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Objective To demonstrate that surgical removal of the left atrial appendage in patients with rheumatic mitral valve disease and long standing persistent atrial fibrillation decreases the possibility of stroke. This also removes the need for long-term oral anticoagulation after surgery. Method A descriptive, prospective, observational study was conducted on 27 adult patients with rheumatic mitral valve disease and long standing persistent atrial fibrillation, who had undergone mitral valve surgery and surgical removal of the left atrial appendage. Oral anticoagulation was stopped in the third month after surgery. The end-point was the absence of embolic stroke. An assessment was also made of postoperative embolism formation in the left atrium using transthoracic echocardiography. Results None of the patients showed embolic stroke after the third post-operative month. Only one patient exhibited transient ischaemic attack on warfarin therapy within the three postoperative months. Left atrial thrombi were also found in 11 (40.7%) cases during surgery. Of these, 6 (54.5%) had had embolic stroke, with no statistical significance (P=.703). Conclusions This study suggests there might be signs that the left atrial appendage may be the main source of emboli in rheumatic mitral valve disease, and its resection could eliminate the risk of stroke in patients with rheumatic mitral valve disease and long-standing persistent atrial fibrillation.

The cox-maze III procedure is designed to eliminate atrial fibrillation (AF).To determine the relationship of left atrial (LA) postoperative size after undergoing the Cox-maze III procedure.From July 2012 to April 2016, 50 patients with primary mitral valve disease and concomitant AF were operated on. A "cut-and-sew" cox-maze III procedure with a full biatrial lesion pattern was used. AF preoperative duration was 3.5 ± 2.1 years.There was no operative mortality. Freedom from AF was 92%, 88% and 73.7% at three months and at one and 3 years, respectively. A direct relationship was found between LA postoperative size and the probability of cox-maze failure when LA is6.5 cm at one year (relative risk [RR] = 10.5; 95% confidence interval [CI]:4.30-26.67, p0.0001) and at 3 years (RR = 27.1; 95% CI: 3.87-189.86, p = 0.0009). LA size decreased from 7.1 ± 0.5 cm to 6.2 ± 0.5 cm (p0.0001).The cox-maze III procedure is efficacious for eliminating mitral valve disease-associated AF when LA postoperative size is ≤ 6.5 cm.El procedimiento de Cox-maze III está diseñado para eliminar la fibrilación auricular.Determinar la relación del tamaño posoperatorio de aurículas izquierdas en las que se realizóprocedimiento de Cox-maze III.De julio de 2012 a abril de 2016 se operó a 50 pacientes con enfermedad mitral primaria y fibrilación auricular concomitante. Se utilizó Cox-maze III mediante “corte y sutura” biatrial completo. La duración preoperatoria de la fibrilación auricular fue de 3.5 ± 2.1 años.No hubo mortalidad operatoria. La ausencia de fibrilación auricular fue de 92 88 y 73.7 % a tres meses uno y tres años. Se encontr relación directa entre el tamaño posoperatorio de la aurícula izquierda y la probabilidad de falla del Cox-maze cuando la aurícula izquierda fue6.5 cm a un año (RR = 10.5 IC 95 % = 4.30-26.67 p0.0001) y a tres ańos (RR = 27.1 IC 95 % = 3.87-189.86 p = 0.0009). El tamaño de la aurícula izquierda disminuyó de 7.1 ± 0.5 cm a 6.2 ± 0.5 cm (p0.0001).El Cox-maze III es eficaz para eliminar la fibrilación auricular asociada con enfermedad mitral cuando el tamaño posoperatorio de la aurícula izquierda es ≤ 6.5 cm.

AIM To compare the efectiveness of the cut-and-sew Cox-maze III procedure against the Cox-maze IV peocedure by means of intraoperative bipolar radiofrequency delivery clamp. MATERIAL From January 2011 to October 2014, 50 patients were operated on with surgery for atrial fibrillation. All cases underwent mitral valve surgery as the first procedure, and secondarily a surgical procedure for atrial fibrillation was also performed. There were 2 groups. Group I (Cox-maze III «cut-and-sew»), and Group II (Cox-maze IV, intraoperative bipolar radiofrequency ablation). Group I was formed by 36 patients, and Group II by 14. All cases had atrial fibrillation longer than 1 year. The end-point was freedom of atrial fibrillation. RESULTS There was no statistically significant difference between both groups regarding the basal and operative characteristics. Operative mortality was of 2 cases in the Group I, and no cases for Group II (P=0.9). A high tendency to eliminate atrial fibrillation in favour of Group I was observed (92% vs 53%, P

Background Pulmonary vein isolation has been employed to eliminate paroxysmal atrial fibrillation. However, the long-term outcome in terms of long-standing persistent atrial fibrillation is unclear. Methods One hundred patients with rheumatic mitral valve disease and long-standing (>1 year) persistent atrial fibrillation were operated on between July 1998 and June 2007. Mitral valve surgery and surgical isolation (cut-and-sew) of the pulmonary veins were performed in all cases. Transthoracic echocardiography and 24-h Holter monitoring were obtained after 3 and 6 months and yearly thereafter. Results Early and late follow-up was 99% and 92% complete, respectively. The endpoint was freedom from atrial fibrillation. There was one (1%) hospital death. Atrial fibrillation was present in 39%, 47%, 63% and 68% of patients at 3 months, 1 year, 3 years, and 5 years after surgery, respectively. The odds ratios for recurrence of atrial fibrillation postoperatively were 1.41 (95% confidence interval 1.14–1.74), 2.17 (95% confidence interval 1.63–2.90), and 3.62 (95% confidence interval 2.44–5.38) at 1 week, 3 years, and 5 years, respectively. Actuarial freedom from atrial fibrillation was 35% at 3 years, and 30% at 5 years. A direct relationship was observed between preoperative left atrial size >6 cm and atrial fibrillation recurrence at 5 years ( p Conclusions No beneficial effects of simple pulmonary vein isolation for long-standing persistent atrial fibrillation concomitant with rheumatic mitral valve disease were observed. Atrial fibrillation cannot be fully treated using only pulmonary vein isolation.

Superior septal approach is a very useful technique to address the mitral valve surgery. Since this approach virtually divides the left atrium in two parts between the ascending aorta and the superior vena cava, mitral valve exposure becomes quite easy. We present a case of mitral valve repair by means of this approach.

In the treatment of patients with atrial fibrillation (AF), the efficacy and safety of epicardial thoracoscopic ablation (TA) versus endocardial catheter ablation (CA) using radiofrequency energy remains unclear. This meta-analysis was performed to assess the efficacy and safety of each ablation technique using a pooled comparative analysis.Studies comparing the efficacy and safety of TA and CA were identified by searching electronic databases. Those that reported patients' freedom from atrial arrhythmia and significant side effects were included.Three randomized controlled trials (RCTs) and two retrospective cohort studies with a total of 587 patients were included in the meta-analysis (273 patients underwent TA and 314 patients underwent CA). The proportion of patients who were free of atrial arrhythmia without antiarrhythmic drugs during 12 months of follow-up was significantly higher after TA than after CA in the RCTs [P0.001; relative risk (RR), 1.77; 95% confidence interval (CI), 1.34-2.32] and in the retrospective cohort studies (P = 0.010; RR, 1.68; 95% CI, 1.12-2.51). The incidence of significant side effects during the post-procedural period was significantly higher in the TA group than in the CA group in both the RCT (P = 0.007; RR, 7.23; 95% CI, 1.71-30.49) and the retrospective cohort studies (P = 0.020; RR, 4.39; 95% CI, 1.33-14.46).Based on the available data, TA was found to be more effective than CA in achieving freedom from atrial arrhythmia; however, TA had a higher rate of immediate post-procedural complications than CA.

We report the case of 23-year-old man with mitral valve regurgitation and Glanzmann thrombasthenia, who underwent mechanical mitral valve replacement. Warfarin therapy was devastating, causing bilateral hemothorax, pericardial effusion, gastrointestinal bleeding, and hematuria. Redo mitral valve replacement with a biological prosthesis was required to resolve this critical situation. To our knowledge, this is the first report of mitral valve replacement in Glanzmann thrombasthenia, highlighting the danger of oral anticoagulation in this pathology.

C l i n M e d International Library Citation: Garcia-Villarreal OA (2015) Functional Mitral Regurgitation Tenting Area is Directly Related to Non-Ischemic Cadiomyopathy. Int J Clin Cardiol 2:025 Received: March 01, 2015: Accepted: March 20, 2015: Published: March 22, 2015 Copyright: © 2015 Garcia-Villarreal OA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Garcia-Villarreal et al. Int J Clin Cardiol 2015, 2:2 ISSN: 2378-2951

Optimal exposure is one of the key factors for a successful MV surgery. Because the left atrium is located at the back of the heart, MV exposure may be very difficult. This article describes an approach which consists in sectioning the antrum of the pulmonary veins. By rotating and pulling out the heart, the mitral valve can be fully exposed. This technique is highly recommended for those cases with small left atrium.

Introduction and objectives. Mitral valve disease often is accompanied by chronic atrial fibrillation, especially when the left atrium is enlarged. Mitral valve surgery alone cannot resolve the arrhythmia in most cases. Several surgical techniques have been proposed. We have used surgical left atrial reduction and pulmonary vein isolation to eliminate chronic atrial fibrillation associated with mitral valve disease. The aim of this paper is to report our experience with this new surgical concept. Patients and method. Twenty-three patients (18 women and 5 men, mean age 44.1 ± 14.7 years) with mitral valve disease and chronic atrial fibrillation for more than 3 months underwent surgery. Mitral valvuloplasty was performed in 11 cases, and mitral valve replacement in 12. Left atrial reduction was used to eliminate chronic atrial fibrillation in all cases. Results. There was no operative mortality. Three patients (13%) had recurrent atrial fibrillation between postoperative days 6 and 8. No atrioventricular conduction disturbances were observed. An important reduction in left atrial size was evident on echocardiography (4.8 ± 0.77 vs. 8.1 ± 1.47 cm, p < 0.01). In 3 to 36 months of follow-up (13.9 ± 11 months), all patients preserved sinus rhythm. Conclusions. Left atrial reduction seems to be an effective and easily applied alternative method for treating mitral valve disease with chronic atrial fibrillation.

Surgical excision of the left atrial appendage is an essential key in the Cox maze IV procedure. Management of very thin, friable, and delicate tissue in the base of the left atrial appendage can be difficult. We have designed a simple method to expose adequately without handling the base of the left atrial appendage. With this technique, the risk of bleeding due to excessive traction or manipulation of the heart is dramatically reduced.

The case described by Ikegami and McCarthy [1] exemplifies one of the rarest complications after mitral prosthetic implantation. It is difficult to know which of the conditions described here, such as perforation of the aortic valve, mitral periprosthetic leak, left ventricular (LV) pseudoaneurysm, or the amount of all of them was the cause of the patient's symptoms. Left ventricular rupture after mitral valve replacement is a rare but dreaded and potentially lethal complication of mitral valve surgery, with an incidence up to 1%. Predisposing factors include non-sparing subvalvular structures of the posterior leaflet, extensive annular decalcification, insertion of an oversized prosthesis, redo mitral valve replacement, a stented bioprosthesis implanted in a small LV cavity, and infective endocarditis. Sometimes, this rupture is incomplete and may be noticed only as a small hematoma on the posterolateral wall of the LV. Theoretically, LV pseudoaneurysm can develop at the site of a previous rupture, contained by the surrounding pericardium or extracardiac tissue [2]. Nowadays, the wide use of echocardiography allows detection of acute pseudoaneurysms. Chronic pseudoaneurysms are generally detected during investigation of cardiac failure, and up to 10% to 20% incidentally [3]. The presence of a neck smaller than the aneurysmal cavity is strongly suggestive of a pseudoaneurysm, especially if colour Doppler shows a turbulent flow at the neck [4]. The decision to operate is given taking into account the presence of congestive heart failure, and the size of the pseudoaneurysm (>3 cm in diameter). Otherwise, surveillance with echocardiographic control is indicated [5]. Pretre et al. emphasize this attempt of guidelines for the management of LV pseudoaneurysms [5]. Finally, the video is very nice. Conflict of interest: none declared.

It is very exciting to discuss this beautiful article by Pan et al. [1]. There is considerable documentation in the literature about the use of partial heart autotransplantation for a variety of purposes. My teacher, Arrigo Lessana in Aubervilliers, France, had begun to use partial cardiac autotransplantation in the spring of 1998 [2] for adequate visualization to reduce the size of the left atrium (LA). Later, when I came back to Mexico, I operated on three cases of mitral valve disease and chronic atrial fibrillation (AF) with giant LA from 2000 to 2001 [3]. All three cases had a spectacular outcome. After this very nice experience, I promptly realized that by sectioning only the superior vena cava (SVC) one can get an effective access to the whole LA. So I performed about 100 cases of surgical isolation of the pulmonary veins to treat AF in mitral valve disease [4]. But it is clear that this was not a left-sided maze, and the sinus rhythm conversion rate was lower than those reported by Cox et al. [5]. With all this experience, I made contact with Professor Jim Cox in 2012. After he emphasized the key aspects for successful completion of the Cox maze III 'cut-and-sew' procedure, I started to perform it by adding the transection of the SVC. This modification from the original technique can be termed as mini-partial heart autotransplantation. And this is just the point that I want to emphasize in this comment. Once the entire LA has been circumferentially divided and the SVC sectioned, the heart is lifted up and twisted towards the left side of the patient. I have found that this technique allows an extraordinary visualization of the mitral valve. Since the heart is twisted, the surgeon works from 'ground level'. I have performed 14 cases of the Cox maze III procedure and mitral valve surgery by means of mini-partial heart autotransplantation with an excellent outcome. Re-anastomosis of the SVC is performed in 5 to 10 minutes in a beating heart. No additional risks are added with this technique. I encourage cardiac surgeons to use this technique to make both mitral valve surgery and the Cox-maze III procedure more amenable. Conflict of interest: none declared

I have read with interest the article by Taramasso et al. [1]. They compared retrospectively the efficacy of the MitraClip (percutaneous edge-to-edge [E2E] procedure) with surgical treatment (E2E stitch plus annuloplasty) in patients with severe functional mitral regurgitation (FMR) and heart failure. They concluded that MitraClip therapy is a good alternative, particularly in patients who are not amenable to surgery. It could be that MitraClip improves safety because of its percutaneous deployment. However, one cannot forget the good outcome of the E2E stitch especially when ring annuloplasty is included as a part of the procedure [2]. For those of us who have learned the traditional concepts of Dr Carpentier’s ‘old school’, the use of annuloplasty ring is a requirement in any mitral valve repair [3]. Indeed, the same Milan group found that the best outcome is achieved when E2E is used with ring annuloplasty [2]. Although Maisano et al. [4] demonstrated that it is possible to perform E2E repair without annuloplasty in 29 cases of FMR with an acceptable outcome, a limitation of their study is the small sample size that does not allow to make any firm inference. In addition, we know that, in chronic ischaemic mitral regurgitation, the mitral valve annulus is misshaped and deformed, and tethering forces arising from the adversely remodelled left ventricle towards the mitral valve are responsible for mitral valve regurgitation [5]. So, if we are to learn from our failures, one should conclude that the reshaping of the mitral valve annulus by means of a prosthetic ring is an absolute ‘must’ in the treatment of FMR. This does not mean that we do away with all we have learned about ring annuloplasty. I would propose that long-term follow-up studies are needed to clarify the safety and efficacy of the percutaneous MitraClip therapy without annuloplasty ring for FMR. Keeping in mind that the percutaneous mitral valve annuloplasty has its own shortcomings [6], the role and place of MitraClip therapy in the treatment of FMR are yet to be elucidated.

I read with great interest the article by Okonta et al. [1], and I think that the discussion should be primarily focused on early surgery in left-sided infective endocarditis (IE) to prevent stroke. The three main indications for early surgery in IE are heart failure, uncontrolled infection and prevention of embolic events [2]. Although embolic stroke is a major cause of morbidity in patients with IE, the value of early surgery in preventing embolic events still remains controversial. According to the data analyzed by Okonta et al. [1], it is very clear that a vegetation length >10 mm and severe vegetation mobility are the most potent independent predictors of a new embolic event. If we use the term "new embolic event" in relation to the time after the beginning the antibiotic therapy in IE, then the benefits of surgery in preventing embolism may be greatest during the first week of antibiotic therapy. This is because the risk of new embolism is highest during the first days following the initiation of antiobiotic therapy and decreases two weeks thereafter [3]. Although new recommendations of European Society of Cardiology guidelines for IE emphasize the timing of surgery [2], the exact role of early surgical intervention in order to avoid embolic events is still unclear. Vegetation size can be one of the reasons for surgery, but is rarely the only one. In the absence of a previous embolism, surgery is indicated with vegetation length >10 mm and some other predictor of complicated IE (heart failure, uncontrolled infection). Eventually, surgery may be considered in cases with very large (>15 mm) vegetations on the aortic or mitral valve, according to the possibility of valve repair. Cabell et al. [4] have demostrated that in native IE, mitral valve IE is associated with higher risk of embolism than aortic valve IE (OR 3.6; 95% CI 1.1-11.6). That is why earlier surgery should be especially emphasized in the cases of mitral valve vegetations. Finally, one must keep in mind that the major complications with early surgery are valve dysfunction because of tissue inflammation, and the increased risk of recurrent infection resulting in early prosthetic valve endocarditis [5]. Any current conclusions must be open to continuing review as new data become available to allow more enlightened judgements in preventing the risk of embolism in left-sided IE. Some personal conclusions regarding the indication of early surgery in IE include: i) vegetation lengths >10 mm associated with one of the following conditions: complicated course of IE (haemodynamic deterioration, uncontrolled infection, neurological complication), severe vegetation mobility located on the mitral valve, valve repair appears feasible immediately after antibiotic therapy is started; ii) vegetation length >15 mm in aortic or mitral valve with or without other complication. Conflict of interest: none declared

At Odense University Hospital (OUH), 5–9% of all unselected cardiac surgical patients undergo reoperation due to excessive bleeding. The reoperated patients have an approximately three times greater mortality than non-reoperated. To reduce the rate of reoperations and mortality due to postoperative bleeding, we aim to identify risk factors that predict reoperation. A total of 1452 consecutive patients undergoing cardiac surgery using extracorporeal circulation (ECC) between November 2005 and December 2008 at OUH were analysed. Statistical tests were used to identify risk factors for reoperation. We performed a case-note review on propensity-matched patients to assess the outcome of reoperation for bleeding regarding morbidity and mortality. In total, 101 patients (7.0%) underwent surgical re-exploration due to excessive postoperative bleeding. Significant risk factors for reoperation for bleeding after cardiac surgery was low ejection fraction, high EuroSCORE, procedures other than isolated CABG, elongated time on ECC, low body mass index, diabetes mellitus and preoperatively elevated s-creatinine. Reoperated patients significantly had a greater increase in postoperative s-creatinine and higher mortality. Surviving reoperated patients significantly had a lower EuroSCORE and a shorter time on ECC compared with non-survivors. The average time to re-exploration was 155 min longer for non-survivors when compared with survivors.

Left atrial reduction is a surgical technique that has been proposed for eliminating chronic atrial fibrillation associated with mitral valve disease. A potential complication of the technique is the unnoticed rotation of the heart while the left atrium is anastomosed. Such an event makes it impossible to reconstruct the superior vena cava, leading to superior vena cava syndrome due to the rotation of that vessel. We report our experience with a case of left atrial reduction and rotation of the superior vena cava while it was being anastomosed. The complication was successfully resolved by placing an autologous pericardial tube between the two ends of the superior vena cava.