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Background Tricuspid valve repair for functional regurgitation is effectively performed with different annuloplasty devices. However, it remains unclear whether there are advantages associated with rigid rings compared to flexible bands. This prospective randomised study aimed to compare results of using a flexible band ring versus a rigid ring for functional tricuspid regurgitation in patients undergoing mitral valve surgery. Methods A single-centre randomised study was designed to allocate patients with functional tricuspid regurgitation undergoing mitral valve surgery to be treated with a flexible band or rigid ring. These patients were analysed by echocardiographic follow-up. The primary outcome was freedom from recurrent tricuspid regurgitation at 12-months follow-up. Secondary outcomes were 30-day mortality, survival, freedom from tricuspid valve reoperation, right ventricular reverse remodelling, and rate of major adverse events. Results A total of 308 patients were allocated to receive concomitant tricuspid valve annuloplasty with the flexible band or rigid ring. There was no between-group difference in freedom from recurrent tricuspid regurgitation: 97.3% in Rigid group (95% CI, 93.0-98.8) and 96.2% in the Flexible group (95% CI, 92.0-98.5) at 12-months follow-up (log-rank, p=0.261). Early mortality, survival, freedom from tricuspid valve reoperation, and global right ventricle systolic function were also comparable in both groups of patients. However, the flexible band had advantage in restoring regional right ventricle function (Doppler-derived systolic velocities of the annulus [S], tricuspid annular plane systolic excursion) at 12-months follow-up. Conclusion Both the rigid ring and flexible band offered acceptable outcomes for functional tricuspid regurgitation correction without significant differences, as assessed at 12-months follow-up.

Septal myectomy is the gold standard treatment for hypertrophic obstructive cardiomyopathy. This study aimed to evaluate the results from patients with hypertrophic cardiomyopathy who had undergone septal myectomy.Data were analysed that has been prospectively collected over 7 years from 345 patients with hypertrophic cardiomyopathy who underwent septal myectomy at Meshalkin National Medical Research Center.Six (6) patients (1.7%) died within 30 days of surgery. The mean (standard deviation, SD) resting left ventricular outflow tract gradients reduced from 83.4 (24.2) mmHg preoperatively to 16.2 (8.5) mmHg at discharge (p 0.001). Of the 345 patients, 329 (95.4%) attended the most recent follow-up assessments, and of these, 254 (77.2%) were categorised as New York Heart Association (NYHA) class I, 64 (19.5%) class II, and 11 (3.3%) class III. The mean overall long-term survival rate after septal myectomy was 95.7% (SD 1.7%) (95% CI, 90.0-97.9). This did not differ from the age-matched and gender-matched general population (log-rank, p = 0.109). At the last follow-up assessments, six of 67 patients who had undergone concomitant Cox-Maze IV procedures had late atrial tachyarrhythmia recurrences. A preoperative short-axis view of left atrial diameter of 57.5 mm (hazard ratio, 1.30 (95% CI, 1.03-1.65), p 0.001) predicted late atrial tachyarrhythmias (p 0.002).At this hypertrophic cardiomyopathy centre, septal myectomy is associated with low operative and early mortality rates (2%), a low risk of early adverse events, and acceptable intermediate-term clinical and haemodynamic results.

OBJECTIVES Concomitant atrial fibrillation ablation during mitral valve (MV) surgery using radio frequency energy sources has been reported previously with excellent outcomes. However, data regarding the effectiveness of concomitant cryoablation remain limited. This study aimed to assess the efficacy of concomitant cryoablation in patients scheduled for MV surgery. METHODS Between 2012 and 2020, 242 adult patients who underwent MV surgery and concomitant cryoablation were included. Data on rhythm, medication status and clinical events were assessed at 3, 6 and 12 months, then annually thereafter. RESULTS Early mortality was 0.4%. The mean follow-up period duration was 43.9 months. The survival rates at 1, 3 and 5 years were 97.3%, 94.3% and 87.7%, respectively. The rates of freedom from atrial arrhythmia paroxysms at 1, 3 and 5 years were 79.0%, 64.0% and 60.5%, respectively. Atrial arrhythmia recurrence was associated with isolated left atrial lesion set (P = 0.038), large right atrial size (P = 0.002), lower surgeon experience (P = 0.003) and atrial fibrillation paroxysms in the early postoperative period (P = 0.002). CONCLUSIONS Concomitant cryoablation during MV surgery is a safe and reproducible technique. The procedure provides acceptable freedom from atrial arrhythmias recurrences during long-term follow-up. The biatrial lesion set has advantages over the left atrium pattern in terms of atrial arrhythmias freedom. Surgeon experience significantly influences atrial fibrillation ablation success. Randomized trials are needed to compare radiofrequency and cryoablation.

Cardiac surgery in patients with hemophilia remains a serious problem due to the risk of bleeding complications. Here, we report successful treatment of mitral valve insufficiency and concomitant atrial fibrillation in a patient with severe hemophilia A.

The influence of left atrium (LA) enlargement on atrial arrhythmia recurrence (AAR) after surgical ablation in patients with mitral valve (MV) disease remains unresolved.Left atrial size is critical to the success of concomitant atrial fibrillation (AF) ablation in patients scheduled for MV surgery. However, a large LA should not be a limiting factor when evaluating surgical candidates with AF if they receive appropriate treatment during concomitant ablation. This randomised study assessed whether adding LA reduction (LAR) to the maze procedure for MV surgery patients can improve freedom from AAR.From September 2014 to September 2017, 140 patients were randomly assigned into two groups. The maze group underwent MV surgery with concomitant surgical AF ablation (n=70). The maze + LA reduction group underwent MV surgery with concomitant AF ablation and LA reduction procedure (n=70). Rhythm outcomes were estimated by Holter monitoring, according to Heart Rhythm Society guidelines.The concomitant LA reduction procedure did not increase early mortality and complications rates. Significant differences in freedom from AAR were observed at 24 months (maze, 78.4%; maze + LAR group, 92.3%; p=0.025). A significant difference in LA volume was detected at discharge (p0.0001); however, it was not significantly different at 24 months (p=0.182).Adding LA reduction to the maze procedure led to improvements in freedom from AAR for patients with AF and LA enlargement scheduled for MV surgery. A concomitant LA reduction procedure did not increase mortality and perioperative risk.

OBJECTIVES There is very little evidence comparing the safety and efficacy of alcohol septal ablation versus septal myectomy for a septal reduction in patients with hypertrophic obstructive cardiomyopathy. This study aimed to compare the immediate and long-term outcomes of these procedures. METHODS Following propensity score matching, we retrospectively analysed outcomes in 105 patients who underwent myectomy and 105 who underwent septal ablation between 2011 and 2017 at 2 reference centres. RESULTS The mean age was 51.9 ± 14.3 and 52.2 ± 14.3 years in the myectomy and ablation groups, respectively (P = 0.855), and postoperative left ventricular outflow tract gradients were 13 (10–19) mmHg vs 16 (12–26) mmHg; P = 0.025. The 1-year prevalence of the New York Heart Association class III–IV was higher in the ablation group (none vs 6.4%; P = 0.041). The 5-year overall survival rate [96.8% (86.3–99.3) after myectomy and 93.5% (85.9–97.1) after ablation; P = 0.103] and cumulative incidence of sudden cardiac death [0% and 1.9% (0.5–7.5), respectively P = 0.797] did not differ between the groups. The cumulative reoperation rate within 5 years was lower after myectomy than after ablation [2.0% (0.5–7.6) vs 14.6% (8.6–24.1); P = 0.003]. Ablation was associated with a higher reoperation risk (subdistributional hazard ratio = 5.9; 95% confidence interval 1.3–26.3, P = 0.020). At follow-up, left ventricular outflow tract gradient [16 (11–20) vs 23 (15–59) mmHg; P CONCLUSIONS Both procedures improved functional capacity; however, myectomy better-resolved classes III–IV of heart failure. Septal ablation was associated with higher reoperation rates. Myectomy demonstrated benefits in gradient relief and mitral regurgitation elimination. The results suggest that decreasing rates of myectomy procedures need to be investigated and reconsidered.

Background To evaluate whether the Alfieri technique improves clinical and haemodynamic results and compare it with transaortic mitral valve secondary cord cutting in patients scheduled for septal myectomy for severely symptomatic hypertrophic obstructive cardiomyopathy. Methods Forty-eight (48) patients with moderate-to-severe systolic anterior motion (SAM)-mediated mitral regurgitation were randomly assigned to the Alfieri or Cutting groups in addition to septal myectomy. The primary endpoint was postoperative mean transmitral pressure gradient (TPG). The secondary endpoints were residual left ventricular outflow tract (LVOT) gradient after procedure, residual mitral regurgitation (MR), postoperative SAM, repeating bypass, and survival. Results There were no 30-day mortality and ventricular septal defects. The postoperative LVOT gradient was 15.4±7.6 mmHg and 11.1±4.9 mmHg (p=0.078) in the Alfieri and Cutting groups, respectively. The Alfieri technique was associated with higher peak (7.8±3.3 vs 4.7±2.8 mmHg; p=0.014) and mean (3.9±1.7 vs 2.1±1.6 mmHg; p=0.013) TPG. The Cutting group was associated with higher mild MR rate at discharge (six vs no patients; p=0.009). One (1) patient (4.2%) in the Alfieri group required pacemaker implantation owing to conduction disturbances (p=0.312). Two-year (2-year) freedom from late mortality and sudden cardiac death rates were 95.5%±4.4% and 100% for the Alfieri and Cutting groups, respectively (log rank, p=0.317). No patients had New York Heart Association functional class III or IV or moderate or severe MR. The maximum LVOT gradient was 20.4±15.2 mmHg and 16.7±10.4 mmHg, respectively (p=0.330). There were no reoperations during follow-up. Conclusions Both techniques with septal myectomy effectively eliminated SAM-induced MR and LVOT obstructions in hypertrophic cardiomyopathy patients.

Surgical septal myectomy is a standard treatment option for patients with hypertrophic obstructive cardiomyopathy. Subvalvular abnormalities of the mitral valve might play an important role in residual left ventricular outflow tract obstruction. This randomized study aimed to compare the surgical outcomes of septal myectomy with vs without subvalvular interventions. Between July 2015 and December 2016, 80 eligible patients were randomly assigned to undergo septal myectomy with vs without subvalvular intervention. The peak gradient was 92.3 ± 16.9 and 88.1 ± 15.4 mm Hg, respectively (P = 0.281). The mean septum thickness was 26.8 ± 4.5 and 26.1 ± 4.2 mm, respectively (P = 0.504). Moderate or severe systolic anterior motion syndrome-mediated mitral regurgitation was observed in all patients. There was no residual mitral regurgitation in the group with subvalvular intervention, while 15% of patients in the control group had regurgitation (P = 0.013). Residual systolic anterior motion syndrome was observed in 5% and 27.5% of patients, respectively (P = 0.007). The median postoperative gradient was 13 (interquartile range 9–16) mm Hg and 8 (interquartile range 4–12) mm Hg, respectively (P = 0. 0.019). At the 12-month follow-up, all patients were alive. There were 87.5% vs 77.5%, and 12.5% vs 22.5% of patients categorized as having New York Heart Association functional classes I and II, respectively (P = 0.378). The prevalence rate of residual mitral regurgitation was 10% and 32.5%, respectively (P = 0.010). Concomitant subvalvular intervention during septal myectomy more effectively eliminates left ventricular outflow tract obstruction, providing better freedom from residual mitral regurgitation without clinical benefit 1 year after surgery.

We evaluated the differences in mitral valve (MV) plasty (MVP) and MV replacement (MVR) with respect to death, postoperative MV dysfunction, reoperation rates and thromboembolic events (DFRE) in patients with hypertrophic obstructive cardiomyopathy and systolic anterior motion of the anterior mitral leaflet-mediated MV regurgitation (HOCM & MR). We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, searching PubMed, Cochrane library and ClinicalTrials.gov for studies that evaluated DFRE in adults with HOCM & MR after MVP/MVR. We used a risk of bias assessment tool for non-randomized studies, and analyses were performed using Cochrane Review Manager 5.3.5 for I2 statistics, funnel plots and forest plot and the generic inverse variance method for hazard ratios (HRs). We developed qualitative and quantitative syntheses of 35 and 23 studies, respectively, including levels of evidence of ½/3/4/5 = 3/1/11/11/9 and ½/3/4/5 = 0/1/11/11/0, respectively, from January 1980 to August 2017. A statistically significant difference between MVP and MVR favoured MVP for the prevention of DFRE in patients with HOCM & MR, on the basis of a significant reduction of the HR for DFRE: HR = 0.68 (0.57, 0.82), I2 = 68% (P = 0.002). The findings were as follows: (i) MVP should be the first-line treatment in patients with HOCM & MR (accuracy LEVEL A) and (ii) MVR may be harmful if it is used as the first-line treatment (accuracy LEVEL A).

OBJECTIVES To compare the outcomes of left atrial ablation and biatrial (BA) ablation in patients with persistent and long-standing persistent atrial fibrillation undergoing open heart surgery. METHODS Between January 2007 and December 2016, 588 consecutive patients with either persistent (20.9%) or long-standing persistent atrial fibrillation (79.1%) were enrolled in this study. To reduce between-group differences, propensity score-matched groups (156 patients/group) were obtained, with similar preoperative and perioperative characteristics. RESULTS The propensity score-matched left atrial and BA groups did not differ regarding 30-day mortality (1.9% vs 0.6%; P = 0.617), 5-year overall survival (93.5 ± 2.2% vs 92.8 ± 2.9%, P = 0.998) or survival free from thromboembolic events (97.1 ± 2.8% vs 96.2 ± 2.7%, P = 0.309). The BA lesion set was more beneficial in terms of freedom from atrial arrhythmia recurrence (85.3 ± 4.5% vs 91.9 ± 3.1%, P = 0.049; hazard ratio 3.26; 95% confidence interval 1.33-7.99), but it was associated with higher pacemaker implantation rate (3.8% vs 17.3%; P

Objectives The type of conduit used for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure remains problematic because of the limited availability of pulmonary allografts and the unsatisfactory long-term results associated with the use of xenografts. Polytetrafluoroethylene (PTFE) conduits have been proposed as an alternative. This study evaluated the results of RVOT reconstruction using a PTFE conduit during the Ross procedure. Methods Between 2007 and 2015, 28 patients underwent RVOT reconstruction using PTFE conduits. The mean age of the patients was 35.9 ± 18.1 (range 4-58) years. The total root replacement technique was used in all patients. The mean PTFE conduit size was 25.3 ± 2.3 mm. Results The early mortality rate was 3.6% (1 patient). The mean follow-up duration was 48.5 ± 31.2 months; there were no late deaths. The transprosthetic gradients increased significantly over time. The conduit size was the only independent predictor of peak RVOT gradient progression (P = 0.02). None of the patients demonstrated significant RVOT regurgitation. One patient required an RVOT reoperation. Conclusions The PTFE conduit demonstrates acceptable haemodynamic results at the mid-term follow-up and could be considered as an alternative substitute for RVOT reconstruction during the Ross procedure.

Although the Ross procedure provides excellent long-term survival and a high quality of life, its use has been limited to relatively few centers. In this study, we evaluated long-term Ross procedure results in adults to assess the predictors of pulmonary autograft durability.Between 1998 and 2015, 793 consecutive adult patients underwent the Ross procedure. The total root replacement technique was used in all patients.The early mortality rate was 2.9%. The mean follow-up duration was 6.5 ± 3.2 years, and the 10-year survival rate was 90.4%. Longitudinal mixed-effects ordinal regression identified a combination of bicuspid aortic valve and aortic insufficiency (odds ratio, 2.19; P .001) as predictors for progression of autograft valve insufficiency at follow-up. The cumulative incidence of autograft reoperations at 10 years was 8.6%. Competing risk regression identified bicuspid aortic valve insufficiency as the independent predictor of autograft reoperation (subdistribution hazard ratio, 2.16; P = .030). Moreover, patients with bicuspid aortic valve and aortic insufficiency had greater increases in annulus (P .001), sinus (P .001), and ascending aorta (P .001) diameters over time.For patients undergoing the Ross procedure, a combination of bicuspid aortic valves and aortic insufficiency is the main risk factor for late autograft dilatation and dysfunction.

Objective The appearance of atrial fibrillation is associated with significant clinical deterioration in patients with obstructive hypertrophic cardiomyopathy; therefore, maintenance of sinus rhythm is desirable. Guidelines and most articles have reported the results of catheter ablation and pharmacologic atrial fibrillation treatment; nevertheless, data regarding concomitant procedures during septal myectomy are limited. The aim of this study was to assess the outcomes of concomitant atrial fibrillation treatment in patients with obstructive hypertrophic cardiomyopathy. Methods Between 2010 and 2013 in our clinic, 187 patients with obstructive hypertrophic cardiomyopathy underwent extended myectomy. In 45 cases, concomitant Cox-Maze IV procedure was performed; however, obstructive hypertrophic cardiomyopathy was the primary indication for surgery. Atrial fibrillation was paroxysmal in 26 patients (58%) and nonparoxysmal in 19 patients (42%). The mean age of patients was 52.8 ± 14.2 years (range, 22-74 years). Mean peak gradient was 90.7 ± 24.2 mm Hg, and interventricular septum thickness was 26.1 ± 4.3 mm. Mean atrial fibrillation duration was 17.3 ± 8.5 months. Results There were no early deaths. No procedure-related complications occurred with regard to ablation procedure. Complete atrioventricular block was achieved in 2 patients (4.0%). Mean crossclamping time was 61 ± 36 minutes. Peak left ventricular outflow tract gradient was 12.6 ± 5.5 mm Hg based on transesophageal echocardiography. The Maze IV procedure was used for ablation in all patients (radiofrequency ablation with bipolar clamp + cryolesion for mitral and tricuspid lines). Because of the atrial wall thickness (5-6 mm), applications were performed 8 to 10 times on each line. There were no cases of pacemaker implantation due to sinus node dysfunction. All patients were discharged in stable sinus rhythm. Mean follow-up was 23.7 ± 1.3 months. The rate of atrial fibrillation freedom was 100% (45 patients) at 6 months, 89% (40 patients) at 1 year, and 78% (35 patients) at 24 months. Conclusions Concomitant ablation atrial fibrillation during septal myectomy in patients with obstructive hypertrophic cardiomyopathy is a safe and effective procedure and should be considered carefully in this patient group.