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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.

A 46-year-old woman known with relapsing Hodgkin's lymphoma diagnosed at age 5, treated with repeated cycles of radiotherapy and chemotherapy, presented with severe symptomatic radiation-induced aortic stenosis. She also had other late sequelae of radiotherapy including thyroid cancer, mediastinal fribrosis and left pulmonary fibrosis with severe restrictive lung disease and a newly diagnosed renal carcinoma. Due to the prohibitively high surgical risk and need for urgent treatment, she underwent successful transcatheter aortic valve replacement with transfemoral implantation of a 23 mm Edwards SAPIEN-XT prosthesis, which was performed without valvuloplasty of the noncalcified fibrotic valve. The final result was excellent with reduction of the transaortic gradient and no residual aortic regurgitation.

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.

Focal atrial tachyardia constitutes more than 10% of the supraventricular tachycardias and it could be responsible for the initiation of other atrial arrhythmias, like atrial fibrillation and atrial flutter. Frequently, the focal atrial tachycardia does not respond to the medical treatment, while a definitive cure is often obtained with radiofrequency transcatheter ablations and integrated minimally-invasive approaches (atrial appendage clip). This paper describes physiopathological mechanisms underlying the focal atrial tachycardia, its anatomical localizations, the clinical patterns and the fundamentals of the diagnosis. Finally, the more recent treatment strategies will be illustrated and discussed.

Introduction: Atrial fibrillation (AF) in mitral regurgitation (MR) is a complex disease where multiple factors may induce left-atrial structural remodeling (SR). We explored the differential SR of the left-atrial posterior wall (LAPW) of patients affected by MR with or without persistent AF, and the expression of key proteins involved in its pathogenesis., Methods and Results: Light microscopy of LAPW samples from 27 patients with MR and persistent AF (group 1), 33 with MR in sinus rhythm (group 2), and 15 autopsy controls (group 3) was used to measure myocyte diameter, percentage of myocytolytic myocytes, interstitial fibrosis, and capillary density; RT-PCR and Western blotting were used to assess the mRNA and protein levels of SOD-1, SOD-2, HO-1, calpain, MMP-2, MMP-9, TIMP-1, TIMP-2, and VEGF; immunofluorescence was used to locate these proteins. Myocyte diameter was similar in groups 1 and 2, but larger than controls. Compared to group 2, group 1 had more myocytolytic myocytes (20.8 ± 5.6% vs 14.7 ± 4.5%; P < 0.0001), increased interstitial fibrosis (10.4 ± 5.1% vs 7.5 ± 4.2%; P < 0.05), and decreased capillary density (923 ± 107 No/mm(2) vs 1,040 ± 100 No/mm(2); P < 0.0001). All of the proteins were more expressed in groups 1 and 2 than in controls. The protein and mRNA levels of SOD-1, SOD-2, MMP-2, and MMP-9 were higher in group 1 than in group 2., Conclusions: The LAPW of MR patients with or without AF shows considerable SR. The former has more severe histopathological changes and higher levels of proteins involved in SR, thereby reaching a threshold beyond which the sinus impulse cannot normally activate atrial myocardium., (© 2011 Wiley Periodicals, Inc.)

Background: The present study was aimed at determining the impact of type 2 diabetes mellitus (DM) on postoperative bioprosthetic structural valve degeneration., Methods and Results: Twelve Italian centers participated in the study. Patient data refer to bioprosthetic implantations performed from November 1988 to December 2009, which resulted in 6184 patients (mean age 71.3±5.4 years, 60.1% male) being enrolled. Of these patients, 1731 (27.9%) had type 2 DM. The propensity score-matching algorithm successfully matched 1113 patients with type 2 DM with the same number of no-DM patients. The postmatching standard differences were less than 0.1 for each of the covariates, and 64.2% of DM patients were matched. The early (30 days) mortality rate was 7.8% (n=87) versus 2.9% (n=33) in patients with or without type 2 DM (P<0.001), respectively. Seven-year freedom from valve deterioration was significantly lower in patients with DM (73.2% [95% confidence interval, 61.6-85.5] versus 95.4% [95% confidence interval, 83.9-100], P<0.001). In Cox regression models with robust SEs that accounted for the clustering of matched pairs, DM was the strongest predictor of structural valve degeneration (hazard ratio 2.39 [95% confidence interval 2.28-3.52]). When we allowed for interaction between type 2 DM and other key risk factors, DM remained a significant predictor beyond any potentially associated variable., Conclusions: Patients with type 2 DM undergoing bioprosthetic valve implantation are at high risk of early and long-term mortality, as well as of structural valve degeneration.

Blood cysts of the mitral valve are mostly benign diverticuli lined by endothelium and filled with blood and can be safely monitored with echocardiographic follow-up. We report a case of asymptomatic blood cyst of the mitral valve in a 63-year-old woman referred for a systolic murmur. At 3-year echo follow-up, the patient is free from notable clinical events.

The mitral-aortic intervalvular fibrosa (MAIF) is involved in the functional integrity of the two valves. We discuss the clinical decision-making in a population with MAIF pseudoaneurysms following valve replacement surgery. From 2003 to 2010, 16 patients (age 65 ± 17 years) were referred to our institute with worsening valvular disease. All the patients had undergone previous aortic or mitral valve replacement surgery. Transthoracic and transesophageal echocardiography was performed in these patients. According to the echocardiographic findings, we described two groups of patients with MAIF pseudoaneurysms: group 1 (seven patients) without previously known infective disease, and group 2 (nine patients) with a medical history of endocarditis. For asymptomatic patients without an infective background or valve regurgitation (group 1), clinical and echocardiographic follow-up was selected. Reintervention was planned for postinfection pseudoaneurysms (group 2), on account of the residual paravalvular leak and the high-risk of MAIF rupture. The case series emphasizes the need for more awareness about MAIF pseudoaneurysms, rare complications of aortic and mitral valve surgery, which occur far more frequently than expected. Although clinical decision-making is debatable, it may be helpful to differentiate patients into those with or without previous endocarditis, and according to heart failure symptoms.

We describe a modification of the Cox-Maze III using bipolar radiofrequency combined with off-pump coronary artery surgery for the treatment of patients with coronary artery disease and long-standing permanent atrial fibrillation. This study reports the midterm outcome of 12 patients with coronary artery disease and long-standing permanent atrial fibrillation who underwent off-pump coronary artery surgery and concomitant modified Maze with bipolar radiofrequency. At a mean follow-up of 23 months, all patients were alive, and 75% (9 of 12) had sinus rhythm. Our modified Maze can be safely and effectively combined with coronary artery surgery in an off-pump setting., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The aim of the study was to evaluate the additional diagnostic value of real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) for surgically recognized mitral valve (MV) prolapse anatomy compared to 2-dimensional transthoracic echocardiography (2D-TTE), 2D-transesophageal echocardiography (2D-TEE), and real-time 3D-transthoracic echocardiography (RT3D-TTE). We preoperatively analyzed 222 consecutive patients undergoing repair for prolapse-related mitral regurgitation using RT3D-TEE, 2D-TEE, RT3D-TTE, and 2D-TTE. Multiplanar reconstruction was added to volume-rendered RT3D-TEE for quantitative prolapse recognition. The echocardiographic data were compared to the surgical findings. Per-patient analysis of RT3D-TEE identified prolapse in 204 patients more accurately (92%) than 2D-TEE (78%), RT3D-TTE (80%), and 2D-TTE (54%). Even among those 60 patients with complex prolapse (>1 segment localization or commissural lesions), RT3D-TEE correctly identified 58 (96.5%) compared to 42 (70%), 31 (52%), and 21 (35%) detected by 2D-TEE, RT3D-TTE, and 2D-TTE (p < 0.0001). Multiplanar reconstruction enabled RT3D-TEE to differentiate dominant (≥5-mm displacement) and secondary (2 to <5-mm displacement) prolapsed segments in agreement with surgically recognized dominant lesions (100%), but with a low predictive value (34%) for secondary lesions. In addition, owing to the identification of clefts and subclefts (indentations of MV tissue that extended ≥50% or <50% of the total leaflet height, respectively), RT3D-TEE accurately characterized the MV anatomy, including that which deviated from the standard nomenclature. In conclusion, RT3D-TEE provided more accurate mapping of MV prolapse than 2D imaging and RT3D-TTE, adding quantitative recognition of dominant and secondary lesions and MV anatomy details., (Copyright © 2011 Elsevier Inc. All rights reserved.)

We report how to perform a complete open-heart ablation with bipolar radiofrequency through a transseptal incision. The connecting left atrial lines were performed by inserting one jaw of the clamp through a stab wound in the posterior left atrium, beneath the right inferior pulmonary vein. Twenty-five patients underwent concomitant ablation with the described technique in three different centers. All the left lines were easily performed. No ablation-related complication occurred. At 11 +/- 6 months, 80% of the patients were free from arrhythmias., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery, occurring in 20% to 60% of patients. Advanced age, history of atrial fibrillation (AF), heart failure, peripheral arterial disease and chronic obstructive pulmonary disease are predictors of POAF. The pathogenesis of AF seems to be multifactorial, and includes electrical and structural remodeling as well as inflammation (a systemic response caused by cardiopulmonary bypass and cardiotomy). Numerous pharmacologic agents can decrease the incidence of POAF. It is also necessary to evaluate an agent's ability to decrease stroke, mortality, length of stay and hospital costs. Currently, the use of beta-blockers with adjunctive amiodarone has been shown to reduce POAF and several of its complications. Two therapeutic choices exist in patients with POAF: rate control and rhythm control. The decision which is more important to target should be based on the symptoms of the individual patient. Unlike in patients with chronic AF, POAF is generally transient, and the risks of anticoagulation may outweigh the benefits. Surgical ablation techniques and ablation devices have progressed considerably. This made the procedures quicker and simpler, and therefore feasible in virtually all clinical contexts. In turn, this has raised the issue of post-ablation arrhythmias. Although relapsing AF is generally addressed conservatively, it may require ablation, frequently transseptal. Further research is needed to identify the predictors of POAF and the most effective pharmacological and invasive methods for the prevention and treatment of POAF.

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., (2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

The authors report two cases of unexplained active inflammatory endocarditis with totally different clinical presentations. The patients had undergone previous mitral repair surgery and were referred for multiple soft mobile masses on the mitral ring without clinical or laboratory signs of endocarditis. Serologic screening and blood culture results were negative, including those for specific fastidious bacteria, as well as immunologic tests to rule out "nonbacterial thrombotic endocarditis." Before new surgery, both patients were treated with long-term antibiotic and anticoagulant therapy, with no significant changes in clinical setting and echocardiographic patterns. In neither case was it possible to characterize a specific microorganism: the intraoperative findings were highly evocative of active endocarditis with a macroscopic infiltration of the mitral ring, and culture results from surgical material and valvular tissue were negative., (Copyright 2010 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.)

Here we report the description of a simple, safe and reproducible technique to perform a complete biatrial set of lines, entailing left and right isthmus lines, using bipolar radiofrequency as a solo modality or in combination with cryoenergy.

Purpose: Although it is deemed important, right atrial ablation is not considered feasible with bipolar radiofrequency alone. Normally, unipolar devices are used to complete the tricuspid connecting lines. We describe a simple technique to achieve a complete maze-like set of right ablations using a standard bipolar radiofrequency device., Description: Thirty-four patients underwent concomitant ablation with a right set of lines performed using bipolar radiofrequency only. The epicardium adjacent to the right atriotomy was entered and after separating the sulcus fat from the atrial wall, the deepest portion of the atrioventricular groove was developed bluntly with the scissors down to the tricuspid annulus. The tricuspid connecting lines were then performed with bipolar radiofrequency in an endo-epicardial fashion., Evaluation: No ablation-related complications occurred. No patient died. Three patients required pacemaker implantation. At a mean follow-up of 8 +/- 5, 85% of the patients were free from arrhythmias. At 6 months 20 of 24 patients (83%) were in stable sinus rhythm., Conclusions: All the maze III right atrial ablations can be performed using a bipolar radiofrequency device alone. The procedure is safe and easily reproducible on a regular basis.

Atrial fibrillation occurs and maintains itself in the context of a morphologically and functionally altered atrial substrate that can be induced by stressors such as underlying diseases (cardiac or noncardiac) or aging. The resultant structural remodeling is a slow process that progressively affects myocytes and the myocardial interstitium, and takes place from as early as the first days of atrial tachyarrhythmia. The left atrium, and particularly its posterior wall, is the location where remodeling is concentrated to the greatest extent. The mechanisms that underlie the remodeling process in atrial fibrillation have not yet been completely elucidated, although experimental and clinical investigations have indicated a number of signaling systems, inflammation, oxidative stress, atrial stretching and ischemia as factors involved in the cascade of events that leads to atrial fibrillation. The aim of this Review is to provide a comprehensive overview of the morphological changes that characterize the fibrillating atrial myocardium at histological and ultrastructural levels, and the established and hypothetical pathogenetic mechanisms involved in structural remodeling. This article also highlights the emerging therapies being developed to prevent progression of atrial fibrillation.

Atrial fibrillation becomes a self-perpetuating arrhythmia as a consequence of electrophysiologic and structural remodeling involving the atrium. Oxidative stress may be a link between this rhythm disturbance and electrophysiologic remodeling. The aim of this study was to evaluate whether the heme oxygenase-1 (HO-1) marker of oxidative stress was more expressed in left atrial sites with stronger structural remodeling in patients affected by chronic atrial fibrillation (CAF) and mitral valve disease (MD). Myocardial samples were taken from the left atrial posterior wall (LAPW) and left atrial appendage (LAA) of 24 patients with CAF-MD in addition to 10 autopsy controls. The levels of HO-1 messenger RNA (mRNA) and HO-1 protein in each pathologic LAPW and LAA were quantified using reverse transcriptase polymerase chain reaction and enzyme-linked immunosorbent assay. Furthermore, light microscopy was used to morphometrically evaluate the differential myocyte and interstitial changes in the same CAF-MD LAPW and LAA samples. In controls, HO-1 protein was quantified using enzyme-linked immunosorbent assay. Unlike controls, patients with CAF-MD had higher levels of HO-1 mRNA and its protein product, expressed as LAPW/LAA ratios, in the LAPW (2.18 +/- 1.18, P < .0001, and 1.55 +/- 0.67, P < .005), and their LAPW also showed greater histologic changes in myocytolytic myocytes (15.1% +/- 3.1% versus 6.9% +/- 3.3%, P < .0001), interstitial fibrosis (8.2% +/- 2.2% versus 2.8% +/- 1.2%, P < .0001), and capillary density (816 +/- 120 number/mm(2) versus 1114 +/- 188 number/mm(2); P < .05). In addition, markers of oxidative stress were immunohistochemically studied with antinitrotyrosine and anti-iNOS antibodies. In patients with CAF-MD, the inducible enzyme HO-1 is more expressed in the left atrial areas that show greater structural remodeling. This finding strongly suggests a pathogenetic relationship between oxidative stress and the degree of histologic change.

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 euro vs 2403+/-17 euro; 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.

Objective: Some patients submitted to cardiac surgery have concomitant atrial fibrillation and a previously implanted pacemaker. Because it is unknown if there is any potential for these patients to reassume a regular rate sinus rhythm after ablation of atrial fibrillation, we reviewed the results of all patients with pacemaker enrolled in the Registry of Atrial Fibrillation., Materials: Thirty-six patients were included in this study. Twenty-six had valve disease, seven had coronary disease and three had congenital heart disease. They were submitted concomitantly to ablation of atrial fibrillation using biatrial approaches (seven patients), left sided (27), or right sided (three patients). Thirty-three hospital survivors had a mean follow-up of 18 months, and a maximum of 25 months., Results: At 1 year (n=21), patients' rhythm was sinus non-pacing dependent (52%), sinus pacing-dependent (14%), and atrial fibrillation (14%). At 2 years (n=14), patients' rhythm was sinus non-pacing dependent (57%) and atrial fibrillation (43%). The only factor that may have had impact on the recovery of sinus rhythm at 1 year was the small size of the left atrium (p=0.05)., Conclusions: We conclude that in a significant number of patients, having a pacemaker before surgery does not preclude sinus rhythm recovery after a cardiac operation and ablation for concomitant atrial fibrillation.

Objectives: We sought to assess the clinical and survival benefit of atrial fibrillation surgery in patients submitted to mitral valve surgery after stabilization of postoperative rhythm at 1 year., Methods: One thousand seven hundred twenty-three patients were enrolled. Patients with follow-up of longer than 1 year (n = 972) were divided into 3 groups according to surface electrocardiographic rhythm during follow-up visits: stable sinus rhythm, stable atrial fibrillation, and intermittent rhythms. Adverse cardiac event incidence and predictors of long-term outcome were compared among the 3 groups., Results: In-hospital mortality was 2.6%. Risk factors for mortality were the cut-and-sew technique (odds ratio, 8.92; 95% confidence interval, 1.71-46.50; P = .009) and isolated left atrial procedure (odds ratio, 0.16; 95% confidence interval, 0.04-0.56; P = .004). At 1 year, 63.4% patients were in stable sinus rhythm. Stable sinus rhythm was found to be associated with early and late survival (P = .01, log-rank analysis). Multivariate binary logistic regression analysis found that left atrial dimension (odds ratio, 0.97; 95% confidence interval, 0.96-0.99; P = .005) and concomitant coronary revascularization (odds ratio, 0.48; 95% confidence interval, 0.25-0.92; P = .027) were independent predictors of stable sinus rhythm at 1 year after surgical intervention. At 48 months' follow-up, predictors for stable sinus rhythm were biatrial surgical approach and absence of preoperative permanent atrial fibrillation (odds ratio, 3.56; 95% confidence interval, 1.62-7.83; P < .002). Left atrial size (each millimeter) has a borderline statistical significance (odds ratio, 0.97; 95% confidence interval, 0.93-1.00; P = .065). Thromboembolic events were found to be associated with absence of stable sinus rhythm (P = .010, log-rank analysis)., Conclusions: The achievement of stable sinus rhythm is a predictor of better survival and lower incidence of thromboembolic events. Predictors of stable sinus rhythm were smaller dimensions of the left atrium, biatrial approach, absence of preoperative permanent atrial fibrillation, and absence of concomitant coronary artery bypass grafting.

A suction device, currently used to lift the heart in off-pump coronary surgery, was used to facilitate an extraanatomic bypass grafting procedure in a patient with recoarctation of the aorta, hypoplasia of the aortic arch, and dilatation of the ascending aorta.

Congestive heart failure is a major public health problem in western countries. Although substantial efforts have been made in the last decades in the prevention, diagnosis and treatment of cardiovascular disease, the incidence of end-stage dilated cardiomyopathy is still increasing. Heart transplantation represents the most effective therapy in this setting, but due to shortage of donors, it remains a realistic option just for a very small number of patients. Therefore, conventional surgical treatment for end-stage heart disease has gained increasing attention in recent years and a variety of surgical interventions have been improved or optimized to manage the multifactorial pathophysiology of the heart failure picture. The aim of this review is to report our experience with more than 500 patients with advanced dilated cardiomyopathy, treated with conventional surgical procedures such as myocardial revascularization, left ventricular restoration, mitral valve repair and surgical ablation of atrial fibrillation. Indications, results, controversial issues and future perspectives will be discussed.

It has been found that the pulmonary veins and adjacent left atrial posterior wall (LAPW) are deeply involved in both the initiation and maintenance of atrial fibrillation (AF), and the identification of these high-risk sites has aroused great interest in investigating their histopathologic substrate. We used light and conventional electron microscopy to evaluate the differential myocyte and interstitial changes in LAPW and left atrial appendage (LAA) samples from 28 patients with chronic AF undergoing mitral valve surgery and from 12 autoptic controls. There were always more myocytes with loss of sarcomeres in the LAPW than in the LAA (19.9% +/- 7.7% versus 8.2% +/- 5.0%; P < .0001), and the LAPW showed more marked immunohistochemical evidence of dedifferentiation, characterized by the reexpression of smooth muscle actin. In pathological left atria, myocyte diameter in the LAPW and LAA was comparable (19.0 +/- 1.5 versus 18.5 +/- 2.0 microm; not significant) but larger than in the controls (11.9 +/- 0.8 and 12.1 +/- 1.3 microm, respectively; P < .0001). A terminal deoxynucleotidyltransferase assay did not reveal any myocyte apoptosis. The LAPW also showed more interstitial fibrosis than the LAA (7.49% +/- 3.34% versus 2.80% +/- 1.35%; P < .0001). Ultrastructural examination confirmed the presence of myocyte myocytolysis in the perinuclear area and showed changes in mitochondrial shape. In conclusion, the LAPW in patients with chronic AF related to mitral valve disease seems to be a particular anatomical site in which major myocyte and interstitial changes are concentrated, whereas the LAA is more protected. This remodeling may increase the heterogeneity of LAPW electrical conduction, thus confirming this location as an elective target for the ablation treatment of AF.

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.

All patients undergoing heart surgery experience a certain amount of nonspecific myocardial injury documented by the release of cardiac biomarkers and associated with poor outcome. We investigated the role of unipolar radiofrequency ablation of atrial fibrillation on the release of cardiac biomarkers in 71 patients undergoing mitral valve surgery and concomitant left atrial ablation case-matched with 71 patients undergoing isolated mitral surgery. The study was powered to detect a 3 ng/mL difference. There was no difference between the 2 groups in terms of cardiac troponin I (10 +/- 5.3 versus 12 + 10.4 ng/mL; P = 0.7) or creatine kinase-MB (50 +/- 21.8 versus 57 +/- 62.0 ng/mL; P = 0.5) release. Postoperative peak cardiac troponin I levels had univariate associations with the duration of cardiopulmonary bypass (P = 0.002) and aortic cross-clamping (P = 0.001) and with the surgical technique (15 +/- 12 ng/mL for mitral valve replacement versus 9 +/- 4.8 for mitral valve repair; P = 0.0007) at univariate analysis. Mitral valve replacement was the only independent predictor of postoperative peak release of cardiac troponin I identified with multivariate analysis (P = 0.005). Radiofrequency ablation of atrial fibrillation does not significantly increase cardiac biomarker release compared with isolated mitral surgery; mitral valve repair is associated with less release of cardiac biomarkers compared with mitral valve replacement.

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.

In recent years, the interest towards non-pharmacological treatment of atrial fibrillation has dramatically increased. Less invasive left atrial approaches are today widely adopted in cardiac surgery, mainly for concomitant treatment of secondary AF. Epicardial ablation, especially with the latest generation devices, has rendered most of the ablation feasible off pump, on the beating heart, thus opening the way to minimally invasive and thoracoscopic developments. In the meantime, percutaneous procedures have been greatly refined. Complete left lesion sets similar to those performed surgically are today feasible with good clinical results. Presently, even if percutaneous approaches seem more suitable as a first-line treatment for lone AF, surgical ablation is proving useful in a growing number of patients. It is possible to envision a stronger role of surgery in patients with lone AF refractory to percutaneous ablation or in those with a higher thromboembolic risk.

Objective: Atrial fibrillation is the most common complication after coronary artery bypass graft surgery. This arrhythmia may lead to hemodynamic compromise, prolonged hospitalization, and increased risk for cerebral thromboembolism. Older age is the only variable consistently associated with the development of postoperative atrial fibrillation; however, no strong predictive model exists. The purpose of this study was to identify perioperative characteristics associated with new-onset atrial fibrillation in patients undergoing off-pump coronary artery bypass grafting., Design: Prospective, observational., Setting: University tertiary care hospital., Participants: One hundred sixty consecutive patients undergoing off-pump coronary artery bypass grafting., Interventions: None., Measurements and Main Results: Incidence of postoperative atrial fibrillation was the major outcome. Atrial fibrillation occurred in 33 patients (20.6%). Multivariate analysis identified reintervention (odds ratio 26.8), revascularization of the ramus medianus (odds ratio 3.9), and age (odds ratio 1.069 per year) as the only independent predictors of postoperative atrial fibrillation. All patients were in sinus rhythm at hospital discharge. One hospital death was noted., Conclusions: Despite the less invasive approach, the incidence of postoperative atrial fibrillation is high after off-pump coronary artery bypass grafting. Older age, grafting of the ramus medianus, and a redo operation were predictors of new-onset postoperative atrial fibrillation. It is possible that left atrial stretching with heart dislocation during revascularization of the lateral wall could lead to postoperative atrial fibrillation.

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: Bleeding and inflammation are major complications of extracorporeal circulation. Off-pump coronary artery bypass grafting may reduce the rate of complications, but it can only be applied in selected cases. Pilot studies have shown a potential benefit from the use of antifibrinolytic drugs, but efficacy in randomized double-blind studies evaluating off- and on-pump coronary artery bypass grafting has not been proved., Methods: We enrolled 102 patients scheduled for on-pump (n = 51) or off-pump (n = 51) coronary artery bypass grafting. Patients were separately double-blind randomly assigned to treatment with tranexamic acid (1 g as 20-minute bolus before skin incision, followed by continuous infusion of 400 mg/h, with 500 mg added to priming in patients undergoing on-pump coronary artery bypass grafting) or placebo (saline solution of equivalent volume). Bleeding in the first 24 postoperative hours was the primary outcome. Requirement for allogeneic transfusions, thrombotic complications, outcomes, and monitoring of coagulation, fibrinolysis, and inflammation were also recorded., Results: Tranexamic acid reduced total postoperative bleeding by 43% in patients undergoing on-pump coronary artery bypass grafting and by 27% in those undergoing off-pump coronary artery bypass grafting (P <.0001), with 80% reduction in bleeding exceeding 600 mL (P <.001), 58% reduction in the requirement for all allogeneic transfusions (P =.07), and no apparent effect on thrombotic complications or outcome. This was associated with a reduction in plasma D-dimer levels (P <.0001), to a greater degree in patients undergoing on-pump coronary artery bypass grafting (P <.0001), and interleukin 6 levels (P <.0001), to a greater degree in patients undergoing off-pump coronary artery bypass grafting (P <.001)., Conclusions: By affecting fibrinolysis, tranexamic acid significantly reduces bleeding both in off- and on-pump coronary artery bypass grafting and may modulate inflammation in these surgical settings.

Background: Radiofrequency ablation for atrial fibrillation is becoming widely practiced., Methods and Results: Two patients undergoing circumferential pulmonary vein ablation for atrial fibrillation in different centers developed symptoms compatible with endocarditis 3 to 5 days after the procedure. Their clinical condition deteriorated rapidly, and both suffered multiple gaseous and/or septic embolic events causing cerebral and myocardial damage. One patient survived after emergency cardiac and esophageal surgery; the other died of extensive systemic embolization. An atrio-esophageal fistula was identified in both patients., Conclusions: Atrio-esophageal fistulas can occur after catheter ablation in the posterior wall of the left atrium. This diagnosis should be excluded in any patient with symptoms or signs of endocarditis after left atrial ablation, and expeditious cardiac surgery is critical if the diagnosis is confirmed. Lower power and temperature settings for applications of radiofrequency energy along the posterior left atrial wall may prevent further cases of fistula formation.

The prevalence of ischemic dilated cardiomyopathy in western countries is increasing despite improvements in prevention, diagnosis, and treatment of cardiovascular disease. The management of patients with coronary artery disease and severe left ventricular dysfunction continues to be challenging and the mortality rate with medical therapy alone in this setting remains very high. Since heart transplantation represents a realistic option just for a very small number of patients, in recent years a variety of classic surgical interventions have been improved or optimized to address the complex and multifactorial pathophysiology of the ischemic heart failure picture. Myocardial revascularization, left ventricular restoration, mitral valve repair, passive containment device implantation, and surgical ablation of atrial fibrillation represent some of the "conventional" procedures which are currently in use or under development for the surgical treatment of ischemic cardiomyopathy. For several of them, the exact indications and results are not yet established and significant changes and improvements should reasonably be waited over the next few years. As techniques are refined and more data become available, the optimum surgical strategy for patients with advanced ischemic heart failure is likely to become clearer and more effective.

Unlabelled: We evaluated the blood-sparing effects of intraoperative moderate acute normovolemic hemodilution (ANH) combined with intraoperative tranexamic acid treatment and shed blood reinfusion in patients undergoing off-pump coronary artery bypass (OPCAB). One-hundred consecutive OPCAB patients (baseline hematocrit >34%) were prospectively randomized to tranexamic acid treatment (control group; 50 patients) or to tranexamic acid treatment plus normovolemic (1:1 replacement with colloids) withdrawal of 17% +/- 2% of the circulating blood volume (ANH group; 50 patients). All patients had shed blood reinfused with intraoperative bleeding in excess of 250 mL. The requirement for allogeneic transfusions, based on strict a priori defined criteria, was the primary end point of the study. Hematochemical evaluations, bleeding, major complications, and other outcomes were also recorded. Demographics, baseline hematochemical data, and operative characteristics were similar in the two groups. Patients in the ANH group had a median of 850 mL of blood withdrawn and showed a lower intraoperative minimum hematocrit (31% vs 37%; P < 0.0001). Two patients in the ANH group versus 10 patients in the control group (odds ratio, 0.17; 95% confidence interval, 0.03-0.89; P = 0.028) required transfusion of a significantly smaller number of packed red blood cell units (5 vs 24; P < 0.001). Postoperative hematochemical variables, bleeding, and outcomes were similar in the two groups of patients. Moderate ANH, combined with tranexamic acid administration and on-demand shed blood reinfusion, may reduce allogeneic transfusion requirements in OPCAB patients., Implications: We studied the blood-sparing effects of moderate acute normovolemic hemodilution (ANH) in 100 patients undergoing off-pump coronary surgery (OPCAB). Combined with tranexamic acid administration and shed blood reinfusion when the intraoperative bleeding exceeded 250 mL, ANH was effective in reducing the number of OPCAB patients who required allogeneic transfusions and the number of packed red blood cell units transfused.

Background: In recent years left atrial approaches have become popular because of technical simplicity, reproducibility and minor surgical trauma compared to the standard maze procedure. We analysed mid-term results of intraoperative left radiofrequency ablation of atrial fibrillation., Methods: From February 1998 to August 2002, 206 patients (mean age 59.1 +/- 10.2 years) scheduled for open-heart surgery underwent combined treatment of atrial fibrillation at our Institution. In 163 patients (79.1%) a standard left epicardial approach was performed while 43 patients (20.9%) needed a totally endocardial approach., Results: All patients but 3 underwent mitral valve surgery (104 repair and 99 replacement). Hospital mortality was 1.9%. Actuarial freedom from atrial fibrillation was 78% at 2 years and 74% at 4 years. At 4 years survival was 94% and freedom from neurological events was 98%. All patients with stable sinus rhythm 3 months after surgery recovered biatrial contractility., Conclusions: Left radiofrequency ablation of atrial fibrillation is effective in restoring sinus rhythm and normal atrial function. Combined atrial fibrillation treatment should be considered in all patients undergoing open-heart surgery.

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.

Atrial fibrillation ablation surgery has grown very popular in recent years. Modern techniques involve creation of linear scars on the left atrial wall using different ablation devices. That raises the concern about new major surgical complications that can be caused by the ablation procedure. Postablation coronary obstruction and esophageal injury have been described. We report our present strategy for left atrial ablation in which the lesion set is tailored to the specific coronary anatomy. Safeguards to prevent esophageal and bronchial injury are also outlined.

In recent years, the popularity of simplified intraoperative ablation approaches to treat atrial fibrillation (AF) has been progressively increasing. Our group has described a left atrial procedure based on epicardial radio frequency ablation on cardiopulmonary bypass (CPB). We report our CPB and myocardial protection strategy in 157 patients who underwent AF ablation combined with open-heart surgery from February 1998 to February 2002. Since epicardial ablations are performed on CPB on the beating heart, the CPB strategy is crucial. Total normothermic CPB allows a safe dissection around the pulmonary veins on the decompressed heart; after the ablating catheter has been positioned, an adequate filling of the left atrium favours a uniform contact with the atrial wall. After crossclamping, low-flow retrograde cardioplegia delivery is administered while ablating endocardially to protect the main coronary arteries in the atrio-ventricular groove from radio frequency-related trauma. All patients were successfully weaned from CPB. Sinus rhythm was restored in 152 of 157 (96.8%) patients immediately after surgery. No procedure-related complications were recorded. Epicardial ablations allowed us to reduce significantly the aortic crossclamping time required for ablations. The conduct of CPB and myocardial protection play a central role in the surgical strategy by improving intraoperative feasibility and effectiveness of radio frequency ablation and preventing some of the potential postoperative complications related to the procedure.