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Background : Post-operative AF (POAF) is the most common complication following cardiac surgery, occurring in 30% to 60% of patients undergoing bypass and/or valve surgery. POAF is associated with longer intensive care unit/hospital stays, increased healthcare utilization, and increased morbidity and mortality. Injection of botulinum toxin type A into the epicardial fat pads resulted in reduction of AF in animal models, and in 2 clinical studies of cardiac surgery patients, without new safety observations. Methods : The objective of NOVA is to assess the use of AGN-151607 (botulinum toxin type A) for prevention of POAF in cardiac surgery patients. This randomized, multi-site, placebo-controlled trial will study one-time injections of AGN-151607 125 U (25 U / fat pad) and 250 U (50 U / fat pad) or placebo during cardiac surgery in ∼330 participants. Primary endpoint: % of patients with continuous AF ≥ 30 s. Secondary endpoints include several measures of AF frequency, duration, and burden. Additional endpoints include clinically important tachycardia during AF, time to AF termination, and healthcare utilization. Primary and secondary efficacy endpoints will be assessed using continuous ECG monitoring for 30 days following surgery. All patients will be followed for up to 1 year for safety. Conclusion : The NOVA Study will test the hypothesis that injections of AGN-151607 will reduce the incidence of POAF and associated resource utilization. If demonstrated to be safe and effective, the availability of a one-time therapy for the prevention of POAF would represent an important treatment option for patients undergoing cardiac surgery.

During the Italian Phase-2 of the coronavirus pandemic, it was possible to restart elective surgeries. Because hospitals were still burdened with coronavirus disease 2019 (COVID-19) patients, it was focal to design a separate "clean path" for the surgical candidates and determine the possible effects of major surgery on previously infected patients.From May to July 2020 (postpandemic peak), 259 consecutive patients were scheduled for elective cardiac surgery in three different centers. Our original roadmap with four screening steps included: a short item questionnaire (STEP-1), nasopharyngeal swab (NP) (STEP-2), computed tomography (CT)-scan using COVID-19 reporting and data system (CO-RADS) scoring (STEP-3), and final NP swab before discharge (STEP-4).Two patients (0.8%) resulted positive at STEP-2: one patient was discharged home for quarantine, the other performed a CT-scan (CO-RADS:2), and underwent surgery for unstable angina. Chest-CT was positive in 6.3% (15/237) with mean CO-RADS of 2.93 ± 0.8. Mild-moderate lung inflammation (CO-RADS: 2-4) did not delay surgery. Perioperative mortality was 1.15% (3/259), and cumulative incidence of pulmonary complications was 14.6%. At multivariable analysis, only age and cardiopulmonary bypass (CPB) time were independently related to pulmonary complications composite outcome (age75 years: odds ratio [OR]: 2.6; 95% confidence interval [CI]: 1.25-5.57; p = 0.011; CPB 90 min. OR: 4.3; 95% CI: 1.84-10.16; p = 0.001). At 30 days, no periprocedural contagion and rehospitalization for COVID-19 infections were reported.Our structured roadmap supports the safe restarting of an elective cardiac surgery list after a peak of a still ongoing COVID-19 pandemic in an epicenter area. Mild to moderate CT residuals of coronavirus pneumonia do not justify elective cardiac surgery procrastination.

Background Several aetiologies account for exercise intolerance, with cardiac sarcoidosis (CS) constituting a rare cause thereof. The pathogenesis of CS is still unresolved and its diagnosis still difficult to establish, in the absence of any extracardiac manifestations in particular. Case summary A 49-year-old amateur athlete presented with exercise intolerance during running over a 3-week period. Coronary artery and structural lung disease were excluded by coronary angiography and computer tomography. The symptoms could be reproduced during spiroergometry during which an exercise-induced high-degree atrioventricular (AV) block was documented. During electrocardiographic monitoring, a 2:1 AV block was observed. Different imaging modalities showed inferobasal septal inflammation and fibrosis. Transthoracic and transoesophageal echocardiography-guided endomyocardial biopsies were inconclusive and only subsequent epicardial biopsy performed by transdiaphragmatic minimally invasive surgery lead to the histological diagnosis of non-caseating granuloma, confirming CS. The patient was treated with high-dose steroids 1 week after implantation of a primary prevention dual-chamber implantable cardioverter-defibrillator (ICD). While tapering steroids, recurrence of myocardial inflammation occurred. However, no tachytherapies and Discussion Differential diagnoses were either an infiltrative disease, a tumour, or an infectious disease. Due to the different treatment options, we had to establish definite diagnosis by myocardial biopsy. Retrospectively, the implantation of the ICD can be discussed. However, cardiac magnetic resonance imaging showed fibrosis which is usually irreversible and substrate for potentially lethal ventricular arrhythmia. Confirming the diagnosis of isolated CS is challenging. Long-term management should be guided individually based on clinical and imaging findings.

Hide - Deep sternal wound infection is a major complication of cardiac surgery, with a low incidence but with catastrophic consequences in terms of morbidity, mortality, and health-care costs. Negative pressure wound therapy and appropriately timed sternal revision, with or without muscle flap mobilization, can improve the outcomes. This video tutorial illustrates the technical aspects of the surgical treatment of mediastinitis with the Robicsek method for sternal closure and an original wound closure technique, very effective and much simpler than the pectoral muscle flap technique.

Aortic root disease can be treated with different surgical techniques. The surgical approach of choice depends on patients’ comorbidities and aortic valve conditions. We describe an operation combining a Sleeve aortic rootplasty with an aortic valve replacement, as an alternative to the classical Bentall procedure. The patient, a 63-year-old man, was admitted to our institution in April 2019 with severe aortic regurgitation, left ventricle dysfunction (ejection fraction = 44%), and aortic root ectasia (476 mm). Since a sparing aortic valve procedure was judged not feasible because of the thickness and retraction of the leaflets, we decided to perform a procedure through a sleeve operation to treat the aortic ectasia and a standard bioprosthetic aortic valve replacement to treat the aortic regurgitation. The patient had an uneventful postoperative course and was discharged on the sixth postoperative day with aspirin as sole antiplatelet treatment. This procedure may be considered an alternative to the Bentall operation. In fact, it may also offer complete treatment for the aortic root disease, avoiding coronary complications due to coronary ostia manipulation and reimplantation.

Introduction Atrial fibrillation (AF) is the most common cardiac related arrhythmia, independently associated with an increased risk of death and high level of morbidity, such as stroke, heart failure, as well as frequent hospitalization and reduced quality of life. Surgical ablation is an effective therapy for patients with AF undergoing concomitant cardiac surgery. Purpose In this study we report the results of concomitant surgical AF ablation, in terms of efficacy and safety, with a long-term follow-up at 10 years. Methods Two-hundred fourteen (214) consecutive patients (female, 45.17%) underwent from 1999 to 2016 surgical ablation of AF concomitantly with other major cardiac procedures. Mean age was 67.4±9.82. Patients had persistent and long-standing persistent AF in 64.65% of cases. Primary endpoints were overall survival, freedom from stroke and freedom from AF. Results Perioperative mortality was 2.3% (5/214). Mean EuroSCORE II was 5.2±4.4. Concomitant mitral valve surgery was performed in 56.74% of patients, 31% of patients had a concomitant aortic valve surgery, while myocardial revascularization either isolated or associated with aortic valve was performed in 11.63% and 3.72% of cases respectively. Ablation was carried out by means radio-frequency box lesions set in 35.51% (76/214) of patients while pulmonary veins isolation with bipolar clamp and Cox-MAZE IV was performed in 51.86% (111/214) and 12.61% (27/214) of patients respectively. Left atrial appendage (LAA) exclusion was performed in 57 patients (26.51%) after careful echocardiographic investigation of diastolic and atrial function. Incidence of early postoperative (30 days) permanent pacemaker implantation was as low as 2.3%. The mean follow-up was 6.71±4.47 years. The New York Heart Association functional class (2.84 vs. 1.91, p Conclusions Concomitant surgical ablation of AF was associated with a very low incidence of postoperative PM implantation and provides excellent results in terms of stable rhythm outcome at long-term. Postoperative AF significantly increased the risk of stroke in the early postoperative period. Funding Acknowledgement Type of funding source: None

OBJECTIVES: Feasibility and results of cardiovascular hub-spoke networks to face COVID19 pandemic. The COVID-19 pandemic in Italy had the primary outbreak in the northern part of the country forcing the regional health care system to expand the availability of beds in the wards and intensive care units and to institute a Hub and Spoke hospital network to ensure assistance continuity for urgencies and emergencies. We report a descriptive analysis of the activity of the first 30 days of the Hub center. METHODS: Role of our Hub center was to guarantee 24/24h 7/7days cardiovascular surgical care for an area of 3.145.312 inhabitants’ area. Hub-spoke reorganization permitted a significant increase of ICU and ward beds availability for COVID patients needing hospitalization in all peripheral centers. Records of all consecutive patients admitted were collected and analyzed. RESULTS: a total of 100 patients were evaluated in the study period . Hub and spoke cooperation have been successful, all patients affected by cardiovascular urgencies or emergencies found a highly specialized hospital and was evaluated and treated. Global reduction of elective and non-deferrable interventions in spoke centers was achieved for both vascular and cardiac surgery while we detected a significant increase of urgent vascular interventions for acute limb ischemia. We did not observe an increase of in-hospital mortality in non-infected patients. CONCLUSION: Hub and spoke network for cardiovascular pathology is an effective way to face healthcare needs during the pandemic.

Background: Scientific research on atrial fibrosis in atrial fibrillation (AF) has mainly focused on quantitative or molecular features. The purpose of this study was to perform a clinicoarchitectural/structural investigation of fibrosis to provide one key to understanding the electrophysiological/clinical aspects of AF. Methods: We characterized the fibrosis (amount, architecture, cellular components, and ultrastructure) in left atrial biopsies from 121 patients with persistent/long-lasting persistent AF (group 1; 59 males; 60±11 years; 91 mitral disease–related AF, 30 nonmitral disease–related AF) and from 39 patients in sinus rhythm with mitral valve regurgitation (group 2; 32 males; 59±12 years). Ten autopsy hearts served as controls. Results: Qualitatively, the fibrosis exhibited the same characteristics in all cases and displayed particular architectural scenarios (which we arbitrarily subdivided into 4 stages) ranging from isolated foci to confluent sclerotic areas. The percentage of fibrosis was larger and at a more advanced stage in group 1 versus group 2 and, within group 1, in patients with rheumatic disease versus nonrheumatic cases. In patients with AF with mitral disease and no rheumatic disease, the percentage of fibrosis and the fibrosis stages correlated with both left atrial volume index and AF duration. The fibrotic areas mainly consisted of type I collagen with only a minor cellular component (especially fibroblasts/myofibroblasts; average value range 69–150 cells/mm 2 , depending on the areas in AF biopsies). A few fibrocytes—circulating and bone marrow-derived mesenchymal cells—were also detectable. The fibrosis-entrapped cardiomyocytes showed sarcolemmal damage and connexin 43 redistribution/internalization. Conclusions: Atrial fibrosis is an evolving and inhomogeneous histological/architectural change that progresses through different stages ranging from isolated foci to confluent sclerotic zones which—seemingly—constrain impulse conduction across restricted regions of electrotonically coupled cardiomyocytes. The fibrotic areas mainly consist of type I collagen extracellular matrix and, only to a lesser extent, mesenchymal cells.

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

Robotically assisted mitral valve repair has proven its efficacy during the last decade. The most suitable approach for patients with difficult anatomies, such as morbid obesity, sternal deformities, cardiac rotation, or vascular anomalies, represents a current challenge in cardiac surgery. Herein, we present the case of a 71-year-old patient affected by severe degenerative mitral valve regurgitation with pectus excavatum and a right aortic arch with an anomalous course of the left subclavian artery who was successfully treated using a Da Vinci–assisted approach.

Aims of the study An extracorporeal membrane oxygenation system (ECMO), as a bridge to either recovery, a ventricular assist device (VAD), or heart or lung transplantation, may be the only lifesaving option for critically ill patients suffering from refractory cardiac, respiratory or combined cardiopulmonary failure. As peripheral hospitals may not offer ECMO treatment, tertiary care centres provide specialised ECMO teams for on-site implantation and subsequent patient transfer on ECMO to the tertiary hospital. This study reports the results of the largest ECMO transportation programme in Switzerland and describes its feasibility and safety. Methods Patients transported on ECMO by our mobile ECMO team to our tertiary centre between 1 September 2009 and 31 December, 2016 underwent retrospective analysis. Implantation was performed by our specialised ECMO team (primary transport) or by the medical staff of the referring hospital (secondary transport) with subsequent transfer to our institution. Type of ECMO, transport data, patient baseline characteristics, operative variables and postoperative outcomes including complications and mortality were collected from medical records. Results Fifty-eight patients were included (three patients excluded: one repatriation, two with incomplete medical records). Thirty-five patients (60%) received veno-venous, 22 (38%) veno-arterial and one patient (2%) veno-venoarterial ECMO. Forty-nine (84%) patients underwent primary and nine (16%) secondary transport. Thirty-five (60%) patients were transferred by helicopter and 23 (40%) by ambulance, with median distances of 38.1 (13n225) km and 21 (3-71) km respectively. No clinical or technical complications occurred during transportation. During hospitalisation, three patients had ECMO-associated complications (two compartment syndrome of lower limb, one haemothorax after central ECMO upgrade). Median days on ECMO was 8 (l1n49) and median days in hospital was 17 (l1n122). ECMO weaning was successful in 41 patients (71%), on-transport survival was 100%, 40 patients survived to discharge (69%), and overall survival was 67% (39 patients) at a median follow-up of 58 days (l1n1441). Cumulative survival was significantly affected by cardiogenic shock vs. ARDS (p = 0.001), veno-arterial and veno-venoarterial vs. veno-venous ECMO (p = 0.001) and after secondary vs. primary transport (p l0.001). The ECMO weaning rate was significantly lower after secondary transfer (22%, two patients, both vaECMO) vs. primary transfer (80%, p = 0.002, 39 patients of which 35 (71%) had vvECMO). Conclusions The first results of our ECMO transportation programme show its feasibility, safety and efficacy without on-site implant or on-transport complications or mortality. The favourable early survival may justify the large effort with respect to logistics, costs and manpower. With rising awareness, referring centres may increasingly consider this lifesaving option at an early stage, which may further improve outcomes.

Background: Median sternotomy is still the approach of choice for heart surgery and the most common sternal closure is conventional six-wire technique. Mediastinitis is the frightening complication of the median sternotomy and occurs from 1% up to 2.4% of cases with a mortality rate which ranges from 14% up to 47%. Many methods have been suggested to reinforce the sternum with the common goal to improve sternal stability and prevent mediastinitis, but there is not consensus among cardiac surgeons on the optimal way to close the sternum. For this reason, we report our experience with a sternal device that, although not entirely new as a concept, has new technical features and plays a new role in preventing sternal dehiscence, according to the most recent findings on mechanism which leads to sternal dehiscence. Methods: We enrolled 62 high risk patients for sternal dehiscence (patients with 2 well established historical risk factors), and we closed the sternum of the patients with a new surgical option consisting of passing, in a conventional six-wire sternal closure, the last sixth steel wire (O 1.0 mm, n° 5) through a couple of titanium cannulated screws (O 5.5 mm, self-tap-ping with a length from 10 to 16 mm and 2-mm increments) inserted into the 5th or 6th couple of rib cartilages. Results: Primary chest closure with cannulated screws was performed on 48 males and 14 females. The average age of patients was 67.6 years (range, 43–88 years). The average follow-up was 12.8±16.2 months (range, 1–41 months). Chronic obstructive pulmonary disease (COPD) was the most common preoperative risk factor. The average number of risk factors was 2.4 (range, 2–4). Coronary artery bypass grafting (CABG) was the most common cardiac procedure. There were no peri-operative deaths. BMI >30 Kg/m 2 and diabetes were the associated of risk factors predisposing to superficial skin dehiscence. Conclusions: In our clinical experience with high risk patients, this surgical option suggests that there is evidence of an effective stabilization of standard sternal closure and this option seems a promising technique to prevent the domino effect which starts from the xifoid bone and proceeds to the manubrium with the effect of leading to sternal instability which is the first step to mediastinitis.

The study sought to assess the long-term outcomes of the stand-alone Cox-Maze IV procedure in symptomatic patients with refractory, persistent, or long-standing persistent atrial fibrillation (AF).Fifty-nine consecutive patients (mean age 52 ± 10.5 years, previous catheter ablation 80%, left ventricular ejection fraction 55% ± 3.4%, median left atrial volume index 41 [interquartile range, 34-47] mL/mNo hospital deaths occurred and 1 (1.7%) patient required postoperative pacemaker implantation. Follow-up was 97% complete (median 5.8 [interquartile range, 3.92-7.11] years). The overall survival at 7 years was 97% ± 2.3%. The 7-year cumulative incidence function of AF recurrence and of AF recurrence off class I or III antiarrhythmic drugs (AADs), with death as competing risk, was 14.2% ± 5.6% (95% confidence interval [CI], 5.5%-26.8%) and 26.5% ± 6.9% (95% CI, 14.2%-40.4%), respectively. Multivariate analysis identified the duration of AF as the only predictor of AF recurrence (hazard ratio, 1.01; 95% CI, 1.01-1.02; P.001). At 7 years, the proportion of patients in sinus rhythm was 84%, of whom 74% were off class I or III AADs. At the last follow-up, 75% of patients were in European Heart Rhythm Association functional class I, no stroke and thromboembolic events were documented, and 70% of patients were off anticoagulation therapy. Left ventricular ejection fraction improved from 53% ± 3.4% at baseline to 59% ± 3.4% at follow-up (P = .003).This study confirmed the safety and efficacy in the long term (7 years) of the stand-alone Cox-Maze IV surgical procedure for persistent or long-standing persistent AF. Indeed, more than 70% of the patients were in sinus rhythm off class I or III AADs and off oral anticoagulation.

The aim of this study was to assess the mid-term results after AF ablation in a real-world cohort in a single tertiary care center in Switzerland.

OBJECTIVES: The aim of the present study was to evaluate the prognostic impact and late evolution of associated tricuspid regurgitation (TR) 2/4+ after aortic valve replacement (AVR). METHODS: We evaluated 61 patients who underwent AVR between 2003 and 2012 (35 for aortic stenosis [AS], 26 for aortic regurgitation [AR]) with associated untreated TR 2/4+. Patients with concomitant mitral disease were excluded. Median follow-up was 3.2 years. Serial echocardiographic and clinical data were collected and analyzed. RESULTS: Mean age was 65 ± 13 years; 26% of the patients were in NYHA class III-IV. Left ventricular ejection fraction was 53 ± 11%. Comorbidity included: chronic obstructive pulmonary disease in 5%, chronic renal failure in 13%, coronary artery disease in 20%, history of stroke/TIA in 8%. Thirty-day mortality was 1.6%. Overall actuarial survival was 83 ± 6% at 6.5 years, with a freedom from cardiac death of 90 ± 5%. Freedom from TR ≥3+ was 86 ± 6% at 6.5 years. At last follow-up, 82% of the patients had TR 0-1/4+, 9% had TR 2/4+, 4.5% had TR 3/4+ and 4.5% had TR 4/4+. Occurrence of TR ≥ 3+ at follow-up was associated with increased cardiac mortality (HR 10.5; p = 0.009). CONCLUSIONS: preoperative untreated TR 2/4+ improves or remains stable in the majority of patients. The poor outcomes associated with TR > 2+ suggest the need for better methods to identify subjects at risk for TR progression. doi: 10.1111/jocs.12656 (J Card Surg 2016;31:9-14).

There are major challenges ahead for clinicians treating patients with atrial fibrillation (AF). The population with AF is expected to expand considerably and yet, apart from anticoagulation, therapies used in AF have not been shown to consistently impact on mortality or reduce adverse cardiovascular events. New approaches to AF management, including the use of novel technologies and structured, integrated care, have the potential to enhance clinical phenotyping or result in better treatment selection and stratified therapy. Here, we report the outcomes of the 6th Consensus Conference of the Atrial Fibrillation Network (AFNET) and the European Heart Rhythm Association (EHRA), held at the European Society of Cardiology Heart House in Sophia Antipolis, France, 17-19 January 2017. Sixty-two global specialists in AF and 13 industry partners met to develop innovative solutions based on new approaches to screening and diagnosis, enhancing integration of AF care, developing clinical pathways for treating complex patients, improving stroke prevention strategies, and better patient selection for heart rate and rhythm control. Ultimately, these approaches can lead to better outcomes for patients with AF.

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

Introduction In Switzerland, the first implantation of a subcutaneous implantable cardioverter-defibrillator (S-ICD) took place in November 2012. Up until the end of 2016, a total of 111 S-ICDs have been implanted. The aim of this study was to summarise the experience of a tertiary centre in Switzerland and to discuss the results in the context of international registries. Methods All patients in whom an S-ICD was implanted between November 2012 and the end of December 2016 at the University Heart Centre Zurich were included in this study. The clinical records of all patients were reviewed for retrospective collection of baseline characteristics as well as implantation and follow-up data. Results A total of 37 S-ICDs were implanted. The majority of patients (81%) were male, the mean age was 47 ± 15 years. The most common underlying cardiac condition was coronary artery disease (30%), followed by hypertrophic cardiomyopathy (24%), inherited channelopathies (19%) and nonischaemic cardiomyopathy (11%). The median left ventricular ejection fraction was 44% (interquartile range 28-61%). There were four peri-interventional complications, all of which were pocket site-related. There were no cases of systemic infection or perioperative death. During a median follow up of 3.7 months, there were three appropriate and successful ICD shocks (8.1%). Two patients (5.4%) experienced a total of three inappropriate shocks, all due to T-wave oversensing. Conclusion This first large Swiss experience demonstrates results consistent with available international data. The S-ICD may hence represent an attractive alternative to conventional transvenous ICDs for a variety of patients.

Colli et al., commenting on the electrophysiological efficacy of high-intensity focused ultrasound (HIFU), propose a revision of the acute conduction block theory, as a means to confirm effective pulmonary veins (PVs) isolation [1, 2]. Although this proposal could be original, albeit not supported by evidence, it is in contrast with the general agreement surrounding the end-points for atrial fibrillation (AF) ablation. In the areas of consensus on ablation techniques identified by the task force in the recently published Consensus Statement on AF catheter and surgical ablation [3], complete electrical isolation of all PVs should be the goal in every ablation strategy targeting the PVs and/or the PV antrum. So, if the PVs are targeted, electrical isolation should be the goal, and its achievement requires, at a minimum, the assessment and demonstration of conduction block across the PVs lesion. Likewise for surgical PVs, isolation entrance and/or exit block should be validated. Since such acute validation can overestimate success, the Consensus also suggests an extra period of 20 min following PV isolation, to identify and treat PVs reconduction initially masked by the inflammation process, which gives an apparent acute conduction block. The evidence supporting the correlation between complete electrical isolation and clinical efficacy of ablation is clear-cut, since the major predictor of arrhythmia recurrence after catheter ablations is the absence of PVs isolation, indicating restored PV conduction or ineffective PV disconnection. Such a direct cause– effect relationship between PV isolation and cure supports the central role of durable transmurality of the ablations in AF treatment [4]. Despite the penetration properties of HIFU ablations being extensively studied at histology, the results are reported in the very acute context and the conduction block has normally not been evaluated. Hence, inferences between histological transmurality and electrophysiological block in the long-term remain undocumented. Colli and Romero-Ferrer state that in their surgical experience, the freedom from recurrence after HIFU ablation (unpublished data) improves with time, suggesting a progressive increase of the ablation efficacy. They speculate that these results might be related to a putative alternative modality of delayed cell death caused by HIFU. However, a comprehensive study conducted on eight dogs undergoing PV HIFU ablations suggests that the mechanism of permanent injury is irreversible cell death, through coagulative necrosis due to rapid hyperthermal toxicity occurring within the focused zone [5]. Even if different forms of necrotic cell death can be distinguished, based on their initiating mechanisms, i.e. necrosis, necroptosis and secondary necrosis, the downstream cascade of events that occurs thereafter takes place in an invariant fashion, during the following few hours [6]. In conclusion, to the best of the authors’ knowledge, ablation lesions can only get worse with time. Based on current evidence, there is no described biological mechanism that may explain a delayed myocardial cell death where the triggering event occurs during the ablation and the outcome cannot be detected after 3 weeks, as performed in our study.

Background Based on a reduction in morbidity and mortality, cardiac resynchronisation therapy (CRT) has evolved as a standard therapy for patients with advanced heart failure. Objective To provide insight into patient demographics, safety, echocardiographic remodelling and long-term follow-up of patients treated with CRT in a "real-world" setting at a Swiss tertiary care centre. Methods Patients implanted with a CRT device at the University Heart Centre Zurich between 2000 and 2015 were consecutively enrolled. Initial clinical and echocardiographic therapy response as well as long-term follow-up for mortality (defined as all-cause death, heart transplantation or ventricular assist device implantation) and hospitalisation for heart failure were assessed. Results A total of 418 patients with a median age of 66 years at the time of CRT implantation (78% male) were enrolled. Serious peri-interventional complications (from the time of implantation up to 14 days thereafter) were rare and included systemic infections in 2.4%, pneumothorax in 3.3% and haematoma requiring revision in 2.2% of cases. Overall, the Kaplan-Meier estimate for 5-year freedom from the composite endpoint (hospitalisation for heart failure or mortality) was 55.8%; the Kaplan-Meier estimate for 5-year freedom from mortality was 64.1%. CRT was associated with a significant symptomatic improvement and left ventricular reverse remodelling. Overall, 3.9% of patients did not respond to cardiac resynchronisation therapy (decline in left ventricular ejection fraction [LVEF] >5%), whereas 35.1% experienced neither a continued decline nor a relevant improvement of LVEF (±5%). In the remaining 61% of patients we observed an improvement in LVEF of more than 5%. Forty percent and 31% of patients were super responders, defined as an absolute LVEF improvement of 10% and by a relative reduction of left ventricular end-diastolic volume index by 20% or more. Super-response to CRT was associated with a significant benefit in terms of survival and rehospitalisation rates. Conclusion Our data are consistent with large multicentre trials and indicate that CRT is similarly effective in a real-world setting in Switzerland.

Aims Oral anticoagulation is considered standard therapy for stroke prevention in atrial fibrillation (AF). Endocardial activation triggers expression of pro-thrombotic mediators including tissue factor (TF) and plasminogen activator inhibitor-1 (PAI-1), and contributes to thrombus formation in the left atrial appendage (LAA) of AF patients. Recently, pleiotropic effects of specific P2Y12 receptor antagonists were demonstrated; however, whether these drugs possess antithrombotic effects on LAA endocardial cells currently remains unknown. Methods and results LAA were obtained from 14 patients with known AF undergoing elective cardiac surgery including LAA removal at the University Hospital Zurich. LAA endocardial cells were isolated and pre-incubated with ticagrelor (10−7, 10−6, 10−5M) or clopidogrel active metabolite (CAM) (1.5 × 10−8, 1.5 × 10−7, 1.5 × 10−6 M) before stimulation with tumour necrosis factor-alpha (TNF-α) (10 ng/mL). Finally, TF and PAI-1 expression and activity were analysed. Ticagrelor, unlike CAM, concentration dependently decreased TNF-α-induced TF expression and TF activity in LAA endocardial cells. Further, ticagrelor, but not CAM reduced PAI-1 expression and enzyme activity in TNF-α-stimulated LAA endocardial cells. In contrast, TF pathway inhibitor (TFPI) remained unaffected by both dugs. Conclusion Ticagrelor, but not CAM, reduces expression and activity of TF and PAI-1 in LAA endocardial cells isolated from patients with AF, indicating possible local antithrombotic effects. Such pleiotropic properties of ticagrelor may contribute to a reduction in thromboembolic complications in patients with AF.

Since the introduction of thoracoscopic ablation for atrial fibrillation (AF), the field of minimally invasive AF treatment has evolved toward an established treatment option for AF, with an overall 2-year antiarrhythmic drug free success rate of 77%. Complications are usually minor, and the incidence of bleeding needing conversion to sternotomy or (mini-)thoracotomy varies between 0% and 1.6%. Bleeding is often related to encircling the pulmonary veins, which is a blind maneuver that has to be done without direct camera vision. We propose here a modified surgical technique to simplify the procedure, shorten the operating time, and lower the risk of complications.

An alternative to coronary sinus implantation for a left ventricular pacing lead is frequently needed for cardiac resynchronization therapy. We have developed a transapical approach to implant an endocardial pacing lead that will reach the most delayed segment of the left ventricle. This method is easily combined with other transapical heart surgeries. After some technological improvement, our technique should offer easier access and better results than other currently available implantation methods.

The Task Force for the management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC Endorsed by the European Stroke Organisation (ESO)

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

Cardiac surgery can have severe neurologic complications. The noninvasive monitoring of intracranial circulation during heart surgery is usually performed with transcranial Doppler ultrasonography. We present the case of a 66-year-old man who underwent elective cardiac surgery for aortic valve replacement and coronary artery bypass graft, in whom monitoring was performed by simultaneously assessing blood flow velocity in the central retinal artery and vein. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42:112–115, 2014

Background— We investigated the impact of catheter ablation on ventricular tachycardia (VT) recurrence and survival in a large number of patients with structural heart disease treated in the setting of a dedicated multiskilled unit. Methods and Results— Since January 2007, we have implemented a multidisciplinary model, aiming for a comprehensive management of VT patients. Programmed ventricular stimulation was used to assess acute outcome. Primary end points were VT recurrence and the occurrence of cardiac and sudden cardiac death. Overall, 528 patients were treated by ablation (634 procedures; 1–4 procedures per patient). Among 482 tested with programmed ventricular stimulation after the last procedure, a class A result (noninducibility of any VT) was obtained in 371 patients (77%), class B (inducibility of nondocumented VT) in 12.4%, and class C (inducibility of index VT) in 10.6%. After a median follow-up time of 26 months, VT recurred in 164 (34.1%) of 472 patients. VT recurrence was documented in 28.6% of patients with a class A result versus 39.6% of patients with class B and 66.7% with class C result (log-rank P P =0.002). On the basis of multivariate analysis, postprocedural inducibility of index VT was independently associated both with VT recurrence (hazard ratio, 4.030; P P =0.04). Conclusions— Within a dedicated VT unit, catheter ablation prevents long-term VT recurrences, which may favorably affect survival in a large number of patients who have VT.

The left atrial appendage (LAA) represents one of the major sources of cardiac embolism, responsible for either transient or permanent cerebrovascular accidents in patients with atrial fibrillation (AFib). The LAA morphologies are variable, according to the shape of the neck and the body. …

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.

"Partial forms of Shone complex are rare. Surgical outcomes of the complete forms have generally been poor, whereas there is a lack of data on long-term follow-up of surgically treated adult partial complex. Between 2001 and 2011, nine patients (age: 38 ± 8 years; six males, 67%) were referred for valvular heart disease. Transthoracic and transoesophageal echocardiography was performed. Data were confirmed by intra-operative findings and reports. Patients were diagnosed as partial Shone complex and presented with mitral stenosis (MS) (45%) or mitral regurgitation (22%) or aortic regurgitation (22%). All but one patient (89%) reported previous surgery: coarctation of the aorta repair (87.5%) and aortic valvulotomy (12.5%). Redo intervention included: mitral valve replacement (25%), mitral repair (25%), aortic valve replacement (37.5%) and subvalvular aortic ridge resection (25%). One patient refused surgery. Patients surgically treated before the age of 5 (87.5%) showed favourable outcome (survival rate: 100%) and a 23.6 (± 4.6)-year follow-up free from events. The patient who underwent first intervention at the age of 50 and the patient with MS who refused surgery showed a 45 (± 7)-year follow-up free from major morbidity. Patients with partial Shone complex, properly diagnosed and treated, show favourable surgical outcome free from major clinical events.. . "

Aims Mitral stenosis (MS) may exhibit a dynamic valvular reserve. When resting gradients and systolic pulmonary pressure (sPAP) do not reflect the real severity of the disease, a dynamic evaluation becomes necessary. The aim of the study was to assess the clinical utility of exercise echocardiography in symptomatic patients with apparently subcritical MS. Methods and results One hundred and thirty consecutive patients were referred for symptomatic MS. Patients with unimpressive resting MVA (>1-1.5 cm(2)) and mean PG (>= 5-9 mmHg) underwent exercise echocardiography. Cardiac performance and mitral indices (MVA, peak/mean PG, sPAP) were measured. Exhaustion of valvular reserve capacity under exercise was defined as appearance of symptoms and sPAP > 60 mmHg. Forty-six patients (35%) (age: 53 +/- 10 years; 74%, female) with resting MVA (1.2 +/- 0.36 cm(2)), mean PG (6.8 +/- 2.7 mmHg), and sPAP (38 +/- 7 mmHg) inconsistent with symptoms underwent stress echocardiography. Exercise was stopped for dyspnoea (76%) or fatigue (24%). At peak workloads (57.2 +/- 21.8 Watts), increased mean PG (17.2 +/- 4.8 mmHg, P < 0.001) and sPAP (67.4 +/- 11.4 mmHg; P < 0.0001) were observed, without change in MVA (1.25 +/- 0.4 cm(2); P = n.s.). At univariate analysis, predictors of adaptation to exercise were age (-0.345; P = 0.024), mean PG (0.339; P = 0.023), and sPAP (0.354; P = 0.024); at multivariate analysis, best predictor was resting mean PG, although correlation was poor (-0.339; P = 0.015). Conclusion In MS with limiting symptoms despite unimpressive findings at rest, valvular capacity exhaustion should be tested on a dynamic background, as no single resting index can predict potential haemodynamic adaptation to exercise. In such context, the contribution of exercise echocardiography remains extremely valuable.

Objective: Clinical success of atrial fibrillation ablation depends on persistent transmurality of the lesions. Although bipolar radiofrequency grants acute pulmonary vein isolation, the fate of such ablations in the clinical setting is unknown. We assessed postoperative pulmonary vein isolation up to 3 weeks after open chest bipolar radiofrequency ablation. Methods: Thirteen consecutive patients with mitral valve disease (mean age, 60 +/- 10 years) and atrial fibrillation undergoing concomitant ablation with the BP2 bipolar device (Medtronic, Inc, Minneapolis, Minn) were enrolled for electrophysiologic assessment. During surgery, pairs of additional temporary wires were positioned on the right pulmonary veins and on the roof of the left atrium before bipolar ablation. Entrance block (abatement or disconnection of electrogram potentials) and exit block (no entrainment during pulmonary vein pacing) of the right pulmonary veins and of the free left atrium were assessed before and after ablation. After right pulmonary vein isolation was obtained, one additional encircling line was added. Electrophysiologic assessment was repeated before discharge and at 3 weeks. Results: Baseline right pulmonary vein pacing threshold was 2.9 +/- 1.6 mA. After 3 +/- 1 encircling ablations, bidirectional block was attained in all pulmonary veins. At pre-discharge electrophysiologic study, complete isolation persisted in all cases. At 3 weeks, conduction block persisted in 11 (85%) of 13 patients. All patients were discharged in sinus rhythm. At follow-up (19 +/- 7 months), 12 (92%) of 13 patients were still free from atrial fibrillation. Conclusions: Irrigated bipolar radiofrequency ablation provides acute transmurality after multiple ablations. However, total recovery of conduction occurred in 15% of the patients after 3 weeks. Repeated multiple ablations, possibly complemented by block validation, are suggested to help achieve durable transmurality with such technology. (J Thorac Cardiovasc Surg 2010; 139: 1131-6)

Objective: Despite its efficacy and swiftness, bipolar radiofrequency is generally not used on the left isthmus for concern of injuring a coronary branch. Incomplete lesion sets or use of an additional unipolar device are often considered. We report a technique to perform a full left lesion set involving the mitral line using a standard bipolar radiofrequency device. Methods: An innovative complete left atrial lesion set was performed using only bipolar radiofrequency in 70 consecutive patients (study group). In 67/70 patients (96%) mitral valve disease was the main indication to surgery. Atrial fibrillation was permanent in 42 patients (60%), persistent in 25 (36%) and paroxysmal in three patients (4%). After beating-heart pulmonary vein isolation on-pump, the coronary-free area of the AV groove was marked epicardially by sticking a needle into the left atrial wall, behind the coronary sinus. The projection of the needle marker on the mitral annulus was then identified through the atriotomy and an endo-epicardial ablation was performed with the bipolar device involving the atrial wall, the coronary sinus, up to the annulus. The lesion set was then completed by connecting the encirclings and the left appendage, which was then sutured. Follow-up was 100% complete. Results were compared with those of a control group of 33 patients receiving bipolar radiofrequency left atrial ablations and a mitral connecting line with a second unipolar device. Results: All patients survived. No major complication occurred. Haematoma of the AV groove was observed during retrograde cardioplegia in one case. No myocardial ischaemia or re-exploration for bleeding (median 325 cc, interquartile range 250-442) occurred. Two out of 70 patients required a permanent pacemaker for AV block. Freedom from atrial fibrillation was 84% (95% CI: 75%, 93%) at 6 months and 81% (95% CI: 70%, 93%) at 1 year. One patient had left flutter. Comparison with the control group did not show any difference in clinical outcomes, but revealed bipolar ablation to the mitral annulus to abate the per patient cost of the ablation devices (1245 ± 50 ∈ vs 2403 ± 17 ∈; p < 0.0001). Conclusions: Performing the mitral line with bipolar radiofrequency is safe and cost-effective. A complete left atrial ablation with a single bipolar radiofrequency device yields excellent clinical mid-term results.

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

OBJECTIVE: Clinical success of atrial fibrillation (AF) ablation depends on persistent block of electrical conduction across the ablation lines. The fate of ablations performed with temperature-controlled bipolar radiofrequency (RF) is unknown. The purpose of this study was to validate the electrophysiological (EP) efficacy of these lesions, recording pulmonary vein isolation (PVI) after open chest ablation, in the human being. METHODS: Ten consecutive mitral patients (mean age: 53 +/- 12 years) with concomitant AF were treated with the Cobra Revolution (Estech, San Ramon, CA, USA) bipolar RF device were enrolled for EP assessment. During surgery, pairs of additional temporary wires were positioned on the right PVs (RPV) and on the roof of the left atrium (RLA), before ablation. Pacing thresholds (PTs) were assessed before, after a single encircling ablation and at chest's closure. EP study was repeated before discharge and at 3 weeks. RLA wires served as control. RESULTS: Baseline PTs were 0.83 +/- 0.81 mA (range 0.2-3 mA) from RPV and 1.13 +/- 0.78 mA (range 0.3-3 mA) from RLA. PVI was reached in all patients acutely, and was maintained at 1 week. At 3 weeks, the PTs were 14.3 +/- 4.3 mA from RPV (range 7-20 mA) and 3.1 +/- 1.3 mA (range 1.5-7 mA) from RLA. All patients were discharged in sinus rhythm. CONCLUSIONS: Cobra Revolution temperature-controlled bipolar RF provides complete PVI after a single ablation up to 1 week. This notwithstanding, only 30% of patients were completely isolated (exit block validation) at 3 weeks. OBJECTIVE: Clinical success of atrial fibrillation (AF) ablation depends on persistent block of electrical conduction across the ablation lines. The fate of ablations performed with temperature-controlled bipolar radiofrequency (RF) is unknown. The purpose of this study was to validate the electrophysiological (EP) efficacy of these lesions, recording pulmonary vein isolation (PVI) after open chest ablation, in the human being. METHODS: Ten consecutive mitral patients (mean age: 53 ± 12 years) with concomitant AF were treated with the Cobra Revolution (Estech, San Ramon, CA, USA) bipolar RF device were enrolled for EP assessment. During surgery, pairs of additional temporary wires were positioned on the right PVs (RPV) and on the roof of the left atrium (RLA), before ablation. Pacing thresholds (PTs) were assessed before, after a single encircling ablation and at chest's closure. EP study was repeated before discharge and at 3 weeks. RLA wires served as control. RESULTS: Baseline PTs were 0.83 ± 0.81 mA (range 0.2-3 mA) from RPV and 1.13 ± 0.78 mA (range 0.3-3 mA) from RLA. PVI was reached in all patients acutely, and was maintained at 1 week. At 3 weeks, the PTs were 14.3 ± 4.3 mA from RPV (range 7-20 mA) and 3.1 ± 1.3 mA (range 1.5-7 mA) from RLA. All patients were discharged in sinus rhythm. CONCLUSIONS: Cobra Revolution temperature-controlled bipolar RF provides complete PVI after a single ablation up to 1 week. This notwithstanding, only 30% of patients were completely isolated (exit block validation) at 3 weeks.

Objective When used for epicardial ablation, unipolar devices do not predictably yield transmural scars. Bipolar radiofrequency proved highly effective on the animal model, but clinical experience is still initial. We describe acute electrophysiologic findings and follow-up results of epicardial ablation with a novel bipolar radiofrequency device. Methods A bipolar ablator was used to perform a simplified left atrial lesion set in 90 consecutive patients with atrial fibrillation undergoing open heart surgery. Pacing thresholds were assessed during surgery to validate 24 pulmonary vein encircling lines (12 patients). Follow-up was 100% complete. Results In 67 of 90 patients (84%), mitral valve disease was the main indication to surgery. Atrial fibrillation was continuous in 74 patients (82%) and intermittent in 16 patients (18%). Pacing threshold assessment showed a complete conduction block in 22 of 24 pulmonary vein couples (92%) after a single ablation and in all patients after doubling of the encircling lines. No complications related to the ablation procedure were recorded. The sinus rhythm restoration rate was 79% at 3 months, 87% at 6 months, and 89% (17/18 patients) at 1 year. Postablation organized arrhythmias consisted in right atrial flutter in 2 patients (2%) and left atrial flutter in 6 patients (7%). Conclusions Epicardial ablation with bipolar radiofrequency grants acute transmurality. A simplified lesion set proved highly effective in eliminating atrial fibrillation at 1-year follow-up. Our data suggest that addition of a lesion to the mitral annulus is advisable to prevent left atrial flutter.

Ablation of the left atrial free wall around the pulmonary vein ostia (LAFW) may be effective in the treatment of chronic atrial fibrillation associated with mitral disease (CAF-MVD). Using light and conventional electron microscopy analyses, we wanted to evaluate, in CAF-MVD, the interstitial remodeling in the LAFW as well as in a more remote region, such as the left atrial appendage (LAA). LAFW and LAA samples were obtained from 33 CAF-MVD patients during combined mitral surgery and radiofrequency ablation and from 16 autoptic controls. Interstitial fibrosis (IF) and perivascular fibrosis (PF), capillary densities and the maximal oxygen diffusion distance were morphometrically determined. In CAF-MVD patients, the LAFW, compared with the LAA, showed a higher percentage of IF (7.16+/-3.23% versus 2.51+/-1.40%, respectively), a lower myocardial capillary density per mm(2) (830+/-106 versus 989+/-173) and an increased oxygen maximal diffusion distance (19.70+/-1.27 microm versus 18.13+/-1.58 microm). All these values were also significantly different than controls. No differences were found in evaluating PF. At variance with the LAA, in CAF-MVD patients, the LAFW around the pulmonary vein ostia is a region characterized by a marked interstitial remodeling such that it may be morphologically indicated as an appropriate target for ablation treatment aimed at sinus rhythm restoration.

OBJECTIVES This study was designed to investigate the potential of circumferential pulmonary vein (PV) ablation for atrial fibrillation (AF) to maintain sinus rhythm (SR) over time, thus reducing mortality and morbidity while enhancing quality of life (QoL). BACKGROUND Circumferential PV ablation is safe and effective, but the long-term outcomes and its impact on QoL have not been assessed or compared with those for medical therapy. METHODS We examined the clinical course of 1,171 consecutive patients with symptomatic AF who were referred to us between January 1998 and March 2001. The 589 ablated patients were compared with the 582 who received antiarrhythmic medications for SR control. The QoL of 109 ablated and 102 medically treated patients was measured with the SF-36 survey. RESULTS Median follow-up was 900 days (range 161 to 1,508 days). Kaplan-Meier analysis showed observed survival for ablated patients was longer than among patients treated medically (p < 0.001), and not different from that expected for healthy persons of the same gender and calendar year of birth (p = 0.55). Cox proportional-hazards model revealed in the ablation group hazard ratios of 0.46 (95% confidence interval [CI], 0.31 to 0.68; p < 0.001) for all-cause mortality, of 0.45 (95% CI, 0.31 to 0.64; p < 0.001) for morbidities mainly due to heart failure and ischemic cerebrovascular events, and of 0.30 (95% CI, 0.24 to 0.37; p < 0.001) for AF recurrence. Ablated patients' QoL, different from patients treated medically, reached normative levels at six months and remained unchanged at one year. CONCLUSIONS Pulmonary vein ablation improves mortality, morbidity, and QoL as compared with medical therapy. Our findings pave the way for randomized trials to prospect a wider application of ablation therapy for AF.

Las declaraciones de conflicto de intereses de los expertos participantes en el desarrollo de esta guía están disponibles en la página web de la esc: http://www.escardio.org/guidelines.

Left atrial ablation with bipolar radiofrequency using the epicardial approach is described. After dissection of the pericardial reflections and of the Marshall fold, electrical isolation of the right and left pulmonary veins and that of the left appendage are carried out through epicardial ablation. After aortic cross clamping, through standard atriotomy, the connecting lines are then performed. The possible options for the mitral connecting ablation are discussed. At completion of the ablation procedure the base of the left appendage is sutured from inside.

Electrophysiological efficacy equals the creation of block across the ablations. Here, although exit block and pacing validation are clearly mentioned in the methods: ‘After all ablation lines are created, the integrity of the lesions can be evaluated by placing a pacing lead on the right superior pulmonary vein outside (distal to) the line of ablation. Exit block is verified by the inability to capture the heart while pacing at 15 mA. If exit block has not been obtained, the ablations are re-evaluated and suspicious areas are reablated’, they are nowhere to be found in the results.

BACKGROUND The extent to which atrial myocardium is remodeled in patients with persistent lone atrial fibrillation (LAF) is largely unknown. OBJECTIVE The purpose of this study was to perform a clinicopathologic investigation in patients with persistent LAF. METHODS We characterized structural and molecular remodeling in atrial biopsies from 19 patients (17 males, mean age 49 years) with persistent (> 7 days; n = 8) or long-lasting persistent (> 1 year; n = 11) LAF who underwent surgical ablation. Atrial tissue from 15 autopsy samples without clinicopathologic evidence of heart disease served as controls. RESULTS Morphometric analysis showed cardiomyocyte hypertrophy and greater amounts of myolytic damage and interstitial fibrosis in persistent LAF patients compared to controls (P

The aim of this study is to evaluate the mid-term clinical and functional outcomes of maze surgery in symptomatic refractory lone atrial fibrillation (AF) patients. Between March 2008 and January 2013, 39 highly symptomatic patients [mean age 51 +/- 10 (mean +/- standard deviation); 95% CI, European Heart Rhythm Association class III-IV] underwent maze surgery for lone AF. Biatrial ablations were performed with bipolar radiofrequency and cryoenergy, according to a maze III lesion set (modified by omitting the intercaval line in 5 of 39 patients). Mean ejection fraction was 51 +/- 9% (range 17-60), < 45% in 10 patients (26%). Seventeen of 39 patients (44%) had persistent, 22 of 39 patients (56%) long-standing persistent AF, and 35 of 39 patients (90%) had previous transvenous ablations (median = 2; range 0-8). No patient had concomitant structural heart disease. A minimally invasive approach was adopted in 22 patients (56%). Major complications were 1 mediastinitis, 1 re-exploration for bleeding and 2 pacemaker (5%) implantation. At a mean follow-up of 29.4 +/- 14.2 months, freedom from arrhythmias was 92 and 93% at 24 and 36 months, respectively. Freedom without antiarrhythmic drugs was 75 and 85% at 24 and 36 months, respectively. Ejection fraction normalized in all cases, from 51.3 +/- 9% to 61.1 +/- 3% (P < 0.001) overall, and from 37.0 +/- 10% to 60.3 +/- 3% (P < 0.001) when a parts per thousand currency sign45% preoperatively. AF-related symptoms score decreased to class I in 36 patients (93%). No early or late stroke occurred. Within a dedicated AF centre, maze surgery grants excellent outcomes, with symptoms relief and negligible risk. It provides a complete reversal of arrhythmia-related myocardial dysfunction and is therefore a convenient alternative to His bundle ablation and lifelong pacemaker dependency in symptomatic refractory patients.

A 72-year-old patient with atrial fibrillation and high-grade AV block on pacemaker was admitted with new-onset hemiparesis. His initial cranial CT was normal. Within 1 day his mental status deteriorated; he was diagnosed with upper GI bleeding and developed fever and haemodynamic instability. Blood cultures grew streptococci within 24 h. Transoesophageal …

"OBJECTVIS: Clinical success of atrial fibrillation (AF) ablation depends on persistent blocking of electrical conduction across the ablation lines. Epicor high-intensity focused ultrasound (HIFU) ablation has been credited with a variable clinical efficacy. The aim of this work is to ascertain the electrophysiological (EP) efficacy of such lesions, by assessing pulmonary vein isolation (PVI) after open chest HIFU ablation, in the clinical setting.. METHODS:. Ten consecutive mitral patients (mean age: 57±10 years) with paroxysmal AF undergoing concomitant ablation with the Epicor ablation system (St. Jude Inc.®, Minneapolis, MN, USA) were enrolled for EP assessment. During surgery, pairs of additional temporary wires were positioned on the right PVs (RPVs) and on the roof of the left atrium (RLA), before epicardial ablation. Exit block (no capture during PV pacing) of RPV and of RLA was assessed before, after ablating and immediately after closure of the chest, in order to check the correct positioning of the wires. EP assessment was repeated before discharge and at 3 weeks.. RESULTS:. Baseline RPV pacing threshold (PT) was 3.5±2 mA (range 1.5-8), of RLA 1.73±1.1 mA (range 0.7-4.3 mA). PVI was not reached any time after HIFU ablation. At the pre-discharge EP study, the absence of isolation was observed in all cases. At 3 weeks, the PTs were 6.8±5.8 mA on RPV (range 2-16) and 6.4±5.3 mA (range 1-19) on RLA. All patients were discharged in sinus rhythm.. CONCLUSIONS:. PVI was not achieved after Epicor HIFU ablations, up to 3 weeks after surgery."