Incidence and factors influencing the spontaneous closure of Fontan fenestration

Introduction: The Fontan operation is the final stage of single ventricle palliation in patients with complex congenital heart disease. Fenestration in the Fontan conduit, providing an atrial level right to left shunt, has been shown to reduce early postoperative morbidity. However, there is limited data on the long‐term fate of this fenestration. The aim of this study is to define the rate of spontaneous closure of the fenestration in the Fontan conduit and factors predictive of the fate of the fenestration.
Methods: This was a retrospective study reviewing the medical records of the patients who underwent fenestrated Fontan operation at our center. Preoperative, intraoperative and postoperative variables including the status of the Fontan fenestration were extracted and analyzed.
Results: Of 67 patients included in the study, 15 (22%) had spontaneous closure of the fenestration. Of the remaining 52 patients, 11 (20%) had procedural closure of this fenestration (10 via cardiac catheterization and 1 via surgery) at a median duration of 3 months after the Fontan operation. Patients with higher preoperative pulmonary vascular resistance and a history of postoperative systemic venous thromboembolism had higher likelihood of having persistence of the fenestration with P value of .045 and .037, respectively.
Conclusions: The rate of spontaneous closure of the Fontan fenestration was 22% in our study. Elevated preoperative pulmonary vascular resistance and history of systemic venous thromboembolism are predictive of persistent Fontan fenestration.     

Coronary artery disease screening in adults with congenital heart disease prior to cardiac surgery

Objective: As adults with congenital heart disease (CHD) grow older, preoperative screening for coronary artery disease (CAD) may be indicated prior to CHD surgery. Data regarding the indications for preoperative CAD screening in this population are limited. Current practice is to follow guidelines for patients with valvular heart dis‐ ease; however, the risk for CAD in certain congenital heart diagnoses may be higher than the general population. This study aimed to assess the results of preoperative CAD screening in patients prior to CHD surgery.
Design: Retrospective study.
Setting: Single tertiary center.
Patients: Patients ≥35 years that had CHD surgery from 1/1/2007 to 5/1/2017.
Outcome Measures: Data regarding CAD risk factors and preoperative CAD screen‐ ing results were obtained. Prevalence and risk factors for CAD were analyzed, along with their relationship to perioperative outcomes.
Results: A total of 73 patients underwent CAD screening with either cardiac catheteri‐ zation (56%) or computed tomography angiography (34%) prior to CHD surgery. Overall 16 (22%) patients were found to have CAD. Only two patients had severe coronary stenosis and underwent coronary bypass grafting at time of CHD surgery. Patients with CAD were more likely to be older and have history of hypertension, dyslipidemia, and tobacco smoking. CHD diagnosis was not significantly associated with presence of CAD.
Conclusion: CAD is common in asymptomatic older patients referred for screening prior to CHD surgery; however, severe CAD requiring concomitant coronary inter‐ vention is uncommon. Preoperative CAD screening should be based on age and tra‐ ditional CAD risk factors, rather than underlying CHD.     

Predictors of extracorporeal membrane oxygenation support after surgery for adult congenital heart disease in children's hospitals

Objective: Adult congenital heart disease (ACHD) patients who undergo cardiac surgery are at risk for poor outcomes, including extracorporeal membrane oxygenation support (ECMO) and death. Prior studies have demonstrated risk factors for mortality, but have not fully examined risk factors for ECMO or death without ECMO (DWE). We sought to identify risk factors for ECMO and DWE in adults undergoing congenital heart surgery in tertiary care children’s hospitals.
Design: All adults (≥18 years) undergoing congenital heart surgery in the Pediatric Health Information System (PHIS) database between 2003 and 2014 were included. Patients were classified into three groups: ECMO‐free survival, requiring ECMO, and DWE. Univariate analyses were performed, and multinomial logistic regression models were constructed examining ECMO and DWE as independent outcomes.
Setting: Tertiary care children’s hospitals.
Results: A total of 4665 adult patients underwent ACHD surgery in 39 children’s hospitals with 51 (1.1%) patients requiring ECMO and 64 (1.4%) patients experiencing DWE. Of the 51 ECMO patients, 34 (67%) died. Increasing patient age, surgical complexity, diagnosis of single ventricle heart disease, preoperative hospitalization, and the presence of noncardiac complex chronic conditions (CCC) were risk factors for both outcomes. Additionally, low and medium hospital ACHD surgical volume was associated with an increased risk of DWE in comparison with ECMO.
Conclusions: There are overlapping but separate risk factors for ECMO support and DWE among adults undergoing congenital heart surgery in pediatric hospitals.     

Parental anxiety before invasive cardiac procedure in children with congenital heart disease: Contributing factors and consequences

Objective: Medical information provided to parents of a child with a congenital heart disease can induce major stress. Visual analog scales have been validated to assess anxiety in the adult population. The aim of this study was to analyze parental anxiety using a visual analog scale and to explore the influencing factors.
Design: This prospective cross‐sectional study.
Setting: Tertiary care regional referral center for congenital heart disease of Marseille-La Timone university hospital.
Patients: Parents of children with a congenital heart disease, as defined by the ACC‐ CHD classification, referred for cardiac surgery or interventional cardiac catheterization, were offered to participate.
Intervention and outcome measure: The parental level of anxiety was assessed using a visual analog scale (0‐10) before intervention and after complete information given by the cardiologist, the surgeon or the anesthetists.
Results: Seventy‐three children [7 days‐13 years], represented by 49 fathers and 71 mothers, were included in the study. A total of 42 children required cardiac surgery and 31 children underwent interventional cardiac catheterization. The mean score of maternal anxiety was significantly higher than the paternal anxiety (8.2 vs 6.3, P < .01). A high level of maternal anxiety (visual analog scale > 8) was associated with paternal anxiety (P = .02), the child's comorbidity (P = .03), the distance between home and referral center (P = .04), and the level of risk adjustment for congenital heart surgery (P = .01). In multivariate analysis, maternal anxiety was associated with paternal anxiety (OR = 4.9; 95% confidence interval [1.1‐19.2]), and the level of risk adjustment for congenital heart surgery (OR = 11.4; 95% confidence interval [1.2‐116.2]). No significant association was found between parental anxiety and prenatal diagnosis.
Conclusion: This study highlighted several factors associated with the parental anxiety. Identifying the parents at risk of high stress can be useful to set up psychological support during hospitalization.     

Congenital heart disease and cardiac surgery in childhood: effects on cognitive function and academic ability

OBJECTIVE—To evaluate changes in cognitive and academic functioning following cardiac surgery in children with congenital heart disease.
DESIGN—A prospective cross sectional study in which patients were assessed immediately before treatment and 12 months later.
PATIENTS—Three groups of children aged 3.5-17 years: a group with congenital heart disease awaiting surgery, another awaiting bone marrow transplantation, and a healthy comparison group.
MAIN OUTCOME MEASURES—Intelligence quotient and measures of academic attainment, evaluated with the British Ability Scales.
RESULTS—Preoperatively, children with cyanotic lesions showed deficits in comparison with those with acyanotic lesions. Postoperatively, children with cyanotic lesions showed a deterioration in performance and achieved significantly lower scores than those with acyanotic lesions. While there were significant differences between the congenital heart disease and bone marrow transplantation groups preoperatively, these were no longer apparent at follow up.
CONCLUSIONS—In contrast to previously published findings, the present results suggest that cardiac surgery does not result in early postoperative improvements in cognitive function for children with congenital heart disease. The nature of the cardiac lesion continues to affect cognitive and academic performance, even after surgery.


Keywords: congenital heart disease; cardiac surgery; cognitive ability     

Accuracy of risk prediction scores in pregnant women with congenital heart disease

Objective: To assess performance of risk stratification schemes in predicting adverse cardiac outcomes in pregnant women with congenital heart disease (CHD) and to compare these schemes to clinical factors alone.
Design: Single‐center retrospective study.
Setting: Tertiary care academic hospital.
Patients: Women ≥18 years with International Classification of Diseases, Ninth Revision, Clinical Modification codes indicating CHD who delivered between 1998 and 2014. CARPREG I and ZAHARA risk scores and modified World Health Organization (WHO) criteria were applied to each woman.
Outcome Measures: The primary outcome was defined by ≥1 of the following: arrhyth‐ mia, heart failure/pulmonary edema, transient ischemic attack, stroke, dissection, myo‐ cardial infarction, cardiac arrest, death during gestation and up to 6 months postpartum.
Results: Of 178 women, the most common CHD lesions were congenital aortic ste‐ nosis (15.2%), ventricular septal defect (13.5%), atrial septal defect (12.9%), and te‐ tralogy of Fallot (12.9%). Thirty‐five women (19.7%) sustained 39 cardiac events. Observed vs expected event rates were 9.9% vs 5% (P = .02) for CARPREG I score 0 and 26.1% vs 7.5% (P < .001) for ZAHARA scores 0.51‐1.5. ZAHARA outperformed CARPREG I at predicting adverse cardiovascular outcomes (AUC 0.80 vs 0.72, P = .03) but was not significantly better than modified WHO. Clinical predictors of adverse cardiac event were symptoms (P = .002), systemic ventricular dysfunction (P < .001), and subpulmonary ventricular dysfunction (P = .03) with an AUC 0.83 comparable to ZAHARA (P = .66).
Conclusions: CARPREG I and ZAHARA scores underestimate cardiac risk for lower risk pregnancies in these women. Of the three risk schemes, CARPREG I performed least well in predictive capacity. Clinical factors specific to the population studied are comparable to stratification schemes.     

Mittelfristiges Outcome kardiochirurgischer Patienten mit einer verl?ngerten postoperativen Intensivtherapie

Background

The number of patients of advanced age and with severe comorbidities undergoing cardiac surgery is rising. Therefore, in addition to the cardiac surgery procedure itself, postoperative intensive care treatment plays an increasingly important role. The mid-term outcome of patients with postoperative long-term stays in intensive care and perioperative risk factors for an adverse outcome have not been sufficiently evaluated.

Material and methods

All patients who underwent cardiac surgery in our institution between 2000 and 2004 and who required intensive care treatment on our cardiac surgery intensive care unit for at least 1 week were analyzed. Patients who received heart or lung transplantation or surgery for congenital heart failure were excluded. A total of 31 perioperative variables were evaluated for 230 patients. Follow-up was performed 1?year postoperatively.

Results

In all, 4.3% of our patients required a prolonged stay in intensive care following cardiac surgery. Overall 1-year mortality among patients with a long-term stay in intensive care was 26.9%. The logistic regression identified postoperative renal failure requiring dialysis (OR 4.98) as the strongest predictor for mortality within the first year after surgery, followed by postoperative tracheotomy and preoperatively known atrial fibrillation.

Conclusion

Mid-term survival among patients who underwent cardiac surgery followed by a complicated postoperative course is encouragingly high. The risk factors identified for an adverse prognosis may be helpful in improving therapy strategies and general therapy decision-making.     

Transfusion‐related acute hepatic injury following postoperative platelets administration in pediatric patients undergoing the Fontan procedure

Objective: The final common pathway of single ventricle patients is the Fontan procedure. Among the immediate postoperative complications is acute hepatic injury presented by marked elevation of liver enzymes (alanine transaminase [ALT] and aspartate transaminase [AST]). We aimed to determine the contribution of blood products transfusion to acute hepatic injury.
Design: Single center retrospective cohort study.
Setting: Pediatric Cardiac Intensive Care Unit at a tertiary medical center.
Patients: Ninety‐nine pediatric patients undergoing the Fontan procedure between January 2009 and December 2016.
Interventions: None.
Measurements and Main Results: Out of the four types of blood products, transfusion of platelets was found to significantly affect postoperative levels of ALT and AST. Additional factors included postoperative administration of sodium bicarbonate, decreased flow through the Fontan canal and decreased urine output. Preoperative pulmonary artery pressure and pulmonary vascular resistance, cardiopulmonary bypass time, aortic cross‐clamp time, amount of postoperative bleeding, and vasoactive‐ inotropic score did not influence liver enzymes levels.
Conclusions: In pediatric Fontan patients, platelets transfusions contribute to an acute hepatic injury. The relation between platelets and transfusion‐related acute lung injury (TRALI) has been well described, but this is the first time it is being described in regard to acute hepatic injury (TRAHI). Changing platelet transfusion strategy could decrease morbidity in Fontan patients but further research is needed. KEYWORDS acute hepatic injury, congenital heart defect, Fontan, pediatric cardiac surgery, platelets, transfusion‐related acute hepatic injury     

Lost in the system? Transfer to adult congenital heart disease care-Challenges and solutions

Objective: Transfer of congenital heart disease care from the pediatric to adult set‐ ting has been identified as a priority and is associated with better outcomes. Our objective is to determine what percentage of patients with congenital heart disease transferred to adult congenital cardiac care.
Design: A retrospective cohort study.
Setting: Referrals to a tertiary referral center for adult congenital heart disease pa‐ tients from its pediatric referral base.
Patients: This resulted in 1514 patients age 16‐30, seen at least once in three pediat‐ ric Georgia health care systems during 2008‐2010.
Interventions: We analyzed for protective factors associated with age‐appropriate care, including distance from referral center, age, timing of transfer, gender, severity of adult congenital heart disease, and comorbidities.
Outcome Measures: We analyzed initial care by age among patients under pediatric care from 2008 to 2010 and if patients under pediatric care subsequently transferred to an adult congenital cardiologist in this separate pediatric and adult health system during 2008‐2015.
Results: Among 1514 initial patients (39% severe complexity), 24% were beyond the recommended transfer age of 21 years. Overall, only 12.1% transferred care to the referral affiliated adult hospital. 90% of these adults that successfully transferred were seen by an adult congenital cardiologist, with an average of 33.9 months be‐ tween last pediatric visit and first adult visit. Distance to referral center contributed to delayed transfer to adult care. Those with severe congenital heart disease were more likely to transfer (18.7% vs 6.2% for not severe).
Conclusion: Patients with severe disease are more likely to transfer to adult congeni‐ tal heart disease care than nonsevere disease. Most congenital heart disease patients do not transfer to adult congenital cardiology care with distance to referral center being a contributing factor. Both pediatric and adult care providers need to under‐ stand and address barriers in order to improve successful transfer.     

Postoperative and short‐term atrial tachyarrhythmia burdens after transcatheter vs surgical pulmonary valve replacement among congenital heart disease patients

Objective: We examined the atrial tachyarrhythmia (AT) burden among patients with congenital heart disease (CHD) following transcatheter (TC‐) or surgical (S‐) pulmo‐ nary valve replacement (PVR).
Design/Setting: This was a retrospective observational study of patients who under‐ went PVR from 2010 to 2016 at UCLA Medical Center.
Patients: Patients of all ages who had prior surgical repair for CHD were included. Patients with a history of congenitally corrected transposition of the great arteries, underwent a hybrid PVR procedure, or had permanent atrial fibrillation (AF) without a concomitant ablation were excluded.
Outcome Measures: The primary outcome was a time‐to‐event analysis of sustained AT. Sustained ATs were defined as focal AT, intra‐atrial reentrant tachycardia/atrial flutter, or AF lasting at least 30 seconds or terminating with cardioversion or anti‐ tachycardia pacing.
Results: Two hundred ninety‐seven patients (TC‐PVR, n = 168 and S‐PVR, n = 129) were included. During a median follow‐up of 1.2 years, nine events occurred in TC‐PVR group (5%) vs 23 events in S‐PVR group (18%). In the propensity adjusted models, the following factors were associated with significant risk of AT after PVR: history of AT, age at valve implantation, severe right atrial enlargement, and S‐PVR. In the secondary analysis, TC‐PVR was associated with lower adjusted risk of AT events in the postoperative epoch (first 30 days), adjusted IRR 0.31 (0.14‐0.97), P = .03, but similar risk in the short‐term epoch, adjusted IRR 0.64 (0.14‐2.94), P = .57.
Conclusion: There was an increased risk of AT in the first 30 days following S‐PVR compared to TC‐PVR. Additional factors associated with risk of AT events after PVR were a history of AT, age at valve implantation, and severe right atrial enlargement.     

Incidence and Related Risk Factors of Junctional Ectopic Tachycardia in Infants after Cardiac Surgery for Congenital Heart Disease

Objective: Junctional ectopic tachycardia is common after cardiac surgery for congenital heart disease. However, its incidence and related risk factors in infants after cardiac surgery are not well known. The objective of this study was to determine the overall incidence and related risk factors for junctional ectopic tachycardia in neonates and infants. Methods: We enrolled a total of 271 patients aged <1 year who underwent open cardiac surgery at Severance Cardiovascular Hospital from January 2018 to December 2020. Exclusion criteria were immediate postoperative mortality, other arrhythmias detected in the perioperative period, and prematurity. Result: The overall incidence of junctional ectopic tachycardia was 12.9%. The logistic regression analysis revealed that longer cardiopulmonary bypass time, surgery involving atrioventricular node stretching, and the presence of early repolarization on preoperative electrocardiography increased the risk of junctional ectopic tachycardia. Patients with junctional ectopic tachycardia had longer intubation time and intensive care unit stay. Conclusion: Junctional ectopic tachycardia is a common arrhythmia after cardiac surgery for congenital heart disease in infants. Occasionally, infants developing junctional ectopic tachycardia after cardiac surgery have specific preoperative electrocardiography findings. The risk factors for junctional ectopic tachycardia were associated not only with surgical procedural factors but also with preoperative electrocardiographic parameters.     

Neurodevelopmental assessment of infants with congenital heart disease in the early postoperative period

Objective: Mortality rates for children with congenital heart disease (CHD) have significantly declined, resulting in a growing population with associated neurodevelopmental disabilities. American Heart Association guidelines recommend systematic developmental screening for children with CHD. The present study describes results of inpatient newborn neurodevelopmental assessment of infants after open heart surgery.
Outcome measures: We evaluated the neurodevelopment of a convenience sample of high‐risk infants following cardiac surgery but before hospital discharge using an adaptation of the Newborn Behavioral Observation. Factor analysis examined relationships among assessment items and consolidated them into domains of development.
Results: We assessed 237 infants at a median of 11 days (interquartile range [IQR]: 7‐19 days) after cardiac surgery and median corrected age of 21 days (IQR: 13‐33 days). Autonomic regulation was minimally stressed or well organized in 14% of infants. Upper and lower muscle tone was appropriate in 33% and 35%, respectively. Appropriate response to social stimulation ranged between 7% and 12% depending on task, and state regulation was well organized in 14%. The vast majority (87%) required enhanced examiner facilitation for participation. Factor analyses of assessment items aligned into four domains of development (autonomic, motor, oral motor, and attention organization).
Conclusion: At discharge, postoperative infants with CHD had impairments in autonomic, motor, attention, and state regulation following cardiac surgery. Findings highlight the challenges faced by children with CHD relative to healthy peers, suggesting that neurodevelopmental follow‐up and intervention should begin early in infancy.     

Relation between postoperative mortality and atrial fibrillation before surgical revascularization--3-year follow-up

BACKGROUND: Preoperative atrial fibrillation is one of the predictors of increased morbidity and mortality in patients undergoing surgical revascularization, and consequently, prolongs the duration of stay in the ICU and of overall hospitalization. METHODS: The study included 3000 patients subjected to primary isolated coronary artery bypass grafting from 2000 to 2004. Of the 3000 patients, 5.8 % (n = 174) had electrocardiographically documented, preoperative atrial fibrillation. To evaluate the relationship between preoperative AF and postoperative outcome, all patients were observed for about three years. RESULTS: Patients with preoperative atrial fibrillation were older (P < 0.05), had a lower ejection fraction (P < 0.001), a higher incidence of heart failure (P < 0.001), hypertension (P < 0.001), and more coexistent morbidities including diabetes (P < 0.05), obturative pulmonary disease (P < 0.0001) and mild renal failure (P < 0.001). Statistical analysis showed that survival rates at 6 and 30 days, 6 and 12 months, and 3 years following surgical revascularization of patients with vs. those without preoperative atrial fibrillation were: 96.4% vs. 98.1%, and 94.5% vs. 97.3% (P = ns), 86.2% vs. 93.0% (P < 0.03), and 74.7% vs. 91.0% (P < 0.02), and 70.7% vs. 90.6% (P < 0.01). After 3 years' observation there was a survival difference of 19.9%. We showed that preoperative atrial fibrillation triple increased the risk of postoperative AF and was an independent risk factor for in-hospital death (P < 0.001). CONCLUSIONS: Preoperative atrial fibrillation is a predictor of postoperative complications, including death, and of a significant reduction in patients' long-term survival. Patients with preoperative atrial fibrillation should be considered as high-risk patients with potential postoperative complications and should be well protected with antiarrhythmic and anticoagulant therapy.     

Vasopressor magnitude predicts poor outcome in adults with congenital heart disease after cardiac surgery

Background: High levels of vasoactive inotrope support (VIS) after congenital heart surgery are predictive of morbidity in pediatric patients. We sought to discern if this relationship applies to adults with congenital heart disease (ACHD).
Methods: We retrospectively studied adult patients (≥18 years old) admitted to the intensive care unit after cardiac surgery for congenital heart disease from 2002 to 2013 at Mayo Clinic. Vasoactive medication dose values within 96 hours of admis‐ sion were examined to determine the relationship between VIS score and poor out‐ come of early mortality, early morbidity, or complication related morbidity.
Results: Overall, 1040 ACHD patients had cardiac surgery during the study time frame; 243 (23.4%) met study inclusion criteria. Sixty‐two patients (25%), experi‐ enced composite poor outcome [including eight deaths within 90 days of hospital discharge (3%)]. Thirty‐eight patients (15%) endured complication related early mor‐ bidity. The maximum VIS (maxVIS) score area under the curve was 0.92 (95% CI: 0.86‐0.98) for in‐hospital mortality; and 0.82 (95% CI: 0.76‐0.89) for combined poor clinical outcome. On univariate analysis, maxVIS score ≥3 was predictive of compos‐ ite adverse outcome (OR: 14.2, 95% CI: 7.2‐28.2; P < 0.001), prolonged ICU LOS ICU LOS (OR: 19.2; 95% CI: 8.7‐42.1; P < 0.0001), prolonged mechanical ventilation (OR: 13.6; 95% CI: 4.4‐41.8; P < 0.0001) and complication related morbidity (OR: 7.3; 95% CI: 3.4‐15.5; P < 0.0001).
Conclusions: MaxVIS score strongly predicted adverse outcomes and can be used as a risk prediction tool to facilitate early intervention that may improve outcome and assist with clinical decision making for ACHD patients after cardiac surgery.     

S100B and its relation to cerebral oxygenation in neonates and infants undergoing surgery for congenital heart disease

Objectives: Neonates and infants undergoing surgery for congenital heart disease are at risk for developmental impairment. Hypoxic‐ischemic brain injury might be one contributing factor. We aimed to investigate the perioperative release of the astro‐ cyte protein S100B and its relation to cerebral oxygenation.
Methods: Serum S100B was measured before and 0, 12, 24, and 48 hours after sur‐ gery. Cerebral oxygen saturation was derived by near‐infrared spectroscopy. S100B reference values based on preoperative samples; concentrations above the 75th per‐ centile were defined as elevated. Patients with elevated S100B at 24 or 48 hours were compared to cases with S100B in the normal range. Neonates (≤28 days) and infants (>28 and ≤365 days) were analyzed separately due to age‐dependent release of S100B.
Results: Seventy‐four patients underwent 94 surgical procedures (neonates, n = 38; infants, n = 56). S100B concentrations were higher in neonates before and after sur‐ gery at all time points (P ≤ .015). Highest values were noticed immediately after sur‐ gery. Postoperative S100B was elevated after 15 (40.5%) surgeries in neonates. There was no difference in pre‐, intra‐, or postoperative cerebral oxygenation. In in‐ fants, postoperative S100B was elevated after 23 (41.8%) procedures. Preoperative cerebral oxygen saturations tended to be lower (53 ± 12% vs 59 ± 12%, P = .069) and arterial‐cerebral oxygen saturation difference was higher (35 ± 11% vs 28 ± 11%, P = .018) in infants with elevated postoperative S100B. In the early postoperative course, cerebral oxygen saturation was lower (54 ± 13% vs 63 ± 12%, P = .011) and arterial‐cerebral oxygen saturation difference was wider (38 ± 11% vs 30 ± 10%, P = .008). Cerebral oxygen saturation was also lower for the entire postoperative course (62 ± 18% vs 67 ± 9%, P = .047).
Conclusions: Postoperative S100B was elevated in about 40% of neonates and in‐ fants undergoing cardiac surgery. Infants with elevated postoperative S100B had impaired perioperative cerebral tissue oxygenation. No relation between S100B and cerebral oxygenation could be demonstrated in neonates.     

Radiofrequency ablation for atrial fibrillation during concomitant cardiac surgery

Background

Atrial fibrillation is found in an increasing number of patients undergoing open heart surgery. It is associated with higher mortality rates, risk of stroke and left ventricular dysfunction. Surgical ablation for atrial fibrillation has evolved from the complex“cut and sew” Maze procedure to less invasive techniques, utilizing alternative energy sources. We present our experience with left atrial radiofrequency ablation during cardiac surgery, outlining the technical aspects of the procedure and postoperative outcomes, with emphasis on mid-term freedom from atrial fibrillation.

Methods

The study included 93 consecutive patients with history of atrial fibrillation scheduled for cardiac surgery between January 2008 and December 2011. Concomitant left atrial radiofrequency ablation was performed using monopolar (endocardial) or bipolar (epicardial) systems, depending on the type of underlying cardiac pathology. Duration of the atrial fibrillation, re-do surgery, low ejection fraction, advanced age, or giant left atria were not considered as contraindications.

Results

Of the included patients, 73.1?% were discharged in stable sinus rhythm. Overall freedom from atrial fibrillation was 69.6?% at late follow-up, which ranged from 12 to 48 months (median, 22 months) and did not differ for the two approaches (epicardial vs. endocardial). The presence of early atrial tachyarrhythmia was a predictor of atrial fibrillation recurrence (p?=?0.026). Age was also associated with higher recurrence rates during hospital stay (p?=?0.04), but not for late atrial fibrillation.

Conclusion

Concomitant left atrial radiofrequency ablation conveyed satisfactory early and mid-term rhythm control, with acceptable postoperative outcomes, given the risk profile of our patient cohort.     

The preoperative glomerular filtration rate predicts new-onset postoperative atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy who undergo isolated septal myectomy

BackgroundFew studies have focused on new-onset postoperative atrial fibrillation in patients with hypertrophic obstructive cardiomyopathy who have undergone septal myectomy. Therefore, we investigated the incidence and prognosis effects of postoperative atrial fibrillation following septal myectomy in patients with hypertensive obstructive cardiomyopathy. Additionally, we investigated the relationship of estimated glomerular filtration rate and postoperative atrial fibrillation.MethodsData from 300 patients with hypertrophic obstructive cardiomyopathy who underwent isolated surgical septal myectomy were collected from January 2012 to March 2018.ResultsThe overall incidence of postoperative atrial fibrillation during hospitalization was 22.67% (68 of 300 patients). Patients with postoperative atrial fibrillation were older (P<0.001), had lower preoperative estimated glomerular filtration rate (P<0.001), and a larger preoperative left atrial diameter (P=0.038) compared to patients without. The preoperative estimated glomerular filtration rate predicted postoperative atrial fibrillation with sensitivity and specificity of 0.824 and 0.578 (P<0.001), respectively. Multivariate regression analyses showed that age [odds ratio (OR) =1.090, 95% confidence interval (CI): 1.034–1.110], an New York Heart Association functional class ≥ III (OR =2.985, 95% CI: 1.349–6.604), hypertension (OR =2.212, 95% CI: 1.062–4.608), a history of syncope (OR =3.890, 95% CI: 1.741–8.692), and the preoperative estimated glomerular filtration rate (OR =0.981, 95% CI: 0.965–0.996) were independent risk factors associated in the development of postoperative atrial fibrillation. Survival analysis showed that the incidence of long-term cardiovascular events was higher in the patients with postoperative atrial fibrillation than that in the patients without the condition (P<0.001).ConclusionsThe preoperative estimated glomerular filtration rate was a moderate predictor of postoperative atrial fibrillation after septal myectomy. Postoperative atrial fibrillation affected the early recovery and the long-term prognoses of patients with hypertrophic obstructive cardiomyopathy who underwent septal myectomy.     

Anticoagulation practices in adults with congenital heart disease and atrial arrhythmias in Switzerland

Background: In adults with congenital heart disease (CHD) and atrial arrhythmias, recommendations for thromboprophylaxis are vague and evidence is lacking. We aimed to identify factors that influence decision-making in daily practice.
Methods: From the Swiss Adult Congenital HEart disease Registry (SACHER) we identified 241 patients with either atrial fibrillation (Afib) or atrial flutter/intraatrial reentrant tachycardia (Aflut/ IART). The mode of anticoagulation was reviewed. Logistic regression models were used to assess factors that were associated with oral anticoagulation therapy.
Results: Compared with patients with Aflut/IART, patients with Afib were older (51 ± 16.1 vs 37 ± 16 years, P < .001) and had a higher CHA₂DS₂-VASc (P < .001) and HAS-BLED scores (P = .005). Patients with Afib were more likely on oral anticoagulation than patients with Aflut/IART (67% vs 43%, P < .001). In a multivariate logistic regression model, age [odds ratio (OR) 1.03 per year, 95%CI (1.01-1.05), P = .019], atrial fibrillation [OR 2.75, 95%CI (1.30-5.08), P = .007], nonparoxysmal atrial arrhythmias [OR 5.33, 95%CI (2.21-12.85)], CHA2DS2-VASc-Score >1 [OR 2.93, 95%CI (1.87-4.61), P < .001], and Fontan palliation [OR 17.5, 95%CI (5.57-54.97), P < .001] were independently associated with oral anticoagulation treatment, whereas a HAS-BLED score >1 was associated with absence of thromboprophylaxis [OR 0.32, 95%CI (0.17-0.60), P < .001].
Conclusions: In this multicenter study, age, type, and duration of atrial arrhythmias, CHA2DS2- VASc and HAS-BLED scores as well as a Fontan palliation had an impact on the use of thromboprophylaxis in adult CHD patients with atrial arrhythmias. In daily practice, anticoagulation strategies differ between patients with Afib and those with Aflut/IART. Prospective observational studies are necessary to clarify whether this attitude is justified.