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OBJECTIVES Atrial fibrillation (AF) is a significant risk factor for embolic stroke originating from the left atrial appendage (LAA). This is the first report of long-term safety and efficacy data on LAA closure using a novel epicardial LAA clip device in patients undergoing cardiac surgery. METHODS Forty patients with AF were enrolled in this prospective ‘first-in-man’ trial. The inclusion criterion was elective cardiac surgery in adult patients with AF for which a concomitant ablation procedure was planned. Intraoperative transoesophageal echocardiography (TEE) was used to exclude LAA thrombus at baseline and evaluate LAA perfusion after the procedure, while computed tomography (CT) was used for serial imagery workup at baseline, 3-, 12-, 24- and 36-month follow-up. RESULTS Early mortality was 10% due to non-device-related reasons, and thus 36 patients were included in the follow-up consisting of 1285 patient-days and mean duration of 3.5 ± 0.5 years. On CT, clips were found to be stable, showing no secondary dislocation 36 months after surgery. No intracardial thrombi were seen, none of the LAA was reperfused and in regard to LAA stump, none of the patients demonstrated a residual neck >1 cm. Apart from one unrelated transient ischaemic attack (TIA) that occurred 2 years after surgery in a patient with carotid plaque, no other strokes and/or neurological events demonstrated in any of the studied patients during follow-up. CONCLUSION This is the first prospective trial in which concomitant epicardial LAA occlusion using this novel epicardial LAA clip device is 100% effective, safe and durable in the long term. Closure of the LAA by epicardial clipping is applicable to all-comers regardless of LAA morphology. Minimal access epicardial LAA clip closure may become an interesting therapeutic option for patients in AF who are not amenable to anticoagulation and/or catheter closure. Further data are necessary to establish LAA occlusion as a true and viable therapy for stroke prevention. CLINICAL TRIAL REGISTRATION The trial is registered at www.ClinicalTrials.gov, reference: NCT00567515. [ABSTRACT FROM PUBLISHER]

Objective: Atrial fibrillation puts patients at significant risk for embolic stroke originating from the left atrial appendage. Few means are available for safe, effective, and durable left atrial appendage occlusion. A new clip device was evaluated with regard to safety and effectiveness for epicardial left atrial appendage occlusion. Methods: Patients with atrial fibrillation undergoing elective cardiac surgery through a median sternotomy were enrolled for concomitant epicardial clip placement. Early postoperative and 3-month follow-up computed tomography studies were used to assess clip stability and left atrial appendage perfusion. Results: From September 2007 to December 2008, 34 patients underwent successful clip placement. No device-related complications occurred. Operative mortality was 8.8% and not study or device related. Deployment was rapid, and left atrial appendage occlusion was confirmed by intraoperative transesophageal echocardiography in all patients. In addition to excellent clinical outcomes (no stroke/transient ischemic attack), serial computed tomography demonstrated stable clip location and appendage perfusion at 3 months in all patients. Conclusion: Safe, effective, and durable left atrial appendage occlusion can easily be achieved with this new clip. Further trials are necessary to evaluate the role of the left atrial appendage occlusion in stroke prevention. [Copyright &y& Elsevier]

Objective: Previous studies of the epidemiology of stroke in patients undergoing cardiac surgery have been based primarily on patients having coronary bypass surgery and therefore have limited applicability to the more heterogenous populations seen in the current era. We examine the epidemiology of stroke after cardiac surgery in a contemporary surgical population. Methods: Retrospective analysis was conducted of a prospective database of 5085 adults (coronary bypass 2401, isolated valve 1003, valve/coronary bypass 546, thoracic aorta 517, transplant/assist device 179, adult congenital 124, other 315) who had cardiac surgery at a single institution over a 6-year period (1998–2004). Results: Stroke occurred in 134 (2.6%) patients. Incidence varied according to procedure (coronary bypass 1.7%, isolated valve 1.8%, valve/coronary bypass 4.4%, and ascending aorta 4.6%). Patients who had a stroke had a higher perioperative mortality rate than that of patients who did not (32.8% vs 4.9%; P < .0001) and a longer period of hospitalization (median 30 days vs 7 days; P < .0001). Multivariate logistic analysis identified 10 preoperative predictors of stroke: gender, age, aortic surgery, previous stroke, critical preoperative state, poor ventricular function, diabetes, peripheral vascular disease, unstable angina, and pulmonary hypertension. A logistic model was developed on the basis of these risk factors to predict the likelihood of stroke. Conclusions: We have demonstrated a relatively low incidence of stroke in a diverse contemporary cardiac surgical cohort. By enabling preoperative identification of patients at risk, our logistic model has the potential to improve preoperative patient counseling and selection and could help to define high-risk cohorts for research into stroke prevention. [Copyright &y& Elsevier]

Background: Severe tricuspid regurgitation (TR) with signs of right-sided heart failure is rare after orthotopic heart transplantation (OHT). In some instances, this condition will require surgical correction using reconstructive surgery or prosthetic valve replacement. Repair techniques of atrioventricular valves are now well described. However, the results of the different surgical procedures in this setting have not been widely reported and may depend on the type of valvular dysfunction and lesions present. Herein we report our experience in a group of patients requiring surgical correction of symptomatic severe TR after OHT. Methods: We reviewed our transplant experience during the period from July 1992 to July 1999 (n = 138 cardiac transplants). Eight patients (5.8%) developed symptomatic severe TR requiring surgical correction after a mean duration of 21 months after OHT. Patients were divided into 2 groups based on the mechanism of regurgitation using Carpentier’s functional classification. In Group 1 (n = 4), the mechanism of tricuspid regurgitation was Carpentier’s Type I, secondary to annular dilation. In Group 2 (n = 4) the mechanism of TR was leaflet prolapse (Type II), due to chordal rupture after biopsy injury. Initially, tricuspid valve integrity was surgically restored in all 8 patients with either valve repair (n = 6) or replacement (n = 2). In Group 1, 2 patients underwent valve repair using a ring annuloplasty and 2 patients underwent valve replacement with a bioprosthetic valve (n = 1) or pulmonary allograft (n = 1). In Group 2, all patients underwent valve repair using a variety of techniques in combination with tricuspid annuloplasty. Results: During the follow-up period, 3 of the 6 (50%) primary repairs (1 patient in Group 1 and 2 in Group 2) failed and required replacement with a bioprosthesis at 8 days, 14 days and 4 years, respectively. The pulmonary allograft failed secondary to valvular stenosis and was replaced with a bioprosthesis after 10 months. Overall, no failures occurred in any of the 5 bioprosthetic valves placed at the primary operation (n = 1) or after failed tricuspid repair/pulmonary allograft (n = 4), after a mean follow-up of 55 months. Conclusions: TR requiring surgical correction after OHT is a rare condition and requires a tailored surgical strategy. This strategy should take into account the mechanism of valve dysfunction and specific valvular lesions. In patients with Type I dysfunction secondary to annular dilation, valve repair with a remodeling annuloplasty should be performed; however, in the presence of any residual TR on transesophageal echocardiography (TEE) at the completion of cardiopulmonary bypass (CPB), a valve replacement with a bioprosthesis is warranted during the same procedure. In patients with Type II dysfunction with leaflet prolapse and biopsy-induced chordal injury, a bioprosthetic valve replacement seems a reliable surgical option. [Copyright &y& Elsevier]

Severe coronary artery disease and myocardial infarction can be complicated by ischemic mitral regurgitation (IMR). IMR results from left ventricular remodeling after myocardial infarction and in rare instances can accompany acute ischemia. A better understanding of the pathophysiology of IMR and increased awareness of its negative impact on long-term survival explain the recent rise in the number of patients referred for surgical correction of IMR at the time of coronary revascularization. The most common mechanism of IMR is Carpentier's type IIIb dysfunction, for which an undersized remodeling annuloplasty is the treatment of choice. In this article we define ischemic mitral regurgitation and review its pathophysiology, clinical presentations, diagnosis, indication for surgery, and management. [ABSTRACT FROM AUTHOR]

OBJECTIVES The combination of aortic ‘no-touch’ off-pump surgery (OPCAB) and total arterial revascularization (TAR) can reduce peri-procedural morbidity and yields excellent long-term outcomes albeit at a reported risk of incomplete revascularization. The feasibility of OPCAB-TAR with specific regards to the complete revascularization (CR) in patients with multi-vessel disease was evaluated. METHODS From 2003 to 2010, 712 patients underwent TAR including 526 patients who had OPCAB-TAR and 186 patients who received on-pump TAR [(ONCAB grafting (ONCABG)-TAR)]. Of these, 52% (n = 272; OPCAB) vs. 83% (n = 155; ONCABG) had triple-vessel disease (TVD). To balance patient characteristics, a non-parsimonious, propensity score (PS) model was applied. Endpoints evaluated were mortality, stroke, major adverse cardiac and cerebrovascular events (MACCE). To evaluate CR, an ‘Index of CR’ (ICOR) was calculated, defined as the number of distal anastomoses divided by the number of the diseased coronary vessels. CR was assumed when the following requirements were fulfilled: the number of distal anastomoses was equal to or higher than that of diseased vessels (ICOR ≥ 1), and all affected coronary territories (left anterior descending, circumflex artery and/or right coronary artery) were grafted. RESULTS Mortality was comparable between groups, whereas OPCAB patients suffered from significantly decreased rates of MACCE [3.0 vs. 7.0%; propensity-adjusted odd ratio (PAOR) = 0.24; confidence interval (CI) 95% 0.08–0.66; P = 0.006] including a clear trend towards reduced stroke and myocardial infarction. In the subgroup with TVD, OPCAB patients presented with significantly reduced rates for MACCE (1.8 vs. 5.8%; PAOR = 0.07; CI 95% 0.01–0.65; P = 0.02), including a significantly lower rate for stroke. For all-comers, the number of diseased vessels was lower after OPCAB (2.36 ± 0.73 vs. 2.87 ± 0.39; P < 0.001) and consequently, these patients received an overall lower number of distal anastomoses (2.42 ± 1.15 vs. 3.06 ± 0.98; P < 0.001). Although the ICOR was slightly lower (1.04 ± 0.37 vs. 1.07 ± 0.37; P = 0.02), CR was achieved more frequently in OPCAB patients (82.1 vs. 73.1%; P = 0.01). In the subgroup with TVD, the number of distal anastomoses (2.99 ± 1.14 vs. 3.10 ± 0.98; P = 0.19) and the ICOR (1.00 ± 0.38 vs. 1.03 ± 0.33; P = 0.19) was comparable between groups. The frequency of CR was slightly higher (75 vs. 67.7%; P = 0.11), and the proportion of complete in situ grafting was significantly higher after OPCAB (37.1 vs. 23.9%; P = 0.005). CONCLUSIONS Aortic ‘no-touch’ OPCAB-TAR leads to a significant reduction of MACCE. It does not compromise CR in patients with TVD and thus can be safely applied to these patients. [ABSTRACT FROM AUTHOR]

Objectives. This study investigates the suitability, safety, and efficacy of vernakalant in critically ill patients with new onset atrial fibrillation (AF) after cardiac surgery. Methods. Patients were screened for inclusion and exclusion criteria according to the manufacturers' recommendations. Included patients were treated with 3mg/kg of vernakalant over 10 min and, if unsuccessful, a second dose of 2mg/kg. Blood pressure wasmeasured continuously for 2 hours after treatment. Results. Of the 191 patients screened, 159 (83%) were excluded, most importantly due to hemodynamic instability (59%). Vernakalant was administered to 32 (17% of the screened) patients. Within 6 hours, 17 (53%) patients converted to sinus rhythm. Blood pressure did not decrease significantly 10, 30, 60, and 120 minutes after the vernakalant infusion. However, 11 patients (34%) experienced a transient decrease inmean arterial blood pressure <60mmHg. Other adverse events included nausea (P = 1) and bradycardia (P = 2). Conclusions. Applying the strict inclusion and exclusion criteria provided by the manufacturer, only a minority of postoperative ICU patients with new onset AF qualified for vernakalant. Half of the treated patients converted to sinus rhythm. The drug was well tolerated, but close heart rate and blood pressure monitoring remains recommended. [ABSTRACT FROM AUTHOR]