+ and MR ≥2+. RESULTS A re-repair was possible in 49.4% of patients (39/79). At hospital discharge, residual MR ≥2+ was present in 5 patients in group A, and none in group B (P CONCLUSIONS Recurrent significant mitral regurgitation after re-repair is not rare already at 8 years, but the survival tends to be worse after replacement. This finding calls for a very selective approach in pursuing a re-repair only when the intraoperative findings and the immediate results are very reassuring as far as long-term durability is concerned.

Background: To assess the long-term clinical and echocardiographic outcomes of the edge-to-edge mitral repair added to septal myectomy in patients with mitral regurgitation (MR) and hypertrophic obstructive cardiomyopathy. Methods: This is a single-center study of 26 patients with hypertrophic obstructive cardiomyopathy (septal thickness 17 ± 3 mm, resting left ventricular outflow tract gradient 63 ± 20 mm Hg, MR ≥ 2+/4+) who underwent an EE mitral procedure combined with ventricular septal myectomy. The EE procedure was used to treat MR due to systolic anterior motion in 19 patients (73%) and to posterior leaflet prolapse/flail in 7 (27%). Results: Hospital mortality was 4%. Follow-up was 100% complete (median 6.5 years; interquartile range, 2.7 to 9). Freedom from cardiac death was 88% ± 8.4% at 8 years. The 8-year cumulative incidence function of reoperation with death as competing risk was 7.7% ± 5.2%. At 8 years, the cumulative incidence function of recurrence of MR 3+ or greater with death as competing risk was 7.9% ± 5.3%. Residual MR at discharge (hazard ratio 8.3; 95% confidence interval, 2.1 to 32.6; P = .002) and preoperative systolic pulmonary artery pressure (hazard ratio 1.0; 95% confidence interval, 1.0 to 1.1; P = .005) were identified as predictors of MR recurrence. At the last follow-up, 92% of patients were in New York Heart Association functional class I-II, and 72% were in sinus rhythm. The last echocardiographic follow-up showed a median resting left ventricular outflow tract gradient of 9 mm Hg (interquartile range, 7 to 12; P < .001 vs preoperative). Conclusions: In hypertrophic obstructive cardiomyopathy patients, when septal thickness was considered inadequate to allow a safe and effective myectomy, the edge-to-edge technique provided a simple, quick, and effective solution by abolishing at the same time residual gradient and systolic anterior motion-related MR. Organic mitral valve lesions such as prolapse and flail could be addressed as well, whenever indicated. Satisfactory clinical and echocardiographic results were maintained at long-term follow-up.

OBJECTIVES After mitral repair for degenerative mitral regurgitation (MR), no or mild (≤1+/4+) residual MR should remain. Occasionally patients are left with more than mild residual MR (>1+/4+) for a number of reasons. The aim of this study was to assess the late implications of such a suboptimal repair in a matched cohort study. METHODS From 2006 to 2013, a total of 2158 patients underwent mitral repair for degenerative MR in our institution. Fifty patients (2.3%) with residual MR >1+ at hospital discharge (study group) were matched up to 1:2 with 91 patients operated on during the same period who were discharged with MR ≤1+ (control group). The median follow-up was 8 years (interquartile range 6.3–10.1, longest 12.7 years). A comparative analysis of the outcomes in the 2 groups was performed. RESULTS Overall survival at 8 years was 87 ± 8% in the study group and 92 ± 3% in the control group (P = 0.23). There were 3 late deaths (6.0%) in the study group and 6 deaths (6.6%) in the control group. Freedom from reoperation was similar (P = 1.0). At 8 years the prevalence of MR ≥3+ was significantly higher in the study group (15.6% vs 2.1%, P CONCLUSIONS Residual MR more than mild at hospital discharge is associated with lower durability of mitral repair and the need for more medical therapy in the long term. However, even an initial optimal result does not completely arrest the progression of the degenerative process.

DESPITE PROGRESS IN perioperative management, postoperative pulmonary complications (PPCs) still are a leading cause of morbidity and mortality in cardiac surgery. About 25% of patients with no severe cardiac dysfunction who undergo cardiac surgery experience significant respiratory impairment for at least 1 week after the intervention. Post-cardiac surgery PPCs clinically range from fever with productive cough to acute respiratory distress syndrome (ARDS), requiring prolonged mechanical ventilation (MV) and showing reduced survival. Cardiopulmonary bypass (CPB) is necessary for the majority of procedures in cardiac surgery, making CPB-related lung damage inevitable. Inflammatory response after CPB, exclusion of lung tissue from perfusion and ventilation, and atelectasis due to airway collapse are the most important factors implicated in CPB-related lung injury. Cardiac anesthesiologists commonly need to address post-cardiac surgery respiratory failure and PPCs, such as pneumonia, atelectasis, pleural effusion, diaphragm dysfunction, and ventilation-associated pneumonia, which carry a high burden of morbidity and mortality. Regardless of any specific complication, impairment of gas exchange, reflected by a reduction in the PaO2/FIO2 ratio (the ratio between arterial blood oxygen partial pressure and inspired air oxygen fraction), frequently occurs after cardiac surgery and has been associated with poor hospital outcome, although accurate validation of this parameter in this setting is lacking. A PaO2/FIO2 value of 300 or less indicates reduced efficiency in alveolar-capillary membrane performance. A detailed definition of PPCs can be found in Table 1. The aim of this review was to summarize the evidence in the literature concerning CPB-related lung dysfunction and to show how MV strategies might prevent respiratory insufficiency after cardiac surgery.

BACKGROUND Every year, more than 1.5 million patients, who undergo cardiac surgery worldwide, are exposed to a series of factors that can trigger acute postoperative pain associated with hemodynamic instability, respiratory complications, and psychological disorders. Through an evaluation of literature data about postoperative pain in cardiac surgery we define unmet needs and potential objectives for future research on this often-underestimated problem. METHODS Following PRISMA Guidelines, a systematic literature search was carried out by two independent researchers on Scopus, CINAHL, the Cochrane Library, and PubMed using the key words: (perioperative OR postoperative) analgesia AND "cardiac surgery." Papers concerning children, or published prior to 2000, were considered ineligible, as well as abstracts, animal studies, and studies written in languages other than English. RESULTS Fifty-four papers were selected and subsequently divided into two main categories: systemic analgesic drugs and regional anesthesia techniques. CONCLUSIONS Over the past 17 years, opioids are still the most extensively used therapy, whereas we found only few trials investigating other drugs (e.g. paracetamol). Regional anesthesia techniques, especially thoracic epidural analgesia and intrathecal morphine administration, can effectively treat pain, but have not yet showed any significant impact on major clinical outcomes, with several concerns related to their potential complications. To date multimodal analgesia with implementation of regional analgesia seems to be the best choice. In the future, better-designed studies should consider other drugs stratifying groups according to comorbidities and risk factors, as well as using standardized units of measurement.

Objectives Scanty data are available on 'second cross-clamping' following mitral valve repair in contemporary practice. The aim of this study was to evaluate the incidence, causes and outcomes of this event in patients referred for mitral repair for severe degenerative mitral regurgitation (MR). Methods The study population included 2318 patients with severe degenerative MR referred for mitral repair. A second cross-clamping was performed in 94 (4%) patients. Causes of the second cross-clamping, revising repair procedures, immediate echocardiographic outcomes and postoperative course were assessed and compared with the 'single cross-clamping cases' (2224 patients used as control). Clinical and echocardiographic follow-up information was available for 91 of the 94 second cross-clamping patients (97% complete) (median time 6 years, interquartile range 3-11). Results The most frequent causes of the second cross-clamping were residual MR >1+/4+ and systolic anterior motion. A residual prolapse was identified in 41 (43.5%) patients, systolic anterior motion in 22 (23.5%), untreated clefts in 14 (15%) and other mechanisms in 17 (18%). Second cardiopulmonary bypass and aortic cross-clamping times were 36 (range 28-50) and 23 (range 17-34) min, respectively. Hospital mortality was 0% in the second cross-clamping and 0.3% in the control group (P = 0.2). Postoperative complications and length of hospital stay were similar. At discharge, residual MR ≥2+/4+ was 2.1% in the second cross-clamping and 2.7% in the control group (P = 0.99). In the second cross-clamping, at 12 years, the cumulative incidence function of reoperation, recurrent MR ≥3+ and MR ≥2+ with death as competing risk were 5.7 ± 2.5% (95% confidence interval 2-12), 10.3 ± 4.3% (95% confidence interval 3.8-20) and 17 ± 5.2% (95% confidence interval 8-29), respectively. Conclusions In a large volume centre for mitral repair, a second cross-clamping is still performed in 3-5% of the patients. Because suboptimal immediate results are associated with impaired late outcomes of mitral reconstruction, a low threshold for a second cross-clamping seems to be justified. If the second repair is carried out with a relatively shorter additional cross-clamping time, mortality and morbidity are not increased and immediate and long-term results are very satisfactory.

Background There is no consensus on which lung-protective strategies should be used in cardiac surgery patients. Sparse and small randomized clinical and animal trials suggest that maintaining mechanical ventilation during cardiopulmonary bypass is protective on the lungs. Unfortunately, such evidence is weak as it comes from surrogate and minor clinical endpoints mainly limited to elective coronary surgery. According to the available data in the academic literature, an unquestionable standardized strategy of lung protection during cardiopulmonary bypass cannot be recommended. The purpose of the CPBVENT study is to investigate the effectiveness of different strategies of mechanical ventilation during cardiopulmonary bypass on postoperative pulmonary function and complications. Methods/design The CPBVENT study is a single-blind, multicenter, randomized controlled trial. We are going to enroll 870 patients undergoing elective cardiac surgery with planned use of cardiopulmonary bypass. Patients will be randomized into three groups: (1) no mechanical ventilation during cardiopulmonary bypass, (2) continuous positive airway pressure of 5 cmH2O during cardiopulmonary bypass, (3) respiratory rate of 5 acts/min with a tidal volume of 2–3 ml/Kg of ideal body weight and positive end-expiratory pressure of 3–5 cmH2O during cardiopulmonary bypass. The primary endpoint will be the incidence of a PaO2/FiO2 ratio

Objectives Percutaneous ablation (PA) for relapsing atrial tachyarrhythmias after surgical ablation is an emerging therapy. The aim of this study is to report the electrophysiological findings and the procedural long-term outcomes of reablation, in this particular clinical setting. Methods We retrospectively analysed all patients who were readmitted to our centre for relapsing atrial arrhythmias after surgical ablation for atrial fibrillation (AF). Results From 2000 to 2011, 36 patients with previous surgical ablation of AF received additional percutaneous management. Seven patients had had biatrial Maze, 18 left atrial ablation lesion set and 11 pulmonary vein isolation. Energy sources involved were unipolar radiofrequency (RF) (n = 13), bipolar RF (n = 19), combined bipolar RF and cryoenergy (n = 2), cryoenergy (n = 1) and high intensity focused ultrasound (n = 1). The median time to reablation was 34 months (interquartile range: 10-66). The relapsing arrhythmias were left atrial tachycardia (n = 17), AF (n = 15), right atrial flutter (n = 2), right atrial tachycardia (n = 1) and biatrial atrial tachycardia (n = 1). Origin of re-entrant circuits was perimitral (n = 27), around pulmonary veins (PV) including posterior left atrium (n = 15) and cavotricuspid isthmus (n = 3). Twenty-seven (75%) patients had left isthmus catheter ablation and 11 (30%) reablation of PV. Eighteen out of the 27 perimitral circuits were in patients with previous left-atrial Maze; in 17 patients the mitral line was performed with bipolar RF only, without the addition of cryoenergy. The importance of an appropriate energy source is also underlined by the prevalence of gaps in PV isolation that occurred for two-thirds of patients treated using unipolar RF only, which has been discontinued since 2001. Ten patients (27%) needed more than 1 PA for relapsing arrhythmia. At the last follow-up of 97 ± 42 months, freedom from arrhythmias was 53% after single PAs and 67% after more than one procedure. No morbidity, mortality or strokes were recorded during the follow-up. Conclusions Percutaneous treatment of highly symptomatic patients with unsuccessful previous surgical ablation is feasible, and relatively effective at the late follow-up. A multidisciplinary approach significantly improves the outcomes in these challenging patients.