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Concomitant surgery for atrial fibrillation is a conceptually and clinically difficult area of cardiac surgical decision making. This review introduces the pathophysiological background, provides insight and guidance for cardiac surgeons on some of the conflicting evidence and claims, and explores the fields in which further research may help elucidate a cardiac surgical clinical strategy for tackling this common and potentially lethal form of arrhythmia. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Risks of cardiac surgery in patients with poor [ejection fraction (EF) ≤ 30%] and very poor left ventricular (LV) function (EF ≤ 20%) may be considered high due to increased mortality. We examine our results in this cohort of patients. METHODS: Data were prospectively collected and retrospectively analysed from 4491 consecutive patients referred for cardiac surgery over 18 years ( July 1993-June 2012). Univariate predictors of in-hospital postoperative mortality were analysed by the appropriate tests. Variables with P < 0.1 were entered into multivariable logistic-regression model to identify predictors of in-hospital postoperative mortality, with data presented as odds ratios; P < 0.05 was statistically significant. Data on long-term survival and cardiac-specific mortality were obtained from the UK Office for National Statistics; the date of last follow-up was 13 October 2013 for the alive patients. Univariate predictors influencing cardiac death were determined by log-rank method. Variables with P < 0.1 were entered into multivariable Cox regression model to determine independent predictors of long-term survival, with data presented as hazard ratios; P < 0.05 was statistically significant. RESULTS: Cardiac surgery was performed on 3890 consecutive patients (74.7% male, age 68.7 ± 8.1 years); 601 patients did not undergo surgery. Postoperative hospital mortality was 2.9% (n = 112/3890). Predictors of postoperative hospital mortality included age ≥ 70 years, female sex, hypertension, LVEF < 50%, neurological dysfunction, previous cardiac surgery, early time period 1993-1997, emergency procedures and triple procedures. All patients were followed until the date of last follow-up or date of death, with a median follow-up of 8.1 ± 7.6 years and a total follow-up of 33 208 years. There were 533 (13.7%) postoperative early and late deaths from cardiac causes. Predictors of long-term survival free from cardiac death included LVEF > 50%. Predictors of postoperative cardiac deaths in the long-term follow-up included older age, diabetes, neurological dysfunction, LVEF < 50%, non-coronary artery bypass surgery, early time period of surgery (1993- 1997) and redo-cardiac surgery. CONCLUSIONS: Cardiac surgery provides long-term survival benefit in all subsets of LV function, including advanced LV dysfunction. [ABSTRACT FROM AUTHOR]

We also found that there appears to be an ablation "dose-response" in achieving return to sinus rhythm, with the greatest step-up achieved when the left atrial lesion set includes the mitral isthmus lesion. Keywords: Arrhythmia; Cardiac surgery; Ablation; 5-Year follow-up EN Arrhythmia Cardiac surgery Ablation 5-Year follow-up 1 1 1 02/07/23 20230101 NES 230101 We thank Dr Garcia-Villarreal [[1]] for his comment on our article in which he questions the rate of return to stable sinus rhythm in the Amaze trial [[2]]. We therefore agree with Dr Garcia-Villarreal that concomitant atrial fibrillation surgery should ideally be as complete as possible, and there may be an argument for concentrating such surgery in the hands of interested and experienced surgeons. [Extracted from the article]

Objectives: We reviewed our results and experience over a 14-year period to identify predictors of outcome following surgical repair of postinfarction ventricular septal rupture.Methods: A retrospective review was carried over a 14-year period. All patients had surgical repair of a postinfarction ventricular septal rupture. Patient demographics, perioperative variables, and survival data were collected. Logistic regression identified independent predictors of 30-day mortality. Multivariate analysis determined the effects of independent risk factors on survival.Results: Surgery for postinfarction ventricular septal rupture was carried out on 59 patients. The median age was 69 years, and 69% were male. In 54% of patients, the ventricular septal rupture was anterior, and 75% had concomitant coronary artery bypass grafting. Mortality was 39% at 30 days. Age was the most important predictor of 30-day and long-term outcome. Logistic regression analysis identified age, preoperative ventilation, and female sex as significant predictors of 30-day mortality. Cardiogenic shock, preoperative ventilation, and advanced age were associated with reduced medium-term survival. Surprisingly, anterior ventricular septal rupture was associated with reduced long-term survival. Concomitant coronary artery bypass grafting did not influence 30-day or long-term outcome.Conclusions: Despite advances, the surgical mortality from ventricular septal rupture remains high. Age remains the most important predictor of outcome, and concomitant coronary artery bypass grafting does not appear to have a demonstrable benefit. Interestingly, anterior ventricular septal rupture had poorer long-term outcome than inferior ventricular septal rupture. [ABSTRACT FROM AUTHOR]

Quality monitoring in medicine was a neglected field until the last two decades. Doctors traditionally did their best, but how good that was could not be evaluated. This situation remains in some areas of medicine, but specialties with clearly-defined interventions and outcomes have progressed in quality of care evaluation, and cardiac surgery leads the way. Measuring the risk of an intervention allows prediction of the outcome and is essential for quality monitoring: without knowing the predicted outcome, the actual outcome cannot be evaluated. Cardiac surgery risk models like EuroSCORE and others have been adopted worldwide, so that measuring risk-adjusted performance is now an integral part of the delivery of good cardiac surgical care. When mortality for a procedure is higher for one surgeon (or hospital) than another, this can be due to one of three reasons, or a combination of the three: the difference is due to chance, or variation in risk profile, or better and safer service. We now have the tools to distinguish between the above factors. We can also observe performance over time: cusum curves plot the performance of surgeons and hospitals by showing hypothetical 'lives saved'. This provides early warning of deterioration in performance before a problem reaches statistical significance. With the appropriate tools, it is possible not only to identify a problem, but also to anticipate and thus prevent a problem from happening. Monitoring clinical performance is an exciting and rewarding field for future development, and one that will yield real improvements in patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Cardiac surgery is widely believed to be an excessively high-risk intervention for very elderly patients with coronary artery or valvular disease. However, as life expectancy and the prospect of sustained quality of life into older age increase, this assumption should be challenged so that surgery is not denied to patients who may derive significant symptomatic benefit with acceptable levels of operative risk. Objective: To evaluate outcomes from cardiac surgery in nonagenarian patients. Design: Analysis of prospectively collected single-centre data and review of outcomes reported in the literature. Results: Twenty-three patients (13 males) aged 90 years or more underwent open cardiac surgery between 1998 and 2007. Four patients died within 30 days of surgery (surgical mortality 17.4%) and all-cause in-hospital morbidity was 74%. Actuarial survival at 1 and 5 years was estimated at 72 and 54%, respectively. Comparison of patients’ survival against age-matched life tables for the English population found a standardised mortality ratio of 0.57 (95% CI: 0.24–0.99; one-sample log-rank test χ2 = 3.93; p < 0.05) representing a significant survival benefit associated with surgery. The majority of patients reported symptomatic improvement reflected by significant decreases in angina and dyspnoea scores. Six single-centre series of nonagenarians and 3 reviews from national databases in the US and UK were identified in the literature. Pooled surgical mortality was 12.7% (95% CI: 8.7–17.3%) with no significant heterogeneity (χ2 = 4.12; p = 0.77; I2 = 0). Conclusion: Cardiac surgery in the elderly carries higher operative risk than in younger patients. However, in selected nonagenarians, surgery can be performed with acceptable morbidity and early mortality, and patients gain significant symptomatic relief and survival benefit. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The success of a Fontan circulation depends on several factors including low pulmonary vascular resistance. Pulmonary vascular resistance rises in response to hypoxia. Hypoxia is associated with altitude. Therefore, we wondered whether altitude is a risk factor for early failure after the Fontan operation. The aim was to test this hypothesis. Methods: Data were obtained from all published series of 'total cavopulmonary' Fontan operations since 1990. The early failure rate from each series and the altitude of the respective cities were recorded. Early failure was defined as death, takedown of Fontan, or transplantation during the same hospital admission. The association between altitude and failure rate was investigated by rank correlation and logistic regression. Results: 24 series were identified from centres situated at altitudes ranging from sea level to 520 metres. The plot of failure rate versus altitude suggests that failure rate increases with altitude. Logistic regression did not fit the data adequately. This was possibly due to the influence of unmeasured and unknown factors affecting the results, as well as the fact that centres were not randomly chosen but were self-selected by virtue of publishing their results. However, Spearman's rank correlation was 0.74 (p = 0.001). Conclusion: The early outcome of the Fontan circulation appears to be adversely affected by altitude. [ABSTRACT FROM AUTHOR]

The article offers information on atrial fibrillation and the restoration of sinus rhythm. Topics include the survival rates of the surgery, the management of quality of life, and the use of randomized control trials. The article also discusses the coronary artery bypass grafting technique for patients.

An editorial is presented, in which the author discusses risk scores and evaluation of patients having total arterial coronary revascularization. Topics discussed include risk factors that contribute to the models' power of discrimination, overestimation of mortality for the mode, and specialty of cardiac surgery.